The role of VEGF in the diagnosis and treatment of malignant pleural effusion in patients with non‑small cell lung cancer (Review)

Diagnostic value of CEACAM6 and HE4 in pleural fluid for malignant pleural effusion

OBJECTIVE

This study aimed to assess the diagnostic performance of carcinoembryonic antigen-related adhesion molecule 6 (CEACAM6) and human epididymis protein 4 (HE4) in pleural fluid for the detection of malignant pleural effusion (MPE).

MATERIALS AND METHODS

In this prospective study, pleural levels of CEACAM6 and HE4 were measured in two independent cohorts. The test cohort included 182 patients with exudative pleural effusions (123 malignant and 59 benign), and the validation cohort comprised 117 patients with exudative pleural effusions (65 malignant and 52 benign). Receiver operating characteristic (ROC) curves were used to assess the diagnostic performance of CEACAM6 and HE4 for MPE.

RESULTS

Both CEACAM6 and HE4 levels were significantly elevated in MPE compared to benign pleural effusion (BPE) in both cohorts (p < .001). In the test cohort, CEACAM6 and HE4 demonstrated areas under the curve (AUC) values of 0.862 and 0.826, respectively. The combination of CEACAM6 and HE4 yielded a higher AUC of 0.938 compared to either marker alone. In the validation cohort, both CEACAM6 (AUC = 0.811) and HE4 (AUC = 0.721), along with their combination (AUC = 0.834), exhibited strong diagnostic performance for MPE. Notably, in cytology-negative cases, the combination of CEACAM6 and HE4 also demonstrated a favourable diagnostic efficacy, with an AUC of 0.800. The addition of CEA to the CEACAM6/HE4 combination further improved the AUC to 0.819 (p = .04).

CONCLUSIONS

Pleural CEACAM6 and HE4 are promising biomarkers for distinguishing MPE from BPE. Their combination improves diagnostic accuracy, offering a valuable tool for MPE diagnosis, especially in challenging cases with cytology-negative pleural effusion.

Utility of atezolizumab plus bevacizumab, carboplatin, and paclitaxel combination for the treatment of advanced non-squamous non-small cell lung cancer patients with malignant pleural effusion

Background

Malignant pleural effusion (MPE) remains a negative prognostic factor in non-small cell lung cancer (NSCLC), even after the emergence of immune checkpoint inhibitors. Vascular endothelial growth factor (VEGF) plays a pivotal role in the pathogenesis of MPE. Bevacizumab, a humanized monoclonal antibody against VEGF, is a key agent for patients who develop MPE. However, it is unclear whether MPE is a poor prognostic factor in patients with advanced non-squamous NSCLC receiving treatment with the atezolizumab plus bevacizumab, carboplatin, and paclitaxel (ABCP) regimen. Moreover, the effect of ABCP on MPE control is unknown. This study aimed to elucidate the efficacy and safety of ABCP for non-squamous NSCLC patients with MPE.

Methods

We retrospectively analyzed consecutive patients with advanced non-squamous NSCLC who received treatment with ABCP (January 2019-September 2023). Patients were divided into two groups (non-MPE and MPE), and treatment outcomes were compared. In the MPE group, treatment efficacy for MPE control and toxicity were evaluated.

Results

Of the 46 patients enrolled, 17 and 29 were included in the non-MPE and MPE groups, respectively. The objective response and disease control rates were not significantly different between the non-MPE and MPE groups (76.5% vs. 51.7%, P=0.13; 88.2% vs. 82.8%, P>0.99; respectively). Similarly, the median progression-free survival and median overall survival were not significantly different (9.9 vs. 10.1 months, P=0.87; 16.0 vs. 19.9 months, P=0.87, respectively). In the MPE group, 25 patients (86.2%) achieved MPE control lasting >8 weeks from the initiation of treatment with ABCP; the median progression-free survival without an unequivocal increase in MPE was 15.0 months. The incidence rates of grade ≥3 non-immune- and immune-related adverse events were 83% and 17%, respectively. There was no treatment-related death.

Conclusions

The ABCP regimen may be a promising treatment option for non-squamous NSCLC patients with MPE.

In Vitro and In Silico Studies on 4-Nitroacetophenone Thiosemicarbazone Potential Cytotoxicity Against A549 Cell Lines

Lung malignancy is a major worldwide issue that occurs due to the dysregulation of various growth factors. Lung cancer has no apparent signs in the early stages, which makes it harder to catch it in time and leads to a higher fatality rate. So, the goal of this work was to create and analyze a novel chemical molecule called 4-nitro acetophenone thiosemicarbazone (4-NAPTSc) against the lung cancer cell line A549 and human non-tumorigenic lung epithelial cell line BAES-2B. The ligand was synthesized by refluxing the reaction mixture of 4-nitro acetophenone and thiosemicarbazide and was further characterized by UV, FTIR, and 1H and 13C NMR and Differential Scanning Calorimetry (DSC) study. Cytotoxicity assay/MTT (3-(4,5-dimethylthiazol-2-yl))2,5-diphenyltetrazolium bromide) was used to evaluate the cytotoxicity of the compound. Epidermal growth factor receptors (EGFR), polo-like kinase-1 (PLK1), and vascular endothelial growth factor receptors (VEGFR) were chosen as the target proteins for molecular docking to find potential ligand binding sites and inhibit their function. A novel yellow-colored crystalline solid has been synthesized. 4-NAPTSc had an IC50 of 2.93 μg/mL against the A549 lung cancer cells. When the dosage is increased from 5 to 15 μg/mL along with time, the cell viability falls. Docking results showed that the compound binds with the targeted proteins' amino acid residues, and the likeness profile of the compound is also favorable. This study reveals that the compound has the potential for further investigation and can be used in multitargeted cancer therapies.

Different types of tumor microvessels in stage I-IIIA squamous cell lung cancer and their clinical significance

BACKGROUND

Lung cancer (LC) is the leading cause of morbidity and mortality among malignant neoplasms. Improving the diagnosis and treatment of LC remains an urgent task of modern oncology. Previously, we established that in gastric, breast and cervical cancer, tumor microvessels (MVs) differ in morphology and have different prognostic significance. The connection between different types of tumor MVs and the progression of LC is not well understood.

AIM

To evaluate the morphological features and clinical significance of tumor MVs in lung squamous cell carcinoma (LUSC).

METHODS

A single-center retrospective cohort study examined medical records and archival paraffin blocks of 62 and 180 patients with stage I-IIIA LUSC in the training and main cohorts, respectively. All patients underwent radical surgery (R0) at the Orenburg Regional Cancer Clinic from May/20/2009 to December/14/2021. Tumor sections were routinely processed, and routine Mayer's hematoxylin and eosin staining and immunohistochemical staining for cluster of differentiation 34 (CD34), podoplanin, Snail and hypoxia-inducible factor-1 alpha were performed. The morphological features of different types of tumor MVs, tumor parenchyma and stroma were studied according to clinicopathological characteristics and LUSC prognosis. Statistical analysis was performed using Statistica 10.0 software. Univariate and multivariate logistic regression analyses were performed to identify potential risk factors for LUSC metastasis to regional lymph nodes (RLNs) and disease recurrence. Receiver operating characteristic curves were constructed to discriminate between patients with and without metastases in RLNs and those with and without disease recurrence. The effectiveness of the predictive models was assessed by the area under the curve. Survival was analyzed using the Kaplan-Meier method. The log-rank test was used to compare survival curves between patient subgroups. A value of P < 0.05 was considered to indicate statistical significance.

RESULTS

Depending on the morphology, we classified tumor vessels into the following types: normal MVs, dilated capillaries (DCs), atypical DCs, DCs with weak expression of CD34, "contact-type" DCs, structures with partial endothelial linings, capillaries in the tumor solid component and lymphatic vessels in lymphoid and polymorphocellular infiltrates. We also evaluated the presence of loose, fine fibrous connective tissue (LFFCT) and retraction clefts in the tumor stroma, tumor spread into the alveolar air spaces (AASs) and fragmentation of the tumor solid component. According to multivariate analysis, the independent predictors of LUSC metastasis in RLNs were central tumor location (P < 0.00001), the presence of retraction clefts (P = 0.003), capillaries in the tumor solid component (P = 0.023) and fragmentation in the tumor solid component (P = 0.009), whereas the independent predictors of LUSC recurrence were tumor grade 3 (G3) (P = 0.001), stage N2 (P = 0.016), the presence of LFFCT in the tumor stroma (P < 0.00001), fragmentation of the tumor solid component (P = 0.0001), and the absence of tumor spread through the AASs (P = 0.0083).

CONCLUSION

The results obtained confirm the correctness of our previously proposed classification of different types of tumor vessels and may contribute to improving the diagnosis and treatment of LUSC.

Immune modulation in malignant pleural effusion: from microenvironment to therapeutic implications

Immune microenvironment and immunotherapy have become the focus and frontier of tumor research, and the immune checkpoint inhibitors has provided novel strategies for tumor treatment. Malignant pleural effusion (MPE) is a common end-stage manifestation of lung cancer, malignant pleural mesothelioma and other thoracic malignancies, which is invasive and often accompanied by poor prognosis, affecting the quality of life of affected patients. Currently, clinical therapy for MPE is limited to pleural puncture, pleural fixation, catheter drainage, and other palliative therapies. Immunization is a new direction for rehabilitation and treatment of MPE. The effusion caused by cancer cells establishes its own immune microenvironment during its formation. Immune cells, cytokines, signal pathways of microenvironment affect the MPE progress and prognosis of patients. The interaction between them have been proved. The relevant studies were obtained through a systematic search of PubMed database according to keywords search method. Then through screening and sorting and reading full-text, 300 literatures were screened out. Exclude irrelevant and poor quality articles, 238 literatures were cited in the references. In this study, the mechanism of immune microenvironment affecting malignant pleural effusion was discussed from the perspectives of adaptive immune cells, innate immune cells, cytokines and molecular targets. Meanwhile, this study focused on the clinical value of microenvironmental components in the immunotherapy and prognosis of malignant pleural effusion.

Expression of cytokines in pleural effusions and corresponding cell lines of small cell lung cancer

Background

Small cell lung cancer (SCLC) is a neuroendocrine aggressive tumor with a dismal prognosis due to the lack of curative therapeutic modalities. Approximately 11% of these patients show a malignant pleural effusion (MPE) that increase in frequency with progression of the disease. In MPE, fluid accumulates due to leaky vessels and mesothelial surfaces as well as impaired removal of fluid due to impaired drainage.

Methods

For this investigation, three SCLC MPE samples and supernatants of the corresponding isolated cell lines were analyzed for the content of 105 cytokines, chemokines, and growth factors. Overexpressed pathways including these cytokines were identified using Reactome analysis tools.

Results

A large range of cytokines, including vascular endothelial growth factor A (VEGFA), were found to be expressed in the MPEs and conditioned media of the corresponding cell line. These mediators are involved in pathways such as interleukin (IL) signaling, growth factor stimulation, modulation of cell adhesion molecules and proliferative cell signaling. Cytokine expression by the corresponding SCLC cell lines revealed the specific contributions of the tumor cells and included high expression of VEGFA, tumor-promoting factors and mediators exerting immunosuppressive and protumor effects. MPEs used here showed marked stimulation of the proliferation of four permanent SCLC cell lines.

Conclusions

MPEs comprise a large number of cytokines with mixed activities on tumor cells and the invading SCLC cells release a number of protumor mediators and induce an immunosuppressive pleural environment.

Malignant pleural effusion: current understanding and therapeutic approach

Malignant pleural effusion (MPE) is a common complication of thoracic and extrathoracic malignancies and is associated with high mortality and elevated costs to healthcare systems. Over the last decades the understanding of pathophysiology mechanisms, diagnostic techniques and optimal treatment intervention in MPE have been greatly advanced by recent high-quality research, leading to an ever less invasive diagnostic approach and more personalized management. Despite a number of management options, including talc pleurodesis, indwelling pleural catheters and combinations of the two, treatment for MPE remains symptom directed and centered around drainage strategy. In the next future, because of a better understanding of underlying tumor biology together with more sensitive molecular diagnostic techniques, it is likely that combined diagnostic and therapeutic procedures allowing near total outpatient management of MPE will become popular. This article provides a review of the current advances, new discoveries and future directions in the pathophysiology, diagnosis and management of MPE.

Development and validation of the CAIL prognostic score in non-small cell lung cancer patients with malignant pleural effusion

BACKGROUND

Patients with malignant pleural effusion (MPE) typically have poor prognoses, and predicting survival is challenging. The present study aimed to identify prognostic factors of overall survival (OS) in non-small cell lung cancer (NSCLC) patients with MPE in the time of immunotherapy and targeted therapy.

METHODS

Data of 344 consecutive NSCLC patients with MPE on clinical, radiological, and molecular characteristics and treatment options were collected. The risk factors in the training cohort were assessed using univariate and multivariate proportional hazards analyses. A clinical prognostic score was established and validated.

RESULTS

According to the results of the multivariable survival analysis, the Eastern Cooperative Oncology Group (ECOG) performance score (PS), antiangiogenic therapy, immunotherapy, and lactic dehydrogenase (LDH) in pleural fluid (CAIL) prognostic score was developed (n = 275) and subsequently validated (n = 69). Patients who underwent risk stratification into low-, moderate-, and high-risk groups had median OS of 46.1, 23.1, and 9.6 months, respectively (P < 0.0001). The area under the curve (AUC) analysis showed the CAIL score to be superior at predicting survival compared with the LENT score at 6 (0.84 vs. 0.77, P < 0.01), 12 (0.87 vs. 0.82, P < 0.01), and 36 months (0.80 vs. 0.77, P < 0.01).

CONCLUSIONS

For NSCLC patients with MPE, the validated CAIL prognostic score integrates clinical characteristics and therapeutic modalities to predict survival.

Comparison between pleurodesis results by 50% glucose solution, versus Bleomycin pleurodesis in patients with malignant pleural effusion

BACKGROUND

Following parapneumonic effusions, malignant pleural effusions (MPEs) stand as the second most common cause of exudative pleural effusions. These effusions typically remain unresponsive to systemic chemotherapy, necessitating novel therapeutic approaches. This study aims to ascertain the effectiveness of intrapleural injection with a 50% glucose solution and to compare it with intrapleural injection of Bleomycin sulfate in treating malignant pleural effusion.

METHODS

This prospective, double-blind, randomized clinical trial was conducted at Al-Zahra Hospital in Isfahan. The study protocol gained approval from the Iranian Registry of Clinical Trials (IRCT code: IRCT20201013049017N1) (https://en.irct.ir/trial/52739). The study population encompassed patients with malignant pleural effusion. Sampling occurred through a census approach from October 2019 to March 2020. The first group received a pleurodesis solution containing 12.5 cc of 2% lidocaine with Bleomycin, while the second group received a solution comprising 200 cc of 50% glucose solution (10 grams of glucose) and 12.5 ml of 2% lidocaine, within the same volume. These solutions were injected into the pleural space via the chest tube.

RESULTS

The complete response rate to treatment three months post-injection was 71.9% in the Bleomycin sulfate group and 65.6% in the 50% dextrose group. However, the difference between the two groups did not achieve statistical significance (P = 0.689). The incidence of post-injection fever and pain intensity exhibited comparability in both groups.

CONCLUSION

The treatment involving a combination of 50% glucose solution with Bleomycin for pleurodesis in patients with malignant pleural effusion demonstrated outcomes akin to other treatment options.

Current status and future of anti-angiogenic drugs in lung cancer

Lung cancer, as a malignant tumor with both high incidence and mortality in China, is one of the major causes of death in our population and one of the major public health problems in China. Effective treatment of lung cancer is a major public health task for all human beings. Angiogenesis plays an important role in the development of tumor, not only as a basic condition for tumor growth, but also as a significant factor to promote tumor metastasis. Therefore, anti-angiogenesis has become a vital means to inhibit tumor development, and anti-angiogenic drugs can rebalance pro- and anti-angiogenic factors to inhibit tumor cells. This article reviews the mechanism of blood vessel formation in tumor tissues and the mechanism of action of different anti-angiogenic drugs, the combination therapy of anti-angiogenic drugs and other anti-tumor drugs, and the mechanism of anti-angiogenic drug resistance.

Preclinical Characterization of 22-(4'-Pyridinecarbonyl) Jorunnamycin A against Lung Cancer Cell Invasion and Angiogenesis via AKT/mTOR Signaling

Non-small-cell lung cancer (NSCLC), the most prevalent form of lung cancer, is associated with an unfavorable prognosis owing to its high rate of metastasis. Thus, the identification of new drugs with potent anticancer activities is essential to improve the clinical outcome of this disease. Marine organisms exhibit a diverse source of biologically active compounds with anticancer effects. The anticancer effects of jorunnamycin A (JA) derived from the Thai blue sponge (Xestospongia sp.) and 22-(4'-pyridinecarbonyl) jorunnamycin A (22-(4'-py)-JA), the semisynthetic derivative of JA, have been reported. The present study aimed to investigate the impact of 22-(4'-py)-JA on NSCLC metastasis using in vitro, in vivo, and in silico approaches. The JA derivative inhibited tumor cell invasion and tube formation in human umbilical vein endothelial cells (HUVECs). The computational analysis demonstrated strong and stable interactions between 22-(4'-py)-JA and the AKT protein. Further examinations into the molecular mechanisms revealed the suppression of AKT/mTOR/p70S6K signaling by 22-(4'-py)-JA, leading to the downregulation of matrix metalloproteinases (MMP-2 and MMP-9), hypoxia-inducible factor-1α (HIF-1α), and vascular endothelial growth factor (VEGF). Furthermore, 22-(4'-py)-JA suppressed in vivo metastasis by decreasing the number of colonies in the lung. These findings indicated the antimetastasis activity of 22-(4'-py)-JA, which might prove useful for further clinical applications.

Malignant pleural effusion diagnosis and therapy

Malignant pleural effusion (MPE) is a serious complication of advanced tumor, with relatively high morbidity and mortality rates, and can severely affect the quality of life and survival of patients. The mechanisms of MPE development are not well defined, but much research has been conducted to gain a deeper understanding of this process. In recent decades, although great progress has been made in the management of MPE, the diagnosis and treatment of MPE are still major challenges for clinicians. In this article, we provide a review of the research advances in the mechanisms of MPE development, diagnosis and treatment approaches. We aim to offer clinicians an overview of the latest evidence on the management of MPE, which should be individualized to provide comprehensive interventions for patients in accordance with their wishes, health status, prognosis and other factors.

Research progress on anti-ovarian cancer mechanism of miRNA regulating tumor microenvironment

Ovarian cancer is the most deadly malignancy among women, but its complex pathogenesis is unknown. Most patients with ovarian cancer have a poor prognosis due to high recurrence rates and chemotherapy resistance as well as the lack of effective early diagnostic methods. The tumor microenvironment mainly includes extracellular matrix, CAFs, tumor angiogenesis and immune-associated cells. The interaction between tumor cells and TME plays a key role in tumorigenesis, progression, metastasis and treatment, affecting tumor progression. Therefore, it is significant to find new tumor biomarkers and therapeutic targets. MicroRNAs are non-coding RNAs that post-transcriptionally regulate the expression of target genes and affect a variety of biological processes. Studies have shown that miRNAs regulate tumor development by affecting TME. In this review, we summarize the mechanisms by which miRNAs affect ovarian cancer by regulating TME and highlight the key role of miRNAs in TME, which provides new targets and theoretical basis for ovarian cancer treatment.

Efficacy of Intrapleural or Intrapericardial Injection of Single Bevacizumab in the Treatment of Lung Cancer-Mediated Malignant Effusion

The usage of bevacizumab for malignant pleural effusion (MPE) or malignant pericardial effusion (MPCE) has attracted increasing interest from researchers, but the precise ways of bevacizumab administration remain unknown. Patients with histologically or cytologically confirmed non-small-cell lung cancer (NSCLC) with MPE or MPCE were enrolled in the study and treated with a low dose of single bevacizumab (100 mg) intrapleurally or intrapericardially injected after the drainage of the effusions. The Lung Cancer Symptom Scale (LCSS), efficacy, and safety of drug administration were used as evaluation parameters in this study. The results indicated that lung cancer-related symptoms were significantly improved following treatment, compared with symptoms before the treatment (LCSS, score 494 ± 78 vs. score 377 ± 77, mean ± SD) (P < 0.001). Malignant effusions were well controlled, and the median time to progression (TTP) was 91 days and 111 days in MPE and MPCE, respectively. In addition, no severe side effects were observed, except in one patient with mild dizziness. In summary, the low dose of single bevacizumab (100 mg) with intrapleural or intrapericardial injection is effective and safe in the treatment of lung cancer-mediated malignant effusion, rapidly improving the malignant effusion-related symptoms and quality of life in patients with NSCLC.

Utility of high-frequency B-mode and contrast-enhanced ultrasound for the differential diagnosis of benign and malignant pleural diseases: a prospective study

BACKGROUND

Pleural disease is a prevalent condition. As precision therapy advances, noninvasive imaging modalities play even more important roles in the evaluation of pleural diseases. This study investigated the diagnostic capabilities of high-frequency B-mode ultrasound (US) and contrast-enhanced US (CEUS) in terms of differentiating between benign and malignant pleural diseases.

METHODS

Patients with unexplained thickened pleurae were prospectively analyzed via transthoracic US. High-frequency B-mode US was used to derive the pleural thickness, morphology, and echogenicity. We analyzed the high-frequency CEUS data including the enhancement mode and time intensity curve (TIC). The cause of pleural thickening was confirmed by pleural biopsy and follow-up after the biopsy. We analyzed the differences in various ultrasonic features between the malignant and benign groups. Moreover, we plotted receiver operator curves (ROCs) and obtained the area under the curves, sensitivities, and specificities of all significant continuous variables. Multivariate logistic regression was used to assess the combined usefulness of multiple US indicators in terms of predicting malignant pleurae.

RESULTS

Thirty malignant and twenty benign thickened pleurae were finally diagnosed via pleural biopsy and at least six months of follow-up. The pleural morphology and enhancement modes significantly differed between the two groups (all P<0.05). The thickness derived from B-mode US and CEUS were significantly thicker in the malignant group (both P<0.05). Arrival time (AT) and the time to peak (TTP) of TIC were significantly shorter in the malignant group, whereas peak intensity and the area under the TIC were significantly higher in the malignant group (all P<0.05). The area under the ROC for pleural thickness derived from B-mode US was 0.819; pleural thickness derived from CEUS was 0.848; AT was 0.804; TTP was 0.750; peak intensity was 0.745; the area under the TIC was 0.743; and the combined various B-mode and CEUS parameter was 0.975.

CONCLUSIONS

Pleural thickness, morphology, enhancement mode, and the TIC of high-frequency US aided the differentiation of benign from malignant pleural diseases. Combined analysis of US indicators further improved the diagnostic capability.

Clinical Value of Pleural Effusion and Serum MMP-3 and CYFRA21-1 Combined with ADA in Differential Diagnosis of Pleural Exudative Effusion

Objective

The aim of the study is to investigate the clinical value of matrix metalloproteinases-3 (MMP-3) and cytokeratin 19 fragment antigen 21-1 (CYFRA21-1) combined with adenosine deaminase (ADA) in pleural effusion and serum in benign and malignant pleural exudative effusion (PEE).

Methods

A total of 119 adult patients with PEE admitted in our hospital from May 2018 to October 2021 were selected. According to the patient's condition, the patients were divided into the benign group (n = 75) and the malignant group (n = 44). The levels of MMP-3, CYFRA21-1, and ADA in pleural effusion and serum were detected. The receiver operating characteristic (ROC) curve was used to analyze the individual and combined predictive value of MMP-3, CYFRA21-1, and ADA levels.

Results

In the malignant group, the pleural effusion and serum MMP-3 and CYFRA21-1 levels were higher than those in the benign group and the ADA levels were lower than those in the benign group (P < 0.05). In the malignant group, the positive detection rate of pleural effusion and serum MMP-3 and CYFRA21-1 was higher than that in the benign group and the positive detection rate of pleural effusion and serum ADA were lower than that in the benign group (P < 0.05). The AUC of pleural effusion MMP-3, serum MMP-3 and the combination of them in the diagnosis of PEE were 0.764, 0.722 and 0.810, respectively. The AUC of pleural effusion CYFRA21-1 and serum CYFRA21-1 and combination of them in the diagnosis of PEE were 0.776, 0.748 and 0.822, respectively. The AUC of pleural effusion ADA, serum ADA and their combination in differential diagnosis of PEE were 0.762, 0.737 and 0.836, respectively. The AUC of pleural effusion and serum of MMP-3 and CYFRA21-1 combined with ADA for differential diagnosis of PEE was 0.923.

Conclusions

The diagnostic efficacy of MMP-3 combined with CYFRA21-1 and ADA in pleural effusion and serum for benign and malignant PEE are better than single index, which has certain clinical values for the selection of early intervention scheme for PEE patients.

When to add anti-angiogenesis drugs to EGFR-mutated metastatic non-small cell lung cancer patients: a real-world study from Taiwan

Background

The addition of anti-angiogenesis drugs to epidermal growth factor receptor (EGFR)–tyrosine kinase inhibitor (TKI) or chemotherapy in patients with EGFR-mutant non–small cell lung cancer (NSCLC) can improve disease control. We conducted a study to evaluate the efficacy of combination therapeutic strategies and identify patients who could benefit from combination therapy.

Methods

This study enrolled patients with stage IV EGFR-mutant NSCLC treated with first-line EGFR-TKIs between January 2014 and December 2020. We divided patients into three groups: patients who received an anti-angiogenesis drug as first-line combination therapy, those who received an anti-angiogenesis drug as further-line combination therapy, and those with no anti-angiogenesis therapy.

Results

A total of 204 patients were enrolled in the final analysis. Progression-free survival (PFS) in patients receiving first-line anti-angiogenesis plus EGFR-TKI combination therapy was longer (18.2 months) than those treated with first-line EGFR-TKI monotherapy (10.0 months for both, p < 0.001). No difference in overall survival (OS) was observed among these three groups (30.5 vs. 42.6 vs. 33.7 months, p = 0.326). Multivariate Cox regression analysis revealed L858R mutation, pleural, liver, and bone metastasis as independent prognostic factors for poor OS. However, the addition of anti-angiogenesis therapy to patients with these poor prognostic factors improved OS to levels similar to those without these poor prognostic factors.

Conclusion

First-line combination EGFR-TKI plus anti-angiogenesis therapy improves PFS in patients with stage IV EGFR-mutant NSCLC. Adding an anti-angiogenesis drug at any line to patients harboring L858R mutation with pleural, liver, or bone metastases can provide survival benefits.

Enhancement of Farnesoid X Receptor Inhibits Migration, Adhesion and Angiogenesis through Proteasome Degradation and VEGF Reduction in Bladder Cancers

(1) Background: Bladder cancer is a malignant tumor mainly caused by exposure to environmental chemicals, with a high recurrence rate. NR1H4, also known as Farnesoid X Receptor (FXR), acts as a nuclear receptor that can be activated by binding with bile acids, and FXR is highly correlated with the progression of cancers. The aim of this study was to verify the role of FXR in bladder cancer cells. (2) Methods: A FXR overexpressed system was established to investigate the effect of cell viability, migration, adhesion, and angiogenesis in low-grade TSGH8301 and high-grade T24 cells. (3) Results: After FXR overexpression, the ability of migration, adhesion, invasion and angiogenesis of bladder cancer cells declined significantly. Focal adhesive complex, MMP2, MMP9, and angiogenic-related proteins were decreased, while FXR was overexpressed in bladder cancer cells. Moreover, FXR overexpression reduced vascular endothelial growth factor mRNA and protein expression and secretion in bladder cancer cells. After treatment with the proteosome inhibitor MG132, the migration, adhesion and angiogenesis caused by FXR overexpression were all reversed in bladder cancer cells. (4) Conclusions: These results may provide evidence on the role of FXR in bladder cancer, and thus may improve the therapeutic efficacy of urothelial carcinoma in the future.

Application Value of Serum TK1 and PCDGF, CYFRA21-1, NSE, and CEA plus Enhanced CT Scan in the Diagnosis of Nonsmall Cell Lung Cancer and Chemotherapy Monitoring

Objective

To assess the application value of serum thymidine kinase 1 (TK1) and PC cell-derived growth factor (PCDGF), cytokeratin 19 fragment 21-1 (CYFRA21-1), neuron-specific enolase (NSE), and carcinoembryonic antigen (CEA) plus enhanced CT scan in the diagnosis of nonsmall cell lung cancer (NSCLC) and chemotherapy monitoring.

Methods

Between April 2019 and April 2021, 30 patients with NSCLC assessed for eligibility treated in our institution were included in the experimental group, and 30 healthy individuals screened out from physical examinations were recruited in the control group. The chemotherapy regimens included gemcitabine plus cisplatin, pemetrexed disodium plus cisplatin, and vinorelbine plus cisplatin. The application value of serum TK1, PCDGF, CYFRA21-1, NSE, CEA, and enhanced CT scan in the diagnosis and chemotherapy monitoring of NSCLC was analyzed.

Results

Before treatment, the eligible patients had significantly higher serum levels of TK1, PCDGF, CYFRA21-1, NSE, and CEA than those of the healthy individuals included (P < 0.05). Clinical efficacy was categorized into good and poor, and the good efficacy included complete response and partial response, with the poor efficacy including stable disease and progressive disease. Patients with good clinical efficacy had lower levels of serum TK1, PCDGF, CYFRA21-1, NSE, and CEA than those with poor efficacy (P < 0.05). Joint detection showed a larger area under the curve (AUC) (0.900; 95%CI, 0.812-0.988), a higher sensitivity, and a superior detection outcome to the stand-alone detection (P < 0.05). Diagnostic results were similar between joint detection and pathological examination (P > 0.05).

Conclusion

The application of serum TK1, PCDGF, CYFRA21-1, NSE, and CEA assay plus enhanced CT scan shows high sensitivity and diagnostic accuracy in the diagnosis and chemotherapy monitoring of nonsmall cell lung cancer and thus provides a diagnostic reference basis.

Methamphetamine exposure increases cardiac microvascular permeability by activating the VEGF-PI3K-Akt-eNOS signaling pathway, reversed by Bevacizumab

Methamphetamine (METH) is an illicit amphetamine-like psychostimulant that is commonly abused. However, the modulation of METH-induced cardiac microvascular permeability is still not completely known. Previously, we discovered that the vascular endothelial growth factor (VEGF) regulated the cardiotoxicity produced by METH. In this work, we looked into the effect of METH exposure on cardiac microvascular permeability via the VEGF-PI3K-Akt-eNOS signaling pathway, as well as the efficacy of Bevacizumab treatment in reducing this effect. The findings revealed that METH exposure enhanced cardiac microvascular permeability while also activating the VEGF-PI3K-Akt-eNOS signaling pathway. Furthermore, treatment with Bevacizumab has been shown to be effective in reversing the METH-induced phenomena. Briefly stated, our research may provide fresh insight into the molecular underpinnings of METH-induced cardiac microvascular permeability, and it may also provide evidence for a relationship between METH misuse and Bevacizumab medication.

Fibroblast growth factor 11 (FGF11) promotes non-small cell lung cancer (NSCLC) progression by regulating hypoxia signaling pathway

BACKGROUND

Accumulating evidence highlights the critical roles of fibroblast growth factors (FGFs) in regulating the progression of multiple human cancers, including non-small cell lung cancer (NSCLC). In this study, we investigated the role of FGF11 in the progression of NSCLC.

METHODS

Previously published transcriptomic data (GSE75037 and GSE81089) were used to compare FGF11 expression level between NSCLC tumor tissues and adjacent normal tissues. 100 cases of NSCLC tumor tissues and 30 cases of matched adjacent normal tissues were used to validate FGF11 expression at mRNA and protein level by qPCR and immunohistochemistry. Bioinformatics analysis and dual luciferase reporter analysis were performed to confirm the regulatory effect of miR-525-5p on FGF11 expression. CCK-8 assay and transwell migration assay were employed to examine cellular proliferation, migration and invasion. Gene set enrichment analysis (GSEA) was performed to identify the signaling pathway associated with FGF11 expression. Finally, the functional role of FGF11 in NSCLC tumor growth was evaluated by in vivo study.

RESULTS

FGF11 was upregulated in NSCLC tumor tissues and tumor cell lines. High FGF11 expression was associated with a poor prognosis in NSCLC patients. In vitro loss- and gain-of function experiments demonstrated that FGF11 knockdown inhibited, whereas FGF11 overexpression promoted the proliferation, migration and invasion of NSCLC cells. Dual luciferase reporter assay confirmed that FGF11 was downregulated by miR-525-5p, and the effect of FGF11 on cell proliferation, migration and invasion could be interfered by miR-525-5p. GSEA analysis further revealed that FGF11 expression was enriched with genes in hypoxia signaling pathway and the oncogenic function of FGF11 could be suppressed by knocking down HIF-1α in NSCLC cells. Moreover, FGF11 knockdown suppressed NSCLC tumor growth whereas FGF11 overexpression promoted tumor growth in vivo.

CONCLUSIONS

Our study showed that FGF11 functions as an oncogene in tumor NSCLC progression. miR-525-5p seems to negatively regulate FGF11 and the oncogenic role of FGF11 is dependent on the upregulation of HIF-1α. Our study suggests that targeting FGF11 and HIF-1α may serve as novel strategies for the treatment of NSCLC.

Machine learning applied to near-infrared spectra for clinical pleural effusion classification

Lung cancer patients with malignant pleural effusions (MPE) have a particular poor prognosis. It is crucial to distinguish MPE from benign pleural effusion (BPE). The present study aims to develop a rapid, convenient and economical diagnostic method based on FTIR near-infrared spectroscopy (NIRS) combined with machine learning strategy for clinical pleural effusion classification. NIRS spectra were recorded for 47 MPE samples and 35 BPE samples. The sample data were randomly divided into train set (n = 62) and test set (n = 20). Partial least squares, random forest, support vector machine (SVM), and gradient boosting machine models were trained, and subsequent predictive performance were predicted on the test set. Besides the whole spectra used in modeling, selected features using SVM recursive feature elimination algorithm were also investigated in modeling. Among those models, NIRS combined with SVM showed the best predictive performance (accuracy: 1.0, kappa: 1.0, and AUC_ROC: 1.0). SVM with the top 50 feature wavenumbers also displayed a high predictive performance (accuracy: 0.95, kappa: 0.89, AUC_ROC: 0.99). Our study revealed that the combination of NIRS and machine learning is an innovative, rapid, and convenient method for clinical pleural effusion classification, and worth further evaluation.

Exploration in the mechanism of fucosterol for the treatment of non-small cell lung cancer based on network pharmacology and molecular docking

Fucosterol, a sterol isolated from brown algae, has been demonstrated to have anti-cancer properties. However, the effects and underlying molecular mechanism of fucosterol on non-small cell lung cancer remain to be elucidated. In this study, the corresponding targets of fucosterol were obtained from PharmMapper, and NSCLC related targets were gathered from the GeneCards database, and the candidate targets of fucosterol-treated NSCLC were predicted. The mechanism of fucosterol against NSCLC was identified in DAVID6.8 by enrichment analysis of GO and KEGG, and protein–protein interaction data were collected from STRING database. The hub gene GRB2 was further screened out and verified by molecular docking. Moreover, the relationship of GRB2 expression and immune infiltrates were analyzed by the TIMER database. The results of network pharmacology suggest that fucosterol acts against candidate targets, such as MAPK1, EGFR, GRB2, IGF2, MAPK8, and SRC, which regulate biological processes including negative regulation of the apoptotic process, peptidyl-tyrosine phosphorylation, positive regulation of cell proliferation. The Raf/MEK/ERK signaling pathway initiated by GRB2 showed to be significant in treating NSCLC. In conclusion, our study indicates that fucosterol may suppress NSCLC progression by targeting GRB2 activated the Raf/MEK/ERK signaling pathway, which laying a theoretical foundation for further research and providing scientific support for the development of new drugs.

VEGI downregulation is correlated with nodal metastasis and poor prognosis in lung adenocarcinoma

Although the incidence of lung cancer is increasing worldwide