Current Challenges and Future Advances in Lung Cancer: Genetics, Instrumental Diagnosis and Treatment

CAR T cells in lung cancer: Targeting tumor-associated antigens to revolutionize immunotherapy

Tumor-targeted T cells engineered for targeting and killing tumor cells have revolutionized cancer treatment, specifically in hematologic malignancies, through chimeric antigen receptor (CAR) T cell therapy. However, the migration of this success to lung cancer is challenging due to the tumor microenvironment (TME), antigen heterogeneity, and limitations of T cell infiltration. This review aims to evaluate current strategies addressing these barriers, focusing on the optimization of tumor-associated antigen (TAA) targeting, such as epidermal growth factor receptor (EGFR), mucin-1 (MUC1), and mesothelin (MSLN), which are frequently overexpressed in lung cancer and offer promising targets for CAR T-cell therapy. In this review, we discuss recent progress in CAR T cell engineering, applying enhanced costimulatory molecules, cytokine-secreting CAR T cells, and engineered modifications to improve T cell resilience in immunosuppressive environments. Additionally, this review also evaluates combination therapies of immune checkpoint inhibitors and recently published clinical trials on lung cancer with CAR T cells. We offer insights into the way to optimize CAR T cell therapy for lung cancer by analyzing antigen selection, immune evasion, and the strategies to enhance T cell persistence and tumor infiltration.

FGTI-2734 Inhibits ERK Reactivation to Overcome Sotorasib Resistance in KRAS G12C Lung Cancer

INTRODUCTION

KRAS G12C targeted therapies, such as sotorasib, represent a major breakthrough, but overall response rates and progression-free survival for patients with KRAS G12C lung cancer are modest due to the emergence of resistance mechanisms involving adaptive reactivation of ERK, which requires wild-type HRAS and NRAS membrane localization.

METHODS AND RESULTS

Here, we demonstrate that the dual farnesyltransferase and geranylgeranyltransferase-1 inhibitor FGTI-2734 inhibits wild-type RAS membrane localization and sotorasib-induced ERK feedback reactivation, and overcomes sotorasib adaptive resistance. The combination of FGTI-2734 and sotorasib is synergistic at inhibiting the viability and inducing apoptosis of KRAS G12C lung cancer cells, including those highly resistant to sotorasib. FGTI-2734 enhances sotorasib's anti-tumor activity in vivo leading to significant tumor regression of a patient-derived xenograft (PDX) from a patient with KRAS G12C lung cancer and several xenografts from highly sotorasib-resistant KRAS G12C human lung cancer cells. Importantly, treatment of mice with FGTI-2734 inhibited sotorasib-induced ERK reactivation in KRAS G12C PDX, and treatment of mice with the combination of FGTI-2734 and sotorasib was also significantly more effective at suppressing in vivo the levels of P-ERK in sotorasib-resistant human KRAS G12C lung cancer xenografts and the NSCLC PDX.

CONCLUSION

Our findings provide a foundation for overcoming sotorasib resistance and potentially improving the treatment outcomes of KRAS G12C lung cancer.

Lung Cancer-Epidemiology, Pathogenesis, Treatment and Molecular Aspect (Review of Literature)

Lung cancer is one of the most common malignant cancers in most countries and is the leading cause of death among cancer diseases worldwide. Despite constant progress in diagnosis and therapy, survival rates of patients diagnosed with lung cancer remain unsatisfactory. Numerous epidemiological and experimental studies conducted as early as the 1970s confirm that the most important risk factor for the development of lung cancer is long-term smoking, which remains valid to this day. In the paper, the authors present the latest data on the epidemiology, pathogenesis, treatment and molecular aspects of this cancer. In the last decade, many molecular alterations that are effective in the development of lung cancer have been discovered. In adenocarcinoma, tyrosine kinase inhibitors were developed for EGFR mutations and ALK and ROS1 translocations and were approved for use in the treatment of advanced stage adenocarcinomas. In the case of squamous cell carcinoma, the evaluation of these mutations is not yet being used in clinical practice. In addition, there are ongoing studies concerning many potential therapeutic molecular targets, such as ROS, MET, FGFR, DDR-2 and RET. Constant progress in diagnostic and therapeutic methods gives rise to hopes for an improved prognosis in patients with lung cancer.

