Specific organ metastases and survival in metastatic non-small-cell lung cancer

Interactions and communications in lung tumour microenvironment: chemo/radiotherapy resistance mechanisms and therapeutic targets

The lung tumour microenvironment (TME) is composed of various cell types, including cancer cells, stromal and immune cells, as well as extracellular matrix (ECM). These cells and surrounding ECM create a stiff, hypoxic, acidic and immunosuppressive microenvironment that can augment the resistance of lung tumours to different forms of cell death and facilitate invasion and metastasis. This environment can induce chemo/radiotherapy resistance by inducing anti-apoptosis mediators such as phosphoinositide 3-kinase (PI3K)/Akt, signal transducer and activator of transcription 3 (STAT3) and nuclear factor kappa B (NF-κB), leading to the exhaustion of antitumor immunity and further resistance to chemo/radiotherapy. In addition, lung tumour cells can resist chemo/radiotherapy by boosting multidrug resistance mechanisms and antioxidant defence systems within cancer cells and other TME components. In this review, we discuss the interactions and communications between these different components of the lung TME and also the effects of hypoxia, immune evasion and ECM remodelling on lung cancer resistance. Finally, we review the current strategies in preclinical and clinical studies, including the inhibition of checkpoint molecules, chemoattractants, cytokines, growth factors and immunosuppressive mediators such as programmed death 1 (PD-1), insulin-like growth factor 2 (IGF-2) for targeting the lung TME to overcome resistance to chemotherapy and radiotherapy.

IASLC grading system predicts distant metastases for resected lung adenocarcinoma

AIMS

The International Association for the Study of Lung Cancer (IASLC) has proposed a new histological grading system for invasive lung adenocarcinoma (LUAD). However, the efficacy of this grading system in predicting distant metastases in patients with LUAD remains unexplored. This study aims to assess the potential of the IASLC grading system in predicting the occurrence of brain and bone metastases in patients with resectable LUAD, thereby identifying individuals at high risk of post-surgery distant metastasis.

METHODS

We retrospectively analysed clinical data and pathological reports of 174 patients with early-stage LUAD who underwent surgical resection between 2008 and 2015 at our cancer center. Patients were monitored for 5 years, and their bone and brain metastasis-free survival rates were determined.

RESULTS

28 out of 174 patients developed distant metastases in 5 years with a median overall survival of 60 months for metastasis-free patients and 38.3 months for patients with distant metastasis. Tumour grading of all samples was evaluated by both IASLC grading and predominant pattern-based grading systems. Receiver operating characteristic (ROC) curves were used to evaluate the predictive capabilities of the IASLC grading system and tumour stage for distant metastasis. Compared with the predominant pattern-based grading system, the IASLC grading system showed a better correlation with the incidence of distant metastasis and lymphovascular invasion. ROC analyses revealed that the IASLC grading system outperformed tumour stage in predicting distant metastasis.

CONCLUSIONS

Our study indicates that the IASLC grading system is capable of predicting the incidence of distant metastasis among patients with early-stage invasive LUAD.

Identification of predictive subphenotypes for clinical outcomes using real world data and machine learning

Predicting treatment response is an important problem in real-world applications, where the heterogeneity of the treatment response remains a significant challenge in practice. Unsupervised machine learning methods have been proposed to address this challenge by clustering patients with similar electronic health record (EHR) data. However, they cannot guarantee coherent outcomes within the groups. Here, we propose Graph-Encoded Mixture Survival (GEMS) as a general machine learning framework to identify distinct predictive subphenotypes that guarantee coherent survival and baseline characteristics within each subphenotype. We apply our method to a real-world dataset of advanced non-small cell lung cancer (aNSCLC) patients receiving first-line immune checkpoint inhibitor (ICI) therapy to predict overall survival (OS). Our method outperforms baseline methods for predicting OS and identifies three reproducible subphenotypes associated with distinct baseline clinical characteristics and OS. Our results demonstrate that our method can provide insights in the heterogeneity of treatment response and potentially influence treatment selection.

A rising tide lifts all boats in the personalized cancer care continuum for mNSCLC: bridging inequities in NGS fosters equity in targeted treatment

BACKGROUND

Next-generation sequencing (NGS) testing in patients with metastatic non-small cell lung cancer (mNSCLC) identifies actionable driver oncogenes (ADO) and targeted treatment (TT). Potential inequities were evaluated in NGS testing and TT in patients with mNSCLC.

PATIENTS AND METHODS

This retrospective study used a nationwide electronic health record-derived deidentified database for patients ≥18 years diagnosed with mNSCLC between 4/2018 and 4/2024, ≥2 recorded visits, and follow-up ≥90 days post diagnosis. For TT, patients must have received NGS testing before first-line (1L) treatment and harbored ≥1 1L ADO.

RESULTS

A total of 15 392 patients with mNSCLC were included: 66% with commercial insurance, 16% with Medicare, 12% with other, 4% with Medicaid, and 3% with other government insurance. Patients with commercial insurance had significantly higher odds of receiving NGS testing vs Medicare, Medicaid, or other insurance. While patient characteristics varied across insurances, the effect of insurance type on NGS testing did not differ by race/ethnicity, age, or socioeconomic status (SES). Site of care was a significant effect modifier, with increased odds of NGS testing for community vs academic settings for commercial, Medicare, and other insurance and decreased odds for Medicaid. When all patients received NGS testing, significantly lower odds of receiving TT occurred for patients with SES 2 vs SES 1 (lowest); higher odds occurred for Asian vs white patients.

CONCLUSION

Insurance is a key contributor to inequity in NGS testing. When all patients received NGS testing, equity was achieved in patients receiving TT, except those with lower SES, who potentially did not qualify for Medicaid.

Thermal cycling‑hyperthermia sensitizes non‑small cell lung cancer A549 cells to EGFR tyrosine kinase inhibitor erlotinib

Molecular targeted therapy has emerged as a mainstream treatment for non‑small cell lung cancer (NSCLC), the most common type of lung cancer and the leading cause of cancer‑related death in both men and women. Erlotinib (Erl), a targeted therapy inhibiting EGFR pathways, has shown notable response rate in NSCLC cells. However, limited efficacy of the treatment has been reported due to resistance among a proportion of patients with NSCLC. Therefore, sensitizers are required to potentiate the efficacy of Erl in NSCLC treatment. The present study proposed a novel thermal therapy, thermal cycling‑hyperthermia (TC‑HT), as a supplement to amplify the effects of Erl. It was demonstrated that TC‑HT reduced the half‑maximal inhibitory concentration of Erl to 0.5 µM and TC‑HT sensitized A549 NSCLC cells to Erl via the downstream EGFR signaling cascades. Furthermore, the combination treatment of Erl and TC‑HT induced G2/M cell cycle arrest and inhibition of cell proliferation and migration. In addition, by slightly raising the temperature of TC‑HT, TC‑HT treatment alone produced antineoplastic effects without damaging the normal IMR‑90 lung cells. The method presented in this study may be applicable to other combination therapies and could potentially act as a starter for anticancer treatments, with fewer side effects.

Intervention of a Communication Between PI3K/Akt and β-Catenin by (-)-Epigallocatechin-3-Gallate Suppresses TGF-β1-Promoted Epithelial-Mesenchymal Transition and Invasive Phenotype of NSCLC Cells

The epithelial-mesenchymal transition (EMT) assists in the acquisition of invasiveness, relapse, and resistance in non-small cell lung cancer (NSCLC) and can be caused by the signaling of transforming growth factor-β1 (TGF-β1) through Smad-mediated or Smad-independent pathways. (-)-Epigallocatechin-3-gallate (EGCG), a multifunctional cancer-preventing bioconstituent found in tea polyphenols, has been shown to repress TGF-β1-triggered EMT in the human NSCLC A549 cell line by inhibiting the activation of Smad2 and Erk1/2 or reducing the acetylation of Smad2 and Smad3. However, its impact on the Smad-independent pathway remains unclear. Here, we found that EGCG, similar to LY294002 (a specific inhibitor of phosphatidylinositol 3-kinase [PI3K]), downregulated Akt activation and restored the action of glycogen synthase kinase-3β (GSK-3β), accompanied by TGF-β1-caused changes in hallmarks of EMT such as N-cadherin, E-cadherin, vimentin, and Snail in A549 cells. EGCG inhibited β-catenin expression and its nuclear localization caused by TGF-β1, suggesting that EGCG blocks the crosstalk between the PI3K/Akt/GSK-3β route and β-catenin. Furthermore, it was shown that EGCG suppressed TGF-β1-elicited invasive phenotypes of A549 cells, including invading and migrating activities, matrix metalloproteinase-2 (MMP-2) secretion, cell adhesion, and wound healing. In summary, we suggest that EGCG inhibits the induction of EMT by TGF-β1 in NSCLC not only through a Smad-dependent pathway, but also through the regulation of the PI3K/Akt/β-catenin signaling axis.

Setting the Benchmark: Patterns of Care and Outcomes for Early-stage Non-small Cell Lung Cancer in Queensland, Australia, 2011-2017

AIM

Treatment paradigms for early-stage non-small cell lung cancer (NSCLC) are evolving rapidly. Our aim was to document baseline patterns of care and outcomes at the population level immediately prior to the introduction of immunotherapy.

METHODS

Data were obtained from the Queensland Oncology Repository. The study cohort comprised Queensland residents diagnosed with a non-metastatic primary NSCLC between 2011 and 2017, with follow-up on treatment and mortality to December 31, 2022. Poisson regression was used to determine patient and clinical characteristics associated with receiving different treatment modalities within 1 year of diagnosis. Variations in 5-year observed survival were assessed using flexible parametric modelling.

RESULTS

A total of 4445 people were included, of whom 30% were treated with surgery only, 15% with surgery plus chemotherapy and/or radiotherapy and 44% with chemotherapy and/or radiotherapy only. The remaining 10% did not receive any recorded treatment. People in outer regional/remote areas had lower rates of radiotherapy (relative likelihood [RL] = 0.87, 95% confidence interval [CI] 0.78-0.97) and chemotherapy (RL = 0.89, 95% CI 0.81-0.98) than those in major cities, but there were no significant differences by First Nations status or socio-economic status. Five-year observed survival varied from 63% (95% CI 60%-65%) for stage I to 41% (38%-45%) for stage II and 20% (18%-22%) for stage III. The treatment modality significantly affected survival irrespective of stage at diagnosis (all p < 0.001).

CONCLUSION

Monitoring treatment outcomes for early-stage NSCLC at the population level is crucial for optimizing patient care, resource allocation and informing consumer choice. Emerging approaches involving immunotherapy are expected to further improve outcomes.

In silico-based analysis and in vitro experiments identify SIGMAR1 as a potential marker of putative lung cancer stem cells

BACKGROUND

Lung cancer is the leading cause of cancer-related mortality worldwide; however, despite the development and clinical application of various drugs, the prognosis remains poor. One reason for this is the high rate of recurrence and metastasis. The cancer stem cell (CSC) theory has been proposed to explain their root cause, and removal of CSCs is necessary to cure cancer completely; however, detailed profiles of lung CSCs have not been clarified. Here, we used single-cell RNA sequencing (scRNA-seq) data to identify novel markers for lung CSCs and validated their expression and function in vitro.

METHODS

A549-derived tumorspheres were used as a model for lung CSCs. To identify genes upregulated in CSC-like cells, we reanalyzed two publicly available scRNA-seq datasets from human lung cancer tissues. Additionally, trajectory analysis was performed to examine changes in candidate gene expression during CSC differentiation. The role of these candidate genes in CSC regulation was further investigated through functional assays.

RESULTS

Tumorspheres exhibited increased expression of well-established CSC markers. scRNA-seq analysis suggested that SIGMAR1 expression was significantly upregulated in CSC-like cells and decreased with differentiation. Furthermore, siRNA-mediated SIGMAR1 knockdown suppressed tumorsphere self-renewal capacity and reduced CSC marker expression.

CONCLUSIONS

We propose that SIGMAR1 serves as a potential functional marker of CSCs and plays a crucial role in regulating self-renewal capacity. Targeting SIGMAR1 may provide a novel therapeutic strategy for preventing metastasis and recurrence-major clinical challenges in lung cancer treatment. Future studies should investigate the underlying mechanisms by which SIGMAR1 modulates CSC properties.

Nanoformulations: Reforming treatment for non-small cell lung cancer metastasis

Non-small cell lung cancer (NSCLC) is frequently diagnosed at an advanced stage, with 20 % of cases presenting as localized disease, 25 % with regional metastasis, and 55 % with distant metastasis, contributing significantly to increased morbidity and mortality rates. Current treatments, including chemotherapy, immunotherapy, radiotherapy and targeted therapy, have shown therapeutic efficacy but are limited by issues such as lack of specificity, cytotoxicity, and therapeutic resistance. Nanoparticles (NPs) offer promising solutions to these challenges by enhancing drug penetration and retention, improving biocompatibility and stability, and achieving greater precision in targeting cancer cells. This review provides insights into various types of NPs utilized in anti-metastatic drug delivery, emphasizing their ability to enhance the efficacy of existing chemotherapeutics for the prophylaxis of metastatic NSCLC. The usage of NPs as carriers of synthetic and natural compounds aimed at inhibiting cancer cell migration and invasion have also been reviewed. Special attention has been given to biomimetic nanomaterials including extracellular vesicles and engineered exosomes, that are capable of targeting molecular pathways such as EMT, p53 and PI3K/Akt to treat metastatic NSCLC. Additionally, emphasis has been given to clinical trials of these nanoformulations and their efficacy. Although therapeutic outcomes have demonstrated certain improvements, challenges related to toxicity persist, highlighting the need for further optimization of these formulations to enhance safety and efficacy. Finally, we discuss the current limitations and future perspectives for integrating NPs into clinical settings as novel therapeutic agents for lung cancer metastasis.

A novel tRNA-Derived fragment, tRF-20-M0NK5Y93 inhibits the malignant progression of non-small cell lung cancer by mediating PLOD1

OBJECTIVE

Non-small cell lung cancer (NSCLC) constitutes a common malignant tumor characterized by substantial mortality rates. Transfer RNA (tRNA)-derived small RNAs (tsRNAs) have been implicated in the progression of various cancers, including NSCLC. However, to date, only a limited number of tsRNAs have been reported to be involved in the development of NSCLC. Hence, the present study aimed to investigate the potential roles of tsRNAs in the progression of NSCLC.

MATERIALS AND METHODS

A total of forty-six patients with NSCLC who underwent surgical resection were enrolled in this study. The expression patterns of tRNA-derived fragments (tRFs) in tumor and normal tissues of 6 NSCLC cases were investigated using RNA-sequencing assay. Cell viability, proliferation capacity, and migratory ability were measured utilizing the CCK-8, colony formation, and Transwell assays, respectively. Furthermore, cell apoptosis was evaluated by applying flow cytometry. The xenograft tumor model was constructed to observe tumor growth. The relationship between tRF-20-M0NK5Y93 and PLOD1 was clarified using the luciferase and RIP assays.

RESULTS

The RNA-sequencing assay revealed a significant decrease in the expression of tRF-20-M0NK5Y93 in tumor tissues. In line with this finding, qRT-PCR analysis further confirmed a meaningful downregulation of tRF-20-M0NK5Y93 in 46 patient samples with NSCLC. Importantly, this downregulated expression was strongly correlated with reduced patient survival. Additionally, overexpression of tRF-20-M0NK5Y93 was found to inhibit the proliferation and migration capabilities of NSCLC cells, leading to suppressed tumor growth and accelerated apoptosis. Furthermore, tRF-20-M0NK5Y93 was capable of binding to PLOD1, thereby negatively regulating its expression. Notably, the restoration of PLOD1 expression was able to counteract the inhibitory effects of enforced tRF-20-M0NK5Y93 on NSCLC cell proliferation, migration, and apoptosis.

CONCLUSION

The expression level of tRF-20-M0NK5Y93 was found to be decreased in NSCLC. Overexpressed tRF-20-M0NK5Y93 exhibited inhibitory effects on NSCLC cell proliferation and migration, accelerated apoptosis, and suppressed tumor growth by targeting PLOD1. These findings highlight tRF-20-M0NK5Y93 as a promising target for NSCLC therapy.

Distinct metastatic organotropism shapes prognosis in lung adenocarcinoma with brain metastasis

Background

Metastatic organotropism in lung cancer significantly influences prognosis, yet current treatment and clinical management guidelines are largely generalized for metastatic disease, regardless of organ site involvement. Notably, up to 30% of non-small cell lung cancer (NSCLC) patients present with brain metastases (BM) at diagnosis, underscoring the need for a more nuanced understanding of metastatic patterns. However, real-world clinical data on metastatic organotropism in well-characterized patient cohorts remain surprisingly scarce. Here, we evaluate patterns of metastasis, clinical characteristics and survival outcomes in patients with lung adenocarcinoma (LUAD), the major histological NSCLC subtype.

Methods

We performed a multi-center retrospective study including 913 stage IV LUAD patients, diagnosed and molecularly assessed in western Sweden between 2016-2021. Our primary study outcome was the distribution of specific metastatic sites and its impact on Overall Survival (OS).

Results

Out of 913 stage IV LUAD patients, 23.4% had BM. These patients exhibited markedly different metastatic patterns compared to those without BM, and median survival was significantly shorter (6 months) than those without BM (7.8 months) (p = 0.021). In addition, more than one metastatic tumor in the brain coincided with worse OS, compared to those with no, or with only one metastatic tumor in the brain. Importantly, OS was also influenced by metastasis in specific extracranial organs, like the pleura and lungs.

Conclusions

Our study highlights the distinct metastatic patterns and survival outcomes associated with BM in stage IV LUAD. These findings emphasize the need for site-specific approaches in managing metastatic disease due to BM's impact on survival.

Integrative transcriptomic analysis identifies emetine as a promising candidate for overcoming acquired resistance to ALK inhibitors in lung cancer

Anaplastic lymphoma kinase (ALK; also known as ALK tyrosine kinase receptor) inhibitors (ALKi) are effective in treating lung cancer patients with chromosomal rearrangement of ALK. However, continuous treatment with ALKis invariably leads to acquired resistance in cancer cells. In this study, we propose an efficient strategy to suppress ALKi resistance through a meta-analysis of transcriptome data from various cell models of acquired resistance to ALKis. We systematically identified gene signatures that consistently showed altered expression during the development of resistance and conducted computational drug screening using these signatures. We identified emetine as a promising candidate compound to inhibit the growth of ALKi-resistant cells. We demonstrated that emetine exhibited effectiveness in inhibiting the growth of ALKi-resistant cells, and further interpreted its impact on the resistant signatures through drug-induced RNA-sequencing data. Our transcriptome-guided systematic approach paves the way for efficient drug discovery to overcome acquired resistance to cancer therapy.

Identification of Genomic Instability-Associated LncRNAs as Potential Therapeutic Targets in Lung Adenocarcinoma

BACKGROUND/OBJECTIVES

Non-small cell lung cancer (NSCLC) is the most common type of cancer, with lung adenocarcinoma (LUAD) as the predominant subtype. Despite advancements in targeted therapies, many NSCLC patients still experience poor outcomes due to treatment resistance and disease progression. Genomic instability (GI), a hallmark of cancer, defined as the increased tendency of DNA mutations and alterations, is closely linked to cancer initiation, progression, and resistance to therapy. Emerging evidence suggests that long non-coding RNAs (lncRNAs)-molecules longer than 200 nucleotides that do not encode proteins but regulate gene expression-play critical roles in cancer biology and are associated with GI. However, the relationship between GI and lncRNA expression in LUAD remains poorly understood.

METHODS

In this study, we analyzed the transcript profiles of lncRNAs and mRNAs from LUAD samples in The Cancer Genome Atlas (TCGA) database and classified them based on their Homologous Recombination Deficiency (HRD) score. The HRD score is an unweighted sum of three independent DNA-based measures of genomic instability: loss of heterozygosity, telomeric allelic imbalance, and large-scale transitions. We then performed a differential gene expression analysis to identify lncRNAs and mRNAs that were either upregulated or downregulated in samples with high HRD scores compared to those with low HRD scores. Following this, we conducted a correlation analysis to assess the significance of the association between HRD scores and the expression of both lncRNAs and mRNAs.

RESULTS

We identified 30 differentially expressed lncRNAs and 200 mRNAs associated with genomic instability. Using an RNA interactome database from sequencing experiments, we found evidence of interactions between GI-associated lncRNAs (GI-lncRNAs) and GI-associated mRNAs (GI-mRNAs). Further investigation showed that some GI-lncRNAs play regulatory and functional roles in LUAD and other diseases. We also found that GI-lncRNAs have potential as prognostic biomarkers, particularly when integrated with HRD stratification. The expression of specific GI-lncRNAs was associated with primary therapy response and immune infiltration in LUAD. Additionally, we identified existing drugs that could modulate GI-lncRNAs, offering potential therapeutic strategies to address GI in LUAD.

CONCLUSIONS

Our findings suggest that GI-associated lncRNAs could serve as valuable biomarkers for LUAD prognosis and therapeutic response. Furthermore, modulating these lncRNAs presents potential treatment avenues to address genomic instability in LUAD.

Quality Indicators for Non-Small Cell Lung Cancer in Queensland, Australia, 2012-2021

BACKGROUND

Quality indicators for non-small cell lung cancer (NSCLC) have been implemented in Queensland, Australia, to assess performance across 28 elements relating to diagnosis, access, treatment, and outcomes.

METHODS

Linked data were sourced from the population-based Queensland Oncology Repository. Eligible people were diagnosed with NSCLC between 2012 and 2021, with follow-up on treatment and mortality available to 31 December 2022. For each indicator, changes between 2012-2016 and 2017-2021 were assessed by fitting a multivariable Poisson regression model. Results from the models were expressed in terms of the relative likelihood (RL) using 2012-2016 as the reference period.

RESULTS

Records were included for a total of 20 449 individuals. Significant improvements over the study period were observed for several indicators, including: review by a multidisciplinary team (RL = 1.05, 95% CI 1.03-1.07); any anticancer treatment received (RL = 1.04, 95% CI 1.03-1.06); radiation therapy for inoperable early-stage NSCLC (RL = 1.06, 95% CI 1.01-1.11); concurrent chemo-radiotherapy for stage III disease (RL = 1.35, 95% CI 1.24-1.47); and intravenous systemic therapy (IVST) for metastatic NSCLC (RL = 1.18, 95% CI 1.13-1.22). Two-year survival from the time of surgery increased from 85% to 90% (p < 0.001). In contrast, fewer people had their performance status documented following MDT review during the latter period (RL = 0.95, 95% CI 0.94-0.96), and there was a decrease in people from rural/remote areas who received their first treatment within 30 days of diagnosis (RL = 0.89, 95% CI 0.81-0.97).

CONCLUSIONS

The endorsed suite of quality indicators offers essential benchmarking to enable ongoing monitoring of and improvement in the quality of lung cancer care in Queensland.

An observational study of the causes of an isolated elevated alkaline phosphatase level of unclear etiology

BACKGROUND

Serum alkaline phosphatase (ALP) is a commonly obtained laboratory test, but its diagnostic specificity is limited because it is found in multiple tissues. We investigated patients with isolated, elevated, ALP levels without an obvious etiology at presentation to determine the frequency of different causes of an isolated elevated ALP.

METHODS

This was a retrospective, cohort study of adults (age >18 years old) from January 1st, 2013, to June 30th, 2020 in both the in- and outpatient setting at the Medical University of South Carolina. 260 patients with an isolated, elevated ALP of unknown etiology (patients with known biliary obstruction, underlying parenchymal liver disease, or pregnancy were excluded) were included. A secondary outcome was mean survival time from the ALP result.

RESULTS

The most common cause of ALP elevation was due to underlying malignancy (147, 57 %), with 61 patients having infiltrative intrahepatic malignancy, 52 patients having bony metastasis, and 34 patients having both hepatic and bone metastasis. Bone disease (75, 29 %), unsuspected parenchymal liver disease (18, 7 %), non-malignant infiltrative liver disease (7, 2 %), and other disorders (13, 5 %) accounted for the remainder of the cohort. Notably, 123 of 260 (47 %) patients died within an average of 58 months after identification of isolated, elevated ALP.

CONCLUSIONS

An isolated, elevated ALP of unclear etiology is associated with several very specific and important disorders, in particular metastatic intrahepatic malignancy - and is uncommonly associated with primary parenchymal liver disease. Providers should be aware of the potential clinical significance of an elevated ALP.

FDG PET/CT for Staging Lung Carcinoma: An Update

In non-small cell lung carcinoma (NSCLC) carcinoma, the CT-part of the FDG PET/CT examination is of primary importance for T (tumor)-status assessment, while information derived from the primary tumor on the FDG-part of the examination may provide additional information on N- (lymph node) status. FDG PET/CT imaging was shown to have an overall sensitivity of 85% and a specificity of 84% for identifying LN involvement in NSCLC. Parameters that may predict the presence and quantify the risk of LN-involvement in NSCLC missed on FDG PET/CT imaging are tumor size and its increase over time, tumor differentiation degree, the number of days elapsed from the time of initial diagnosis, an adenocarcinoma subtype, a central versus peripheral location of the primary tumor and a solid versus mixed solid-ground glass radiologic character. Nomograms incorporating several of these variables have been published and made available for clinical usage. Furthermore, FDG PET/CT imaging was shown to have an overall higher sensitivity for identifying extra-thoracic metastases than convential morphological imaging and this especially for bone and adrenal lesions. In small cell lung carcinoma (SCLC), limited available data have shown FDG PET/CT imaging to be systematically more accurate for staging purposes when compared to conventional staging and to lead to a change in disease stage (limited versus extensive disease) in up to 15% of SCLC-patients.

The Role of Clinicopathological Features in Tyrosine Kinase Inhibitory Duration in EGFR Mutant Metastatic Non-Small Cell Lung Cancer

Background: Epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) are effective treatments for EGFR mutant (EGFRm) metastatic non-small cell lung cancer (mNSCLC). However, the benefit of EGFR-TKIs varies. We aimed to determine the impact of clinicopathological features on the duration of response to EGFR-TKIs in EGFRm mNSCLC. Method: Patients diagnosed with EGFRm mNSCLC who underwent EGFR-TKI therapy were retrospectively reviewed. Cox regression analyses were employed to determine the association between the PFS rates of EGFR-TKI treatments and the clinicopathological variables. Results: We included 83 patients in this study. The univariate analysis revealed that male gender, de novo metastatic disease, adrenal metastasis, and the absence of intrathoracic metastasis were significantly associated with poor PFS rates. The multivariate analyses revealed that male gender and adrenal metastasis were correlated with poor PFS rates. Conclusions: Male gender, de novo metastatic disease, adrenal metastasis, and the absence of intrathoracic metastasis negatively impact EGFR-TKI response in patients with EGFRm NSCLC.

Brain Metastasis From Advanced-Stage Lung Carcinoma: Differentiating From Stroke and Exploring Treatment and Prevention Methods

Metastasis is one of the most significant contributors to mortality and treatment-related morbidity in patients with advanced-stage lung cancer, as it is often considered incurable once discovered. Accordingly, a significant challenge with metastasis is identifying its progression early, as initial imaging may be negative while metastasis propagates undetected. Hence, there is a growing consensus that determining the optimal frequency and improving screening protocols for brain metastasis in patients with lung cancer are essential areas of research, as earlier detection could allow for prompt adjustments in treatment and/or prophylactic interventions, thereby potentially improving outcomes and reducing risks associated with more invasive procedures. Moreover, another difficulty in the diagnosis of brain metastasis can arise from its symptom overlap with strokes, often necessitating methods such as the use of the visual-aphasia-neglect assessment scale, as well as accounting for patient history and timeline of symptoms, with definitive diagnosis established through a head CT/MRI. This report presents a patient with a history of a tobacco use disorder, upper esophageal stricture, and a one-year history of advanced stage III non-small-cell lung carcinoma who reported to the emergency department (ED) with concerns of neurological weakness where multiple lesions with vasogenic edema were discovered on head CT, suggestive of brain metastasis. The patient was admitted to the hospital, where he was treated with dexamethasone and subsequent MRI confirmed the diagnosis of brain metastasis. He was discharged home to begin whole brain radiation therapy with orders to temporarily hold his chemotherapy medication. The patient initially responded well, but most recent CT scans have indicated progression of metastasis to bone and gastrointestinal organs. Thus, earlier recognition of impending brain metastasis, especially in advanced-stage lung carcinoma, is a significant area of research, as timely detection can have decisive impacts on patient outcomes and possible interventions.

Metastatic Lung Adenocarcinomas: Development and Evaluation of Radiomic-Based Methods to Measure Baseline Intra-Patient Inter-Tumor Lesion Heterogeneity

Radiomics has traditionally focused on individual tumors, often neglecting the integration of metastatic disease, particularly in patients with non-small cell lung cancer. This study sought to examine intra-patient inter-tumor lesion heterogeneity indices using radiomics, exploring their relevance in metastatic lung adenocarcinoma. Consecutive adults newly diagnosed with metastatic lung adenocarcinoma underwent contrast-enhanced CT scans for lesion segmentation and radiomic feature extraction. Three methods were devised to measure distances between tumor lesion profiles within the same patient in radiomic space: centroid to lesion, lesion to lesion, and primitive to lesion, with subsequent calculation of mean, range, and standard deviation of these distances. Associations between HIs, disease control rate, objective response rate to first-line treatment, and overall survival were explored. The study included 167 patients (median age 62.3 years) between 2016 and 2019, divided randomly into experimental (N = 117,546 lesions) and validation (N = 50,232 tumor lesions) cohorts. Patients without disease control/objective response and with poorer survival consistently systematically exhibited values of all heterogeneity indices. Multivariable analyses revealed that the range of primitive-to-lesion distances was associated with disease control in both cohorts and with objective response in the validation cohort. This metrics showed univariable associations with overall survival in the experimental. In conclusion, we proposed original methods to estimate the intra-patient inter-tumor lesion heterogeneity using radiomics that demonstrated correlations with patient outcomes, shedding light on the clinical implications of inter-metastases heterogeneity. This underscores the potential of radiomics in understanding and potentially predicting treatment response and prognosis in metastatic lung adenocarcinoma patients.

Unraveling the Core Components and Critical Targets of Houttuynia cordata Thunb. in Treating Non-small Cell Lung Cancer through Network Pharmacology and Multi-omics Analysis

OBJECTIVE

This study aimed to preliminary explore the molecular mechanisms of Houttuynia cordata Thunb. (H. cordata; Saururaceae) in treating non-small cell lung cancer (NSCLC), with the goal of screening drug potential targets for clinical drug development.

METHODS

This study employed a multi-omics and multi-source data integration approach to identify potential therapeutic targets of H. cordata against NSCLC from the TCMSP database, GEO database, BioGPS database, Metascape database, and others. Meanwhile, target localization was performed, and its possible mechanisms of action were predicted. Furthermore, dynamics simulations and molecular docking were used for verification. Multi-omics analysis was used to confirm the selected key genes' efficacy in treating NSCLC.

RESULTS

A total of 31 potential therapeutic targets, 8 key genes, and 5 core components of H. cordata against NSCLC were screened out. These potential therapeutic targets played a therapeutic role mainly by regulating lipid and atherosclerosis, the TNF signaling pathway, the IL-17 signaling pathway, and others. Molecular docking indicated a stable combination between MMP9 and quercetin. Finally, through multi-omics analysis, it was found that the expression of some key genes was closely related not only to the progression and prognosis of NSCLC but also to the level of immune infiltration.

CONCLUSION

Through comprehensive network pharmacology and multi-omics analysis, this study predicts that the core components of H. cordata play a role in treating NSCLC by regulating lipid and atherosclerosis, as well as the TNF signaling pathway. Among them, the anti-NSCLC activity of isoramanone is reported for the first time.

Striated muscle: an inadequate soil for cancers

Many organs of the body are susceptible to cancer development. However, striated muscles-which include skeletal and cardiac muscles-are rarely the sites of primary cancers. Most deaths from cancer arise due to complications associated with the development of secondary metastatic tumours, for which there are few effective therapies. However, as with primary cancers, the establishment of metastatic tumours in striated muscle accounts for a disproportionately small fraction of secondary tumours, relative to the proportion of body composition. Examining why primary and metastatic cancers are comparatively rare in striated muscle presents an opportunity to better understand mechanisms that can influence cancer cell biology. To gain insights into the incidence and distribution of muscle metastases, this review presents a definitive summary of the 210 case studies of metastasis in muscle published since 2010. To examine why metastases rarely form in muscles, this review considers the mechanisms currently proposed to render muscle an inhospitable environment for cancers. The "seed and soil" hypothesis proposes that tissues' differences in susceptibility to metastatic colonization are due to differing host microenvironments that promote or suppress metastatic growth to varying degrees. As such, the "soil" within muscle may not be conducive to cancer growth. Gaining a greater understanding of the mechanisms that underpin the resistance of muscles to cancer may provide new insights into mechanisms of tumour growth and progression, and offer opportunities to leverage insights into the development of interventions with the potential to inhibit metastasis in susceptible tissues.

Thoracic SMARCA4-Deficient Undifferentiated Tumor in a 40-Year-Old Male Welder With No Smoking History

Thoracic SMARCA4-deficient undifferentiated tumor (TSDUT) is a rare and quite new classification of primary pulmonary malignancy. It is classified as a non-small cell lung cancer, typically associated with smoking, and is highly aggressive. Its clinical features, immunohistochemistry, and pathology are quite unique. In this case report, we describe the clinical course of TSDUT pancoast tumor in a 40-year-old male, without a substantial smoking history, but a significant history of occupational welding.

Advanced non-squamous NSCLC with no actionable oncogenic driver in Spain: a cross-sectional descriptive analysis of data from the Thoracic Tumor Registry

BACKGROUND

Non-small cell lung cancer (NSCLC) accounts for the vast majority of all diagnosed lung cancers. According to their histology, most NSCLCs are considered non-squamous cell carcinoma (NSCC), and up to 85% of the latter may lack either one of the two main actionable oncogenic drivers (i.e., EGFR mutations and ALK rearrangements).

OBJECTIVE

Our analysis aimed to describe the clinical and epidemiological characteristics of Spanish patients suffering from NSCC with no actionable oncogenic driver in daily clinical practice.

DESIGN

A retrospective, cross-sectional, descriptive analysis.

METHODS

We analyzed the records of all Spanish patients with advanced NSCC diagnosed between January 2011 and January 2020 and included in the Spanish Thoracic Tumor Registry database. We evaluated the presence of metastasis and molecular profiling at the time of diagnosis and treatments received. We also assessed overall survival (OS) and progression-free survival (PFS) according to first-line treatment.

RESULTS

One thousand seven hundred ninety-seven Spanish patients with NSCC were included. They were mainly men (73.2%), smokers (current [44.4%] and former [44.4%]) and presented adenocarcinoma histology (97.6%). Most patients had at least one comorbidity (80.4%) and one metastatic site (96.8%), and a non-negligible number of those tested were PD-L1 positive (35.2%). Notably, the presence of liver metastasis indicated a shorter median OS and PFS than metastasis in other locations (p < 0.001). Chemotherapy was more often prescribed than immunotherapy as first-, second-, and third-line treatment in that period. In first-line, the OS rates were similar in patients receiving either regimen, but PFS rates significantly better in patients treated with immunotherapy (p = 0.026). Also, a high number of patients did not reach second- and third-line treatment, suggesting the failure of current early diagnostic measures and therapies.

CONCLUSIONS

This analysis of the most lethal tumor in Spain could highlight the strengths and the weaknesses of its clinical management and set the ground for further advances and research.

Treatment Options for Patients with Non-Small Cell Lung Cancer and Liver Metastases

Lung cancer represents the most common cause of cancer-related death. Patients with non-small cell lung cancer (NSCLC) and liver metastases have worse prognosis, with an overall survival (OS) from three to six months. The majority of them have a poor response to chemotherapy, and the data are controversial regarding the response to immunotherapy. This could be because the liver is considered to be an immune-tolerant organ, which is characterized by T-cell anergy and immunosuppressive signals. This review evaluates current treatment options for patients with NSCLC and liver metastases. Combination therapies might be a better treatment option for this subgroup of patients. The addition of radiotherapy to immunotherapy could also be an option in selected patients. The resection of single liver metastasis should also be considered.

Intra-tumoral YAP and TAZ heterogeneity drives collective NSCLC invasion that is targeted by SUMOylation inhibitor TAK-981

Non-small cell lung cancer (NSCLC) collective invasion is supported by cooperativity of proliferative (follower) and invasive (leader) cells. H1299-isolated follower cells exhibit higher Yes-associated protein (YAP) expression, while leader cells were found to express elevated transcriptional coactivator with PDZ-binding motif (TAZ/WWTR1) expression. Suppressing TAZ (not YAP) in leader cells reduced invasion. TAZ-regulated leader cell invasion is associated with activation of the EGFR-PI3K-AKT axis. NSCLC patient samples also demonstrated heterogeneity in YAP and TAZ expression. YAP and TAZ regulate proliferation of follower and leader cells. Our results highlight the need to inhibit both YAP and TAZ to effectively target their regulation of collective invasion. We identify that the SUMOylation inhibitor TAK-981 reduces YAP and TAZ expression, decreasing tumor burden and metastasis in a murine NSCLC model. Our study reveals an intra-tumoral division of labor, driven by differential YAP and TAZ expression, which can be effectively targeted with TAK-981 for NSCLC therapy.

Cyproheptadine inhibits in vitro and in vivo lung metastasis and drives metabolic rewiring

BACKGROUND

Non-small cell lung cancer (NSCLC) accounts for 81% of lung cancer cases, among which over 47% presented with distant metastasis at the time of diagnosis. Despite the introduction of targeted therapy and immunotherapy, enhancing the survival rate and overcoming the development of resistance remain a big challenge. Thus, it is crucial to find potential new therapeutics and targets that can mitigate lung metastasis and investigate its effects on biomarkers, such as cellular metabolomics. In the current study, we investigated the role of cyproheptadine (CPH), an FDA-approved anti-histamine drug in lung metastasis in vitro and in vivo.

METHODS AND RESULTS

CPH showed potent cytotoxicity on different lung cancer cell lines in vitro. Moreover, CPH decreased invasion and migration of LLC1 and A549 cells in Matrigel invasion transwell and plate scratch assays. The in vivo LLC1 syngeneic lung cancer model found decreased number of metastatic nodules on the surface of lungs of Setd7 KO mice compared to SETD7 WT. CPH treatment resulted in decreased growth of LLC1 subcutaneous tumors compared to untreated SETD7 WT. Finally, metabolomic study of tumor tissues showed rewiring of metabolomic pathways and downregulation of amino acids, such as arginine, serine, and glycine) in Setd7 KO and WT treated with CPH compared to untreated Setd7 WT mice.

CONCLUSION

These findings identify CPH as a potential therapeutic agent to block metastasis in advanced NSCLC and suggest SETD7 as a potential target for the prevention of lung metastasis.

Single- and multi-site radiomics may improve overall survival prediction for patients with metastatic lung adenocarcinoma

PURPOSE

The purpose of this study was to assess whether single-site and multi-site radiomics could improve the prediction of overall survival (OS) of patients with metastatic lung adenocarcinoma compared to clinicopathological model.

MATERIALS AND METHODS

Adults with metastatic lung adenocarcinoma, pretreatment whole-body contrast-enhanced computed tomography examinations, and performance status (WHO-PS) ≤ 2 were included in this retrospective single-center study, and randomly assigned to training and testing cohorts. Radiomics features (RFs) were extracted from all measurable lesions with volume ≥ 1 cm3. Radiomics prognostic scores based on the largest tumor (RPSlargest) and the average RF values across all tumors per patient (RPSaverage) were developed in the training cohort using 5-fold cross-validated LASSO-penalized Cox regression. Intra-patient inter-tumor heterogeneity (IPITH) metrics were calculated to quantify the radiophenotypic dissimilarities among all tumors within each patient. A clinicopathological model was built in the training cohort using stepwise Cox regression and enriched with combinations of RPSaverage, RPSlargest and IPITH. Models were compared with the concordance index in the independent testing cohort.

RESULTS

A total of 300 patients (median age: 63.7 years; 40.7% women; median OS, 16.3 months) with 1359 lesions were included (200 and 100 patients in the training and testing cohorts, respectively). The clinicopathological model included WHO-PS = 2 (hazard ratio [HR] = 3.26; P < 0.0001), EGFR, ALK, ROS1 or RET mutations (HR = 0.57; P = 0.0347), IVB stage (HR = 1.65; P = 0.0211), and liver metastases (HR = 1.47; P = 0.0670). In the testing cohort, RPSaverage, RPSlargest and IPITH were associated with OS (HR = 85.50, P = 0.0038; HR = 18.83, P = 0.0082 and HR = 8.00, P = 0.0327, respectively). The highest concordance index was achieved with the combination of clinicopathological variables and RPSaverage, significantly better than that of the clinicopathological model (concordance index = 0.7150 vs. 0.695, respectively; P = 0.0049) CONCLUSION: Single-site and multi-site radiomics-based scores are associated with OS in patients with metastatic lung adenocarcinoma. RPSaverage improves the clinicopathological model.

Concurrent sarcoidosis and metastatic lung cancer in a patient with ring-enhancing brain lesions

This case discusses a male in his 40s with no prior medical history who presented to the emergency room with headaches and blurred vision and was found to have ring-enhancing lesions on brain MRI. Chest imaging revealed bilateral pulmonary nodules with a dominant right upper lobe nodule. On lung tissue sampling, he was found to have concurrent sarcoidosis and non-small cell lung cancer. Initial brain biopsy showed non-specific vascular lesions and inflammation which were initially thought secondary to sarcoidosis since there was no evidence of malignancy. However, given the importance of a definitive diagnosis to establish prognosis, repeat brain biopsy was pursued, which confirmed metastatic lung cancer. This case demonstrates the benefits of repeat biopsy in situations where clinical suspicion for malignancy is high, as well as the possibility for multiple concurrent diagnoses in a patient. The patient is currently undergoing stereotactic radiosurgery and chemotherapy with carboplatin, pemetrexed and pembrolizumab.

Assessing the metastatic potential of circulating tumor cells using an organ-on-chip model

Metastatic lung cancer remains a leading cause of death worldwide, with its intricate metastatic cascade posing significant challenges to researchers and clinicians. Despite substantial progress in understanding this cascade, many aspects remain elusive. Microfluidic-based vasculature-on-chip models have emerged as powerful tools in cancer research, enabling the simulation of specific stages of tumor progression. In this study, we investigate the extravasation behaviors of A549 lung cancer cell subpopulations, revealing distinct differences based on their phenotypes. Our results show that holoclones, which exhibit an epithelial phenotype, do not undergo extravasation. In contrast, paraclones, characterized by a mesenchymal phenotype, demonstrate a notable capacity for extravasation. Furthermore, we observed that paraclones migrate significantly faster than holoclones within the microfluidic model. Importantly, we found that the depletion of vascular endothelial growth factor (VEGF) effectively inhibits the extravasation of paraclones. These findings highlight the utility of microfluidic-based models in replicating key aspects of the metastatic cascade. The insights gained from this study underscore the potential of these models to advance precision medicine by facilitating the assessment of patient-specific cancer cell dynamics and drug responses. This approach could lead to improved strategies for predicting metastatic risk and tailoring personalized cancer therapies, potentially involving the sampling of cancer cells from patients during tumor resection or biopsies.

Solitary Renal Metastases From Stage IA Primary Lung Adenocarcinoma With Co-Alteration of EGFR, RB1, and MAP3K1: A Case Report

We report a case of 59-year-old female with solitary bilateral renal metastases after surgery of stage IA primary lung adenocarcinoma who underwent next-generation sequencing (NGS) of both lesions. The patient received right upper lobectomy and lymph node dissection, which revealed primary invasive lung adenocarcinoma (pT1cN0M0, stage IA3). Two years following this, positron emission tomography-computed tomography (PET/CT) revealed multiple masses in both kidneys without other distant metastases, and ultrasonography-guided puncture biopsy indicated the presence of metastatic lung adenocarcinoma. The NGS of both the primary and metastatic lesions revealed the co-alteration of epidermal growth factor receptor (EGFR), RB transcriptional corepressor 1 (RB1), and mitogen-activated protein kinase kinase 1 (MAP3K1), which is potentially associated with the risk of renal metastasis in early postoperative non-small cell lung cancer.

Surgical indication and management of obstructive colonic metastasis from primary lung adenocarcinoma: report of a case and review of the literature

BACKGROUND

Colonic metastasis from lung cancer is very rare and is typically associated with poor prognosis. Herein, we report the case of a patient who achieved intermediate-term survival using a multimodal treatment approach, including chemotherapy, immunotherapy, radiotherapy, and surgical resection for obstructive colonic metastasis from primary lung adenocarcinoma.

CASE PRESENTATION

A woman in her 50s presented with anemia and a positive fecal occult blood test. Computed tomography revealed a tumor in the right upper lobe of the lung with mediastinal lymphadenopathy and wall thickening in the transverse colon. Colonoscopy revealed a stricture involving 50% of the colonic lumen. Biopsy revealed a poorly differentiated adenocarcinoma positive for CK-7 and TTF-1, very focally positive for napsin A, and negative for CK-20 and CDX-2. Furthermore, positron emission tomography/CT (PET/CT) showed a high maximum standardized uptake value (SUVmax) of 8.2 in the iliac bone. Based on these findings, the patient was diagnosed with primary lung adenocarcinoma with simultaneous metastasis to the transverse colon and iliac bone (cT4N3M1c, cStage IVB). After receiving first-line chemotherapy with atezolizumab, pemetrexed, and carboplatin, the tumors shrank after 4 courses. Subsequently, the patient received maintenance therapy with atezolizumab and pemetrexed. However, the tumor enlarged after 10 courses. Second-line chemotherapy with docetaxel and ramucirumab (3 courses) failed to achieve tumor reduction. Colonoscopy revealed an impassable colonic tumor. Nineteen months after diagnosis, surgery was planned for imminent intestinal obstruction. We determined that the colonic tumor was resectable, because laparoscopic exploration revealed no other metastases. The tumor was resected by partial colectomy with ileocolonic anastomosis. The postoperative course was uneventful. Pathological examination revealed a resection margin that was negative for malignancy, and the histological type was consistent with metastatic lung adenocarcinoma. The patient then received nab-paclitaxel therapy; however, she developed symptoms of superior vena cava syndrome after 3 courses. The patient received palliative irradiation (30 Gy/10 fr) followed by nivolumab. She soon developed a solitary brain metastasis, and stereotactic irradiation was planned. After 3 courses of nivolumab, the metastasis was reduced significantly, and stereotactic brain irradiation was canceled. The lung tumor and mediastinal lymphadenopathy gradually shrank, and the patient survived for 13 months after surgery without disease progression.

CONCLUSIONS

In this case, surgical resection of colonic metastasis from primary lung adenocarcinoma may have contributed to the short-term prognosis as a bridge-to-next available multimodal treatment.

Stage IV non-small cell lung cancer with multiple metastases to the small intestine leading to intussusception: A case report

BACKGROUND

Gastrointestinal tract metastasis from lung cancer is rare and compared to small cell lung cancer (SCLC), non-SCLC (NSCLC) is even less likely to metastasize in this manner. Additionally, small intestinal tumors can also present with diverse complications, some of which require urgent intervention.

CASE SUMMARY

In this report, we detail a unique case of stage IV lung cancer, where the presence of small intestine tumors led to intussusception. Subsequent to a small intestine resection, pathology confirmed that all three tumors within the small intestine were metastases from adenocarcinoma of the lung. The postoperative follow-up period extended beyond 14 mo.

CONCLUSION

In patients with stage IV NSCLC, local tumor control can be achieved with various treatments. However, if small intestinal metastasis occurs, surgical intervention remains necessary, as it may improve survival.

Case Report: Lung cancer with rare cardiac and other multiple metastases

Metastasis to the left atrium is exceptionally uncommon, occurring at a rate of only 3.1%. The clinical manifestations of lung cancer metastasizing to the heart can vary widely. They range from paraneoplastic syndrome, dyspnea, and ST-segment elevation on an electrocardiogram to no clinically significant symptoms. Diverging from typical metastatic patterns observed in lung cancer, this case report presents a detailed description, from the perspective of the microenvironment, of a rare instance where lung cancer metastasized to the mediastinal lymph nodes, adrenal glands, brain, and notably, the left atrium, in a non-smoking female patient.

Improved Prediction of Epidermal Growth Factor Receptor Status by Combined Radiomics of Primary Nonsmall-Cell Lung Cancer and Distant Metastasis

OBJECTIVES

This study aimed to investigate radiomics based on primary nonsmall-cell lung cancer (NSCLC) and distant metastases to predict epidermal growth factor receptor (EGFR) mutation status.

METHODS

A total of 290 patients (mean age, 58.21 ± 9.28) diagnosed with brain (BM, n = 150) or spinal bone metastasis (SM, n = 140) from primary NSCLC were enrolled as a primary cohort. An external validation cohort, consisting of 69 patients (mean age, 59.87 ± 7.23; BM, n = 36; SM, n = 33), was enrolled from another center. Thoracic computed tomography-based features were extracted from the primary tumor and peritumoral area and selected using the least absolute shrinkage and selection operator regression to build a radiomic signature (RS-primary). Contrast-enhanced magnetic resonance imaging-based features were calculated and selected from the BM and SM to build RS-BM and RS-SM, respectively. The RS-BM-Com and RS-SM-Com were developed by integrating the most important features from the primary tumor, BM, and SM.

RESULTS

Six computed tomography-based features showed high association with EGFR mutation status: 3 from intratumoral and 3 from peritumoral areas. By combination of features from primary tumor and metastases, the developed RS-BM-Com and RS-SM-Com performed well with areas under curve in the training (RS-BM-Com vs RS-BM, 0.936 vs 0.885, P = 0.177; RS-SM-Com vs RS-SM, 0.929 vs 0.843, P = 0.003), internal validation (RS-BM-Com vs RS-BM, 0.920 vs 0.858, P = 0.492; RS-SM-Com vs RS-SM, 0.896 vs 0.859, P = 0.379), and external validation (RS-BM-Com vs RS-BM, 0.882 vs 0.805, P = 0.263; RS-SM-Com vs RS-SM, 0.865 vs 0.816, P = 0.312) cohorts.

CONCLUSIONS

This study indicates that the accuracy of detecting EGFR mutations significantly enhanced in the presence of metastases in primary NSCLC. The established radiomic signatures from this approach may be useful as new predictors for patients with distant metastases.

Camrelizumab combined with chemotherapy for stage IV pulmonary sarcomatoid cancer with pancreatic metastases

The pancreas is a rare metastatic site for lung cancer. We report the case of a 66-year-old male with pulmonary sarcomatoid carcinoma (PSC) with pancreatic and right posterior renal fascia metastases treated with immunotherapy and platinum-based chemotherapy. A pathological biopsy of the right posterior fascial mass showed lung invasive adenocarcinoma and sarcomatoid carcinoma metastasis. Immunohistochemistry staining showed that PD- L1 expression was high and next-generation sequencing revealed KRAS and TP53 mutations. Camrelizumab and chemotherapy were administered, and the metastasis disappeared. Immunotherapy combined with platinum-based chemotherapy is effective in treating PSC with pancreatic metastases.

Clinical utility of repeated rebiopsy for EGFR T790M mutation detection in non-small cell lung cancer

Purpose

In cases where rebiopsy fails to find the epidermal growth factor receptor (EGFR) T790M mutation, the criteria for selecting patients for repeated rebiopsy remains unclear. This study aimed to assess the impact of repeated rebiopsy on T790M mutation detection in non-small cell lung cancer (NSCLC) patients.

Methods

Patients with advanced EGFR-mutated NSCLC between January 2018 and December 2021 at three-referral hospitals in South Korea underwent retrospective review. Of 682 patients who had rebiopsy after disease progression, T790M mutation status was assessed in plasma circulating tumor DNA (ctDNA) and/or tumor tissues.

Results

The overall T790M positivity rate increased from 40.8% after the first rebiopsy to 52.9% following multiple rebiopsies in the entire study population. Longer duration of initial EGFR TKI use (OR 1.792, ≥8 months vs. <8 months, p=0.004), better EGFR TKI responses (OR 1.611, complete or partial response vs. stable disease, p=0.006), presence of bone metastasis (OR 2.286, p<0.001) were correlated with higher T790M positivity. Longer EGFR TKI use and better responses increased T790M positivity in repeated tissue rebiopsy, while bone metastasis favored liquid rebiopsy. Additionally, T790M status has been shown to be positive over time through repeated rebiopsies ranging from several months to years, suggesting its dynamic nature.

Conclusion

In this study, among patients who initially tested negative for T790M in rebiopsy, repeated rebiopsies uncovered an additional 23.5% T790M positivity. Particularly, it is suggested that repeated rebiopsies may be valuable for patients with prolonged EGFR TKI usage, better responses to treatment, and bone metastasis.

Ivonescimab Plus Chemotherapy in Non-Small Cell Lung Cancer With EGFR Variant: A Randomized Clinical Trial

Importance

For patients with non-small cell lung cancer whose disease progressed while receiving EGFR tyrosine kinase inhibitor (EGFR-TKI) therapy, particularly third-generation TKIs, optimal treatment options remain limited.

Objective

To compare the efficacy of ivonescimab plus chemotherapy with chemotherapy alone for patients with relapsed advanced or metastatic non-small cell lung cancer with the epidermal growth factor receptor (EGFR) variant.

Design, Setting, and Participants

Double-blind, placebo-controlled, randomized, phase 3 trial at 55 sites in China enrolled participants from January 2022 to November 2022; a total of 322 eligible patients were enrolled.

Interventions

Participants received ivonescimab (n = 161) or placebo (n = 161) plus pemetrexed and carboplatin once every 3 weeks for 4 cycles, followed by maintenance therapy of ivonescimab plus pemetrexed or placebo plus pemetrexed.

Main Outcomes and Measures

The primary end point was progression-free survival in the intention-to-treat population assessed by an independent radiographic review committee (IRRC) per Response Evaluation Criteria in Solid Tumors version 1.1. The results of the first planned interim analysis are reported.

Results

Among 322 enrolled patients in the ivonescimab and placebo groups, the median age was 59.6 vs 59.4 years and 52.2% vs 50.9% of patients were female. As of March 10, 2023, median follow-up time was 7.89 months. Median progression-free survival was 7.1 (95% CI, 5.9-8.7) months in the ivonescimab group vs 4.8 (95% CI, 4.2-5.6) months for placebo (difference, 2.3 months; hazard ratio [HR], 0.46 [95% CI, 0.34-0.62]; P < .001). The prespecified subgroup analysis showed progression-free survival benefit favoring patients receiving ivonescimab over placebo across almost all subgroups, including patients whose disease progressed while receiving third-generation EGFR-TKI therapy (HR, 0.48 [95% CI 0.35-0.66]) and those with brain metastases (HR, 0.40 [95% CI, 0.22-0.73]). The objective response rate was 50.6% (95% CI, 42.6%-58.6%) with ivonescimab and 35.4% (95% CI, 28.0%-43.3%) with placebo (difference, 15.6% [95% CI, 5.3%-26.0%]; P = .006). The median overall survival data were not mature; at data cutoff, 69 patients (21.4%) had died. Grade 3 or higher treatment-emergent adverse events occurred in 99 patients (61.5%) in the ivonescimab group vs 79 patients (49.1%) in the placebo group, the most common of which were chemotherapy-related. Grade 3 or higher immune-related adverse events occurred in 10 patients (6.2%) in the ivonescimab group vs 4 (2.5%) in the placebo group. Grade 3 or higher vascular endothelial growth factor-related adverse events occurred in 5 patients (3.1%) in the ivonescimab group vs 4 (2.5%) in the placebo group.

Conclusions

Ivonescimab plus chemotherapy significantly improved progression-free survival with tolerable safety profile in TKI-treated non-small cell lung cancer.

Trial Registration

ClinicalTrials.gov Identifier: NCT05184712.

SMC2 knockdown inhibits malignant progression of lung adenocarcinoma by upregulating BTG2 expression

Lung adenocarcinoma (LUAD) is the most prevalent subtype of lung cancer worldwide. Structural maintenance of chromosomes 2 (SMC2) serves as a predictor of poor prognosis across various cancer types. This study aims to explore the role and underlying mechanisms of SMC2 in LUAD progression. The expression of SMC2 in LUAD tissues and its correlation with prognosis were analyzed by public databases. Knockdown of SMC2 was performed to assess the proliferation, migration and invasion ability of LUAD cells. Bulk RNA sequencing analysis identified enriched cellular pathways and remarkable upregulation of BTG anti-proliferation factor 2 (BTG2) expression after SMC2 knockdown in LUAD cells. Then, BTG2 was silenced to assess the malignant behavior of LUAD cells. Subcutaneous transplantation and intracranial tumor models of LUAD cells in BALB/c nude mice were established to assess the antineoplastic effect of SMC2 knockdown in vivo. Additionally, a lung metastasis model was created to evaluate the pro-metastatic effect of SMC2. Our findings indicated that SMC2 was upregulated in LUAD tissues and cell lines, with higher expression correlating with poor prognosis. SMC2 silencing suppressed the proliferation, migration and invasion ability of LUAD cells by upregulating BTG2 expression via p53 and inactivating ERK and AKT pathways. BTG2 silencing reversed the effects of SMC2 downregulation on malignant behaviors of LUAD cells and restored the phosphorylated ERK and AKT levels. Furthermore, SMC2 knockdown effectively prevented the formation of subcutaneous, intracranial and metastatic tumor in vivo, and upregulation of BTG2 expression after SMC2 knockdown was confirmed in tumor models. This study revealed that SMC2 knockdown restrained the malignant progression of LUAD through upregulation of BTG2 expression and inactivation of ERK and AKT pathways, and SMC2 could be a potential therapeutic target for LUAD treatment.

Capture of circulating metastatic cancer cell clusters from lung cancer patients can reveal unique genomic profiles and potential anti-metastatic molecular targets: A proof-of-concept study

Metastasis remains the leading cause of cancer deaths worldwide and lung cancer, known for its highly metastatic progression, remains among the most lethal of malignancies. Lung cancer metastasis can selectively spread to multiple different organs, however the genetic and molecular drivers for this process are still poorly understood. Understanding the heterogeneous genomic profile of lung cancer metastases is considered key in identifying therapeutic targets that prevent its spread. Research has identified the key source for metastasis being clusters of cells rather than individual cancer cells. These clusters, known as metastatic cancer cell clusters (MCCCs) have been shown to be 100-fold more tumorigenic than individual cancer cells. Unfortunately, access to these primary drivers of metastases remains difficult and has limited our understanding of their molecular and genomic profiles. Strong evidence in the literature suggests that differentially regulated biological pathways in MCCCs can provide new therapeutic drug targets to help combat cancer metastases. In order to expand research into MCCCs and their role in metastasis, we demonstrate a novel, proof of principle technology, to capture MCCCs directly from patients' whole blood. Our platform can be readily tuned for different solid tumor types by combining a biomimicry-based margination effect coupled with immunoaffinity to isolate MCCCs. Adopting a selective capture approach based on overexpressed CD44 in MCCCs provides a methodology that preferentially isolates them from whole blood. Furthermore, we demonstrate a high capture efficiency of more than 90% when spiking MCCC-like model cell clusters into whole blood. Characterization of the captured MCCCs from lung cancer patients by immunofluorescence staining and genomic analyses, suggests highly differential morphologies and genomic profiles. This study lays the foundation to identify potential drug targets thus unlocking a new area of anti-metastatic therapeutics.

Clinicopathological significance of mutation profile detected by next generation sequencing in different metastatic organs of non-small cell lung cancers

BACKGROUND

The primary tumor and it's metastases show heterogeneity in molecular studies for targeted therapies in Non-Small Cell Lung Cancer(NSCLC), the leading cause of cancer-related deaths worldwide. The study aimed to identify somatic mutations in biopsies from NSCLC patients' metastatic organs using Next-Generation Sequencing(NGS) and examine their association with clinicopathological parameters.

MATERIALS AND METHODS

The study included 128 NSCLC patients and, NGS was performed on tumor biopsies from different metastatic organs at Molecular Pathology laboratory of the Department of Medical Pathology in Aydın Adnan Menderes University Faculty of Medicine. The age, gender, histopathological diagnoses, metastatic organs, smoking and mutation status were all recorded, along with the analysis results of 72 genes and 4149 primers in the panel of the NGS system.

RESULTS

53.9 % of the cases had a history of smoking and patients with brain metastases had a higher smoking rate(p=0.000). The most common occurrence(39.8 %) was lymph node metastasis, followed by brain(19.5 %). There was a strong correlation between mutation presence and metastasis in the liver(p=0.012), bone(p=0.002), and pleura(p=0.008). Smokers had a higher frequency of KRAS(p=0.000) and TP53(p=0.001) mutations. Brain metastases showed a statistically significant NF1 mutation(p=0.001), while the liver exhibited a significant BRAF mutation(p=0.000). NF1-TP53, PTEN-TP53 and NF1-PTEN were the most common concomitant mutations and, the brain was the most common metastatic organ in which they occurred.

CONCLUSION

Our results suggest prizing assessing detected mutations, in the prediction, follow-up and management of metastases, especially in patients with lung adenocarcinoma. The assessment also needs to consider the tumor's mutation status in metastatic organs. New therapeutic agents targeting NF1 mutations will be available in the future to treat NSCLC, especially in metastases.

A Case of Primary Lung Adenocarcinoma With Metastasis to Colon Harboring EGFR Exon 19 Deletion

Lung cancer metastasizing to the colon is exceedingly rare and can present similarly to colorectal cancer. It is crucial to conduct further evaluations using immunohistochemical (IHC) stains and genomic testing to differentiate between the two and provide appropriate treatment without delay. Lung cancer generally has a poor prognosis, especially in cases with distant metastases. Although gastrointestinal (GI) metastases from lung cancer have been reported, cases of lung cancer manifesting as colon metastasis are extremely rare, with only a few instances documented.

A novel algorithm to differentiate between primary lung tumors and distant liver metastasis in lung cancers using an exosome based multi gene biomarker panel

The lack of non-invasive methods for detection of early metastasis is a crucial reason for the poor prognosis of lung cancer (LC) liver metastasis (LM) patients. In this study, the goal was to identify circulating biomarkers based on a biomarker model for the early diagnosis and monitoring of patients with LCLM. An 8-gene panel identified in our previous study was validated in CTC, cfRNA and exosomes isolated from primary lung cancer with & without metastasis. Further multivariate analysis including PCA & ROC was performed to determine the sensitivity and specificity of the biomarker panel. Model validation cohort (n = 79) was used to verify the stability of the constructed predictive model. Further, clinic-pathological factors, survival analysis and immune infiltration correlations were also performed. In comparison to our previous tissue data, exosomes demonstrated a good discriminative value with an AUC of 0.7247, specificity (72.48%) and sensitivity (96.87%) for the 8-gene panel. Further individual gene patterns led us to a 5- gene panel that showed an AUC of 0.9488 (p =  < 0.001) and 0.9924 (p =  < 0.001) respectively for tissue and exosomes. Additionally, on validating the model in a larger cohort a risk score was obtained (RS > 0.2) for prediction of liver metastasis with an accuracy of 95%. Survival analysis and immune filtration markers suggested that four exosomal markers were independently associated with poor overall survival. We report a novel blood-based exosomal biomarker panel for early diagnosis, monitoring of therapeutic response, and prognostic evaluation of patients with LCLM.

Investigating socioeconomic disparities in lung cancer diagnosis, treatment and mortality: an Italian cohort study

BACKGROUND

Lung cancer is one of the most lethal cancers worldwide and patient clinical outcomes seem influenced by their socioeconomic position (SEP). Since little has been investigated on this topic in the Italian context, our aim was to investigate the role of SEP in the care pathway of lung cancer patients in terms of diagnosis, treatment and mortality.

METHODS

This observational retrospective cohort study included patients discharged in the Lazio Region with a lung cancer diagnosis between 2014 and 2017. In the main analysis, educational level was used as SEP measure. Multivariate models, adjusted for demographic and clinical variables, were applied to evaluate the association between SEP and study outcomes, stratified for metastatic (M) and non-metastatic (NM) cancer. We defined a diagnosis as 'delayed' when patients received their initial cancer diagnosis after an emergency department admission. Access to advanced lung cancer treatments (high-cost, novel and innovative treatments) and mortality were investigated within the 24-month period post-diagnosis. Moreover, two additional indicators of SEP were examined in the sensitivity analysis: one focusing on area deprivation and the other on income-based exemption.

RESULTS

A total of 13,251 patients were identified (37.3% with metastasis). The majority were males (> 60%) and over half were older than 70 years. The distribution of SEP levels among patients was as follow: 31% low, 29% medium-low, 32% medium-high and 7% high. As SEP increased, the risks of receiving a delayed diagnosis ((high vs low: M: OR = 0.29 (0.23-0.38), NM: OR = 0.20 (0.16-0.25)) and of mortality ((high vs low M: OR = 0.77 (0.68-0.88) and NM: 0.61 (0.54-0.69)) decreased. Access to advanced lung cancer treatments increased in accordance with SEP only in the M cohort (high vs low: M: OR = 1.57 (1.18-2.09)). The primary findings were corroborated by sensitivity analysis.

CONCLUSIONS

Our study highlighted the need of public health preventive and educational programs in Italy, a country where the care pathway of lung cancer patients, especially in terms of diagnosis and mortality, appears to be negatively affected by SEP level.

Site-Specific Response and Resistance Patterns in Patients with Advanced Non-Small-Cell Lung Cancer Treated with First-Line Systemic Therapy

Patients with advanced NSCLC have heterogenous responses to immune checkpoint inhibitors (ICIs) with or without chemotherapy. In NSCLC, the impact of the distribution of metastatic sites and the response to systemic therapy combinations remain poorly understood. In a retrospective cohort study of patients with unresectable stage III/IV NSCLC who received first-line systemic therapy, we sought to assess the association between the site of metastases with patterns of response and progression. Data regarding demographics, tumour characteristics (including site, size, and volume of metastases), treatment, and outcomes were examined at two cancer care centres. The endpoints included organ site-specific response rate, objective response rate (ORR), progression-free survival (PFS), and overall survival (OS). Two-hundred and eighty-five patients were included in the analysis. In a multivariate analysis, patients with bone metastases had a reduced ORR, PFS, and OS. Primary resistance was also more likely in patients with bone metastases. Patients with bone or liver metastases had a shorter OS when receiving ICIs with or without chemotherapy, but not with chemotherapy alone, suggesting an immunological basis for therapeutic resistance. A directed assessment of the tumour microenvironment in these locations and a deeper understanding of the drivers of organ-specific resistance to immunotherapy are critical to optimise novel combination therapies and sequencing in these patients.

Single organ metastatic sites in non-small cell lung cancer: Patient characteristics, treatment patterns and outcomes from a large retrospective Canadian cohort

BACKGROUND

There is a paucity of information about the characteristics, treatment patterns, and outcomes of non-small cell lung cancer (NSCLC) patients with single organ metastasis (SOM).

METHODS

This retrospective cohort study includes all patients with a diagnosis of stage IV NSCLC diagnosed from 2014 to 2016 and treated at Princess Margaret Cancer Centre. We compared baseline characteristics and patterns of metastatic sites between patients with SOM versus multiple (M)OM. Additionally, we identified treatment modalities and outcomes for patients with SOM. Cox multivariable models (MVA) were utilized to evaluate differences in overall survival (OS) between the SOM and MOM cohorts.

RESULTS

Of 893 pts analyzed, 457 (51 %) had SOM, while 436 (49 %) had MOM at initial diagnosis. Demographics were comparable between the two groups. Brain was the most common site of metastasis for SOM patients. When compared to the MOM group, the SOM group had lower percentages of liver and adrenal metastases. Amongst SOM patients, 54 % received single modality treatment, and 20 % did not receive any treatment for their SOM. In MVA, patients with liver (HR 2.4), bone (HR 1.8), and pleural (HR 1.7) metastasis as their SOM site had the worst outcomes, with median OS of 6.8 months, 12.1 months, and 13.0 months respectively. Patients with SOM had a significantly improved median OS compared to those with MOM (15.9 months vs. 10.6 months; HR 0.56, 95 % CI 0.47-0.66, p < 0.001).

CONCLUSION

In NSCLC patients who presented with SOM, survival correlated with the initial organ involved and was better overall compared to patients with MOM. SOM NSCLC may benefit from specific management strategies and SOM patients could be considered as a specific subgroup for survival analyses in observational and non-randomized interventional studies. In clinical trials, SOM can be considered as a stratification factor in the future.

T-plastin contributes to epithelial-mesenchymal transition in human lung cancer cells through FAK/AKT/Slug axis signaling pathway

T-plastin (PLST), a member of the actin-bundling protein family, plays crucial roles in cytoskeletal structure, regulation, and motility. Studies have shown that the plastin family is associated with the malignant characteristics of cancer, such as circulating tumor cells and metastasis, by inducing epithelialmesenchymal transition (EMT) in various cancer cells. However, the role of PLST in the EMT of human lung cancer cells remains unclear. In this study, we observed that PLST overexpression enhanced cell migratory and invasive abilities, whereas its downregulation resulted in their suppression. Moreover, PLST expression levels were associated with the expression patterns of EMT markers, including E-cadherin, vimentin, and Slug. Furthermore, the phosphorylation levels of focal adhesion kinase (FAK) and AKT serine/threonine kinase (AKT) were dependent on PLST expression levels. These findings indicate that PLST induces the migration and invasion of human lung cancer cells by promoting Slug-mediated EMT via the FAK/AKT signaling pathway. [BMB Reports 2024; 57(6): 305-310].

Investigation of the pan-cancer property of FNDC1 and its molecular mechanism to promote lung adenocarcinoma metastasis

BACKGROUND

Fibronectin type III domain containing 1 (FNDC1) has been associated with the metastasis of many tumors, but its function in lung cancer remains uncertain.

METHODS

FNDC1 expression was analyzed in The Cancer Genome Atlas (TCGA) and Genotype-Tissue Expression (GTEx), evaluate its prognostic value. Gene Set Enrichment Analysis (GSEA) enrichment analysis of differential expression of FNDC1 in lung cancer. The expression of FNDC1 was detected in five types of lung cancer cells, and screened to establish FNDC1 stable knockdown cell strains. To observe the migration and invasion ability of lung cancer cells after FNDC1 knockdown. Finally, we used rhIL-6 to interfere with the stable knockdown of FNDC1 in A549 cells and observed the recovery of migration and invasion.

RESULT

Our results showed that FNDC1 expression was increased in 21 tumor tissues, including lung cancer, and was associated with poor prognosis in five cancers, including lung adenocarcinoma (LUAD) (P < 0.05). GSEA enrichment analysis showed that FNDC1 was related to the pathways involved the JAK-STAT signaling pathway. Stable knockdown of FNDC1 in A549 and H292 cells resulted in decreased migration and invasion ability of both cells, accompanied by decreased expression of MMP-2 and Snail, and a significant decline in the expression of p-JAK2 and p-STAT3. The suppressive effect of FNDC1 knockdown on lung cancer cell metastasis counteracted by the JAK-STAT agonist rhIL-6 were presented in the nude mouse metastatic tumor model.

CONCLUSION

FNDC1 is implicated in poor prognosis of a diverse range of malignant tumors, which can promote metastasis and invasion of lung cancer through the JAK2-STAT3 signaling pathway.

Assessing EGFR-mutated NSCLC with bone metastasis: Clinical features and optimal treatment strategy

BACKGROUND

This study aimed to examine the clinical characteristics of bone metastasis (BoM) in patients with non-small cell lung cancer (NSCLC) who have an epidermal growth factor receptor (EGFR) mutation and to identify the most effective treatment strategy using EGFR-tyrosine kinase inhibitors (TKIs).

METHODS

The study included patients with stage IV EGFR-mutated NSCLC who were receiving first-line treatment with EGFR-TKIs between January 2014 and December 2020. These patients were divided into two groups based on the presence or absence of BoM at the time of initial diagnosis. The BoM group was further subdivided based on whether they received denosumab or not.

RESULTS

The final analysis included 247 patients. Those with BoM at initial diagnosis had shorter progression-free survival (12.6 vs. 10.5 months, p = 0.002) and overall survival (OS) (49.7 vs. 30.9 months, p = 0.002) compared to those without BoM. There was a difference in the location of metastatic sites between the two groups, with a higher incidence of extrathoracic metastasis in the BoM group (p < 0.001). The incidence of T790M was higher in patients with BoM than in those without (47.4% vs. 33.9%, p = 0.042). Multivariate Cox regression analysis revealed that sequential osimertinib treatment and the addition of antiangiogenic therapy (AAT) and denosumab therapy improved OS in patients with BoM.

CONCLUSIONS

The presence of BoM is a negative prognostic factor for NSCLC patients with an EGFR mutation, possibly due to the presence of extrathoracic metastases. However, adding AAT and denosumab, along with sequential osimertinib, to the treatment regimen for patients with BoM can improve survival outcomes.