Global estimates of prevalence of chronic painful neuropathy among patients with chemotherapy-induced peripheral neuropathy: systematic review and meta-analysis of data from 28 countries, 2000-24

INTRODUCTION

Although the prevalence of chemotherapy-induced peripheral neuropathy (CIPN) has been reported, the proportion of patients with CIPN who report chronic painful neuropathy remains poorly understood, despite its significant impact on patients' quality of life and treatment outcomes.

METHODS

A systematic review and meta-analysis were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The primary outcome was the pooled prevalence of chronic (≥3 months) painful CIPN among patients diagnosed with CIPN. Estimates from each study were transformed using double arcsine transformation and pooled in a meta-analysis using an inverse variance heterogeneity model. Subgroup analysis was conducted based on geographical region, sex, chemotherapy regimen, primary cancer type, and funding source; meta-regression analysis was conducted based on study design, human development index (HDI), and publication year.

RESULTS

77 studies from 28 countries, encompassing 10 962 patients with CIPN, were included. Among patients diagnosed with CIPN, the pooled prevalence of those reporting chronic painful CIPN was estimated at 41.22% (95% CI 32.40 to 50.19; 95% prediction interval 23.71 to 61.28). Substantial heterogeneity was observed across studies (I²=95.27%; 95% CI for I2 94.58 to 95.86). Subgroup analysis revealed that patients treated with platinum based agents and taxanes had the highest prevalence of chronic painful CIPN (40.44% and 38.35%, respectively), and among primary cancers, those with lung cancer reported the highest prevalence of chronic painful CIPN (60.26%). Study design, HDI, and publication year were non-significant moderators of prevalence estimates. Based on our GRADE (Grading of Recommendations, Assessment, Development and Evaluation) assessment, the certainty of evidence was considered very low.

CONCLUSION

This study provides the first comprehensive global estimate of the prevalence of chronic painful CIPN, highlighting its significant burden on patients worldwide. The variation in prevalence across geographical regions, chemotherapy regimens, and primary cancers underscores the need for tailored pain management strategies and further research to address potential disparities.

TRIAL REGISTRATION

PROSPERO CRD42024579459.

Revolutionizing lung cancer treatment: Introducing PROTAC therapy as a novel paradigm in targeted therapeutics

This comprehensive review explores the transformative potential of PROTAC (Proteolysis-Targeting Chimeras) therapy as a groundbreaking approach in the landscape of lung cancer treatment. The introduction provides a succinct overview of current challenges in lung cancer treatment, emphasizing the significance of targeted therapies. Focusing on PROTAC therapy, the article elucidates its mechanism of action, comparing it with traditional targeted therapies and highlighting the key components and design principles of PROTAC molecules. In the context of lung cancer, the review meticulously summarizes preclinical evidence, emphasizing efficacy and specificity gleaned from studies evaluating PROTAC therapy. It delves into the implications of this preclinical data, discussing potential advantages over existing targeted therapies. An update on ongoing clinical trials involving PROTAC therapy for lung cancer offers a snapshot of the current progress, with a summary of key outcomes and advancements in early-phase trials. The mechanistic insights into PROTAC therapy's impact on lung cancer cells are explored, alongside a discussion on potential biomarkers for patient stratification and response prediction. The influence of tumor heterogeneity on PROTAC therapy outcomes is also addressed. Safety and tolerability assessments, encompassing preclinical and clinical studies, are comprehensively evaluated, including a comparative analysis with traditional targeted therapies and strategies to mitigate side effects. Looking forward, the article discusses the future perspectives of PROTAC therapy in lung cancer treatment and addresses ongoing challenges, providing a nuanced exploration of potential combination therapies and synergistic approaches. In conclusion, the review summarizes key findings and insights, underscoring the tremendous potential of PROTAC therapy as a promising and innovative avenue in pursuing more effective lung cancer treatments.

A Holistic Approach to Implementing Artificial Intelligence in Lung Cancer

The application of artificial intelligence (AI) in lung cancer, particularly in surgical approaches, has significantly transformed the healthcare landscape. AI has demonstrated remarkable advancements in early lung cancer detection, precise medical image analysis, and personalized treatment planning, all of which are crucial for surgical interventions. By analyzing extensive datasets, AI algorithms can identify patterns and anomalies in lung scans, facilitating timely diagnoses and enhancing surgical outcomes. Furthermore, AI can detect subtle indicators that may be overlooked by human practitioners, leading to quicker intervention and more effective treatment strategies. The technology can also predict patient responses to surgical treatments, enabling tailored care plans that improve recovery rates. In addition to surgical applications, AI streamlines administrative tasks such as record management and appointment scheduling, allowing healthcare providers to concentrate on delivering high-quality care. The integration of AI with genomics and precision medicine holds the potential to further refine surgical approaches in lung cancer treatment by developing targeted strategies that enhance effectiveness and minimize side effects. Despite challenges related to data privacy and regulatory concerns, the ongoing advancements in AI, coupled with collaboration between healthcare professionals and AI experts, suggest a promising future for lung cancer care. This article explores how AI addresses the challenges of lung cancer treatment, focusing on current advancements, obstacles, and the future potential of surgical applications.

Etoposide as a Key Therapeutic Agent in Lung Cancer: Mechanisms, Efficacy, and Emerging Strategies

Topoisomerase II inhibitors, particularly etoposide, have long been integral to the treatment of lung cancer, especially small cell lung cancer. This review comprehensively examines the mechanisms of action of etoposide, its clinical efficacy, and its role in current lung cancer treatment regimens. Etoposide exerts its anticancer effects by inducing DNA strand breaks through the inhibition of topoisomerase II, leading to cancer cell apoptosis. Despite their widespread use, challenges such as drug resistance, toxicity, and limited efficacy in non-small cell lung cancer have spurred ongoing research on combination therapies and novel drug formulations. Emerging therapeutic strategies include the integration of etoposide with immunotherapy, targeted therapies, and novel drug delivery systems aimed at enhancing the therapeutic window and overcoming drug resistance. This article aims to inform the development of more effective treatment strategies by providing a critical overview of the clinical applications of etoposide and exploring future directions for lung cancer therapy.

Depside and depsidone-rich hydroalcoholic extract, resourced from the lichen Parmelinella wallichiana (Taylor) Elix & Hale selectively restricts Non-Small Cell Lung Cancer by modulating p53, FOXO1 and PALLADIN genes

The non-specificity of contemporary cancer therapeutics has enticed us to develop safer, anticancer alternatives from natural resources. Lichens are unique natural entities which have long been neglected for explorations in cancer therapy, despite their vast potential. Our present study aims to investigate the anti-cancer potential of a wild lichen Parmelinella wallichiana. The anti-proliferative efficacy of the lichen extracts were screened through MTT assay against a panel of cell lines and the potent hydroalcoholic extract was selected for further evaluation against the most sensitive lung-cancer cell line A549 by implementing a wide range of microscopic and flow cytometric applications. The observations suggest that the extract could selectively induce apoptosis by augmenting ROS and disrupting the mitochondrial membrane potentiality. It was also found that the lichen-induced apoptosis was regulated by two crucial tumor suppressor genes, FOXO1, and p53, along with cell cycle inhibitor p21 which ultimately resulted in robust apoptosis through the up-regulation of pro-apoptotic BAX expression. Moreover, the extract also restricted the cancer progression by down-regulating the PALLADIN expression. Further, an LC-MS-based metabolomic profile highlighted a number of depsides, depsidones and dibenzofurans, which included atranorin, physodalic acid, salazinic acid, constictic acid and usnic acid. Then, an in silico docking with these lichen-derived metabolites against the PI3Kα receptor predicted these compounds has a binding affinity close to a standard PI3Kα inhibitor copanlisib. The study concludes that the extract restricts lung cancer possibly through the PI3Kα/FOXO1 axis and thus Parmelinella wallichiana represents a potential resource for anti-lung cancer drug development in future.

Unveiling ficolins: diagnostic and prognostic biomarkers linked to the Tumor Microenvironment in Lung Cancer

BACKGROUND

Ficolins (FCNs) are a family of proteins, comprising FCN1, FCN2 and FCN3, and integral to the immune system which have been implicated in the onset and progression of tumors. Despite their recognized roles, a comprehensive analysis of FCNs in lung cancer remains elusive.

METHODS

We employed a variety of bioinformatics tools, including UCSC, SangerBox, Ualcan, cBioPortal, String, Metascape, GeneMANIA, TIDE, CTD, and CAMP databases to investigate the differential expression, diagnostic and prognostic significance, genetic alterations, functional enrichment, immune infiltration, and potential immunotherapeutic implications of FCN1, FCN2, and FCN3 in lung squamous cell carcinoma (LUSC) and lung adenocarcinoma (LUAD). Additionally, RT-qPCR and immunohistochemistry were utilized to validate the expressions of FCNs at the mRNA and protein levels in LUSC and LUAD.

RESULTS

Our comprehensive bioinformatic analysis, supported by RT-qPCR and immunohistochemistry, revealed that the expressions of FCN1, FCN2 and FCN3 were consistently downregulated in both LUSC and LUAD tumor tissues. FCNs demonstrated significant diagnostic potential for LUSC and LUAD, with the area under the receiver operating characteristic curve (AUC) for FCN1 and FCN3 exceeding 0.90. Furthermore, FCN2 and FCN3 showed a strong negative correlation with overall survival (OS) in LUSC, whereas FCN1 and FCN2 were positively correlated with OS in LUAD, suggesting their prognostic value in lung cancer. Gene enrichment analysis indicated that FCNs were predominantly associated with the complement system and complement activation pathways. Immune infiltration analysis further revealed a significant positive correlation between FCNs and the presence of neutrophils and resting mast cells. Our analysis of immunotherapy outcomes revealed a significant disparity in the immunophenoscore (IPS) among lung cancer patients treated with immune checkpoint inhibitors (ICIs), distinguishing those with high FCN expression from those with low FCN expression. Additionally, we identified small molecule compounds related to FCNs and drugs pertinent to LUSC and LUAD.

CONCLUSION

FCNs held promise as diagnostic and prognostic biomarkers for LUSC and LUAD. This study also elucidated the relationship of FCNs with the tumor microenvironment, offering novel insights into the immunotherapeutic landscape for LUSC and LUAD.

Correlation of TNF-α polymorphisms with susceptibility to lung cancer: evidence from a meta-analysis based on 29 studies

OBJECTIVE

This meta-analysis aims to clarify the association between the TNF-α -308G > A and - 238G > A polymorphisms and lung cancer risk.

METHOD

A comprehensive search was conducted for relevant articles across databases such as PubMed, Google Scholar, Web of Science, EMBASE, and CNKI, up to September 25, 2023. Lung cancer risk was assessed by calculating odds ratios (ORs) and their 95% confidence intervals (CIs). The Z-test was used to determine the significance of combined ORs, with P < 0.05 considered statistically significant. All analyses were performed using Comprehensive Meta-Analysis (CMA) 2.0 software.

RESULTS

The analysis included 19 case-control studies with 3,838 cases and 5,306 controls for the TNF-α -308G > A polymorphism, along with 10 studies comprising 2,427 cases and 2,357 controls for the - 238G > A polymorphism. The - 308G > A polymorphism showed no significant overall relationships, though in the Asian subgroup, the A allele was significantly reduced compared to G (OR: 0.831, p = 0.028) and the AA genotype showed significant reductions versus GG (OR: 0.571, p = 0.021), with no significant correlation in Caucasians. In non-small cell lung cancer (NSCLC), the A allele was associated with increased risk compared to G (OR: 1.131, p = 0.049). For the - 238G > A polymorphism, the AA genotype significantly increased risk compared to GG (OR: 3.171, p = 0.014), while showing a protective effect in Caucasians (OR: 0.120, p = 0.024) and a heightened risk in Asians (OR: 7.990, p = 0.007). In small cell lung cancer (SCLC), the A allele conferred protective effects, whereas NSCLC showed increased risk for the AA genotype (OR: 11.375, p = 0.002).

CONCLUSION

The - 308G > A polymorphism has no significant overall relationships but suggests a protective role of the A allele in the Asian subgroup. Conversely, the - 238G > A polymorphism presents a complex risk profile, increasing lung cancer likelihood in Asians while protecting Caucasians. Notably, the AA genotype significantly raises risk for NSCLC, indicating its potential as a risk factor.

Targeting ferroptosis regulators in lung cancer: Exploring natural products

Lung cancer remains a formidable global health challenge, necessitating innovative therapeutic strategies for improved efficacy. This review explores the untapped potential of natural products and Traditional Chinese Medicine (TCM) in lung cancer therapy, focusing on targeting ferroptosis regulators. Natural compounds, such as curcumin and resveratrol, exhibit diverse anti-cancer mechanisms, complemented by TCM's holistic approach rooted in a 3500-year history. Emphasizing the induction of cell death, particularly ferroptosis, the review highlights its significance in overcoming challenges like resistance to conventional therapies. Key ferroptosis regulators are explored in the context of natural products and TCM. The impact of these treatments on crucial pathways, such as antioxidant mechanisms (GPX4, SLC7A11, and NRF2), iron metabolism regulators, and lipid and mitochondria pathways, is examined. The findings provide a comprehensive overview of how natural products and TCM modulate ferroptosis in lung cancer, offering valuable insights for the development of innovative, side-effect-reduced therapeutic strategies. This work holds promise for transforming the landscape of lung cancer treatment by integrating the rich resources of nature into conventional therapeutic paradigms.

Hope and its relationship with treatment/ physical related factors in lung cancer patients receiving immunotherapy

BACKGROUNDPURPOSE

Immunotherapy is a new treatment option for patients with Lung Cancer (LC). However, relatively limited research has explored about patients' perception of hope and its associated factors during the process. This study aimed to examine level of perceived hope and the factors related to hope, with a particular focus on treatment and physically related factors, in LC patients receiving immunotherapy.

METHODS

A cross-sectional study was conducted and patients who had already received at least one immunotherapy cycle were recruited from two hospitals in northern Taiwan. The questionnaire included a background information form, the Herth's Hope Index, and the Symptom Severity Scale. Stepwise regression was applied to identify the most robust factors related to level of hope in the participants.

RESULTS

A total of 130 patients were recruited. Overall, patients reported moderate to high levels of hope and mild symptoms. Fatigue, weakness, appearance changes, pruritus, and shortness of breath were identified as the most severe symptoms. Further regression analysis showed that patients with poor performance status, less immunotherapy cycles, higher level of fatigue, and more severe pruritus reported to have lower level of hope which explained 47% of the variances.

CONCLUSIONS

This study revealed that lung cancer patients undergoing immunotherapy had moderate level of hope. Patients' performance status, selected symptoms and times of receiving immunotherapy were the robust factors related to hope. Systematic assessment of patients' symptoms and the development of appropriate interventions to reduce distress and enhance hope are strongly recommended for both clinical care and research.

Biological Activity of Natural and Synthetic Peptides as Anticancer Agents

Cancer is one of the leading causes of morbidity and death worldwide, making it a serious global health concern. Chemotherapy, radiotherapy, and surgical treatment are the most used conventional therapeutic approaches, although they show several side effects that limit their effectiveness. For these reasons, the discovery of new effective alternative therapies still represents an enormous challenge for the treatment of tumour diseases. Recently, anticancer peptides (ACPs) have gained attention for cancer diagnosis and treatment. ACPs are small bioactive molecules which selectively induce cancer cell death through a variety of mechanisms such as apoptosis, membrane disruption, DNA damage, immunomodulation, as well as inhibition of angiogenesis, cell survival, and proliferation pathways. ACPs can also be employed for the targeted delivery of drugs into cancer cells. With over 1000 clinical trials using ACPs, their potential for application in cancer therapy seems promising. Peptides can also be utilized in conjunction with imaging agents and molecular imaging methods, such as MRI, PET, CT, and NIR, improving the detection and the classification of cancer, and monitoring the treatment response. In this review we will provide an overview of the biological activity of some natural and synthetic peptides for the treatment of the most common and malignant tumours affecting people around the world.

Empowering lung cancer treatment: Harnessing the potential of natural phytoconstituent-loaded nanoparticles

Lung cancer, the second leading cause of cancer-related deaths, accounts for a substantial portion, representing 18.4% of all cancer fatalities. Despite advances in treatment modalities such as chemotherapy, surgery, and immunotherapy, significant challenges persist, including chemoresistance, non-specific targeting, and adverse effects. Consequently, there is an urgent need for innovative therapeutic approaches to overcome these limitations. Natural compounds, particularly phytoconstituents, have emerged as promising candidates due to their potent anticancer properties and relatively low incidence of adverse effects compared to conventional treatments. However, inherent challenges such as poor solubility, rapid metabolism, and enzymatic degradation hinder their clinical utility. To address these obstacles, researchers have increasingly turned to nanotechnology-based drug delivery systems (DDS). Nanocarriers offer several advantages, including enhanced drug stability, prolonged circulation time, and targeted delivery to tumor sites, thereby minimizing off-target effects. By encapsulating phytoconstituents within nanocarriers, researchers aim to optimize their bioavailability and therapeutic efficacy while reducing systemic toxicity. Moreover, the integration of nanotechnology with phytoconstituents allows for a nuanced understanding of the intricate molecular pathways involved in lung cancer pathogenesis. This integrated approach holds promise for modulating key cellular processes implicated in tumor growth and progression. Additionally, by leveraging the synergistic effects of phytoconstituents and nanocarriers, researchers seek to develop tailored therapeutic strategies that maximize efficacy while minimizing adverse effects. In conclusion, the integration of phytoconstituents with nanocarriers represents a promising avenue for advancing lung cancer treatment. This synergistic approach has the potential to revolutionize current therapeutic paradigms by offering targeted, efficient, and minimally toxic interventions. Continued research in this field holds the promise of improving patient outcomes and addressing unmet clinical needs in lung cancer management.

[Targeting the spliceosome: A new therapeutic strategy to counteract chemotherapy resistance in lung cancer?]

Lung cancer is the first cancer-related cause of death worldwide. This is in partially due to therapeutic resistance, which occurs in around 70% of patients, especially those receiving platinum salts, the gold-standard chemotherapy. The massive deregulation of alternative transcript splicing processes observed in many cancers has led to the development of a new class of pharmacological agents aimed at inhibiting the activity of the splicing machinery (spliceosome). The molecular mechanisms by which these inhibitors act remain largely unknown, as do the benefits of using them in combination with other therapies. In this context, our work is focused on an inhibitor of the SRPK1 kinase, a major regulator of the spliceosome.

Differentially Expressed Genes Involved in Primary Resistance to Immunotherapy in Patients with Advanced-Stage Pulmonary Cancer

In the last few years, nivolumab has become the standard of care for advanced-stage lung cancer patients. Unfortunately, up to 60% of patients do not respond to this treatment. In our study, we identified variations in gene expression related to primary resistance to immunotherapy. Bronchoscopy biopsies were obtained from advanced non-small cell lung cancer (NSCLC) patients previously characterized as responders or non-responders after nivolumab treatment. Ten tumor biopsies (from three responders and seven non-responders) were analyzed by the differential expression of 760 genes using the NanoString nCounter platform. These genes are known to be involved in the response to anti-PD1/PD-L1 therapy. All the patients were treated with nivolumab. Examining the dysregulated expression of 24 genes made it possible to predict the response to nivolumab treatment. Supervised analysis of the gene expression profile (GEP) revealed that responder patients had significantly higher levels of expression of CXCL11, NT5E, KLRK1, CD3G, GZMA, IDO1, LCK, CXCL9, GNLY, ITGAL, HLA-DRB1, CXCR6, IFNG, CD8A, ITK, B2M, HLA-B, and HLA-A than did non-responder patients. In contrast, PNOC, CD19, TP73, ARG1, FCRL2, and PTGER1 genes had significantly lower expression levels than non-responder patients. These findings were validated as predictive biomarkers in an independent series of 201 patients treated with nivolumab (22 hepatocellular carcinomas, 14 non-squamous cell lung carcinomas, 5 head and neck squamous cell carcinomas, 1 ureter/renal pelvis carcinoma, 120 melanomas, 4 bladder carcinomas, 31 renal cell carcinomas, and 4 squamous cell lung carcinomas). ROC curve analysis showed that the expression levels of ITK, NT5E, ITGAL, and CD8A were the best predictors of response to nivolumab. Further, 13/24 genes showed an adverse impact on overall survival (OS) in an independent, large series of patients with NSCLC (2166 cases). In summary, we found a strong association between the global GEP of advanced NSCLC and the response to nivolumab. The classification of NSCLC patients based on GEP enabled us to identify those patients who genuinely benefited from treatment with immune checkpoint inhibitors (ICIs). We also demonstrated that abnormal expression of most of the markers comprising the genomic signature has an adverse influence on OS, making them significant markers for therapeutic decision-making. Additional prospective studies in larger series of patients are required to confirm the clinical utility of these biomarkers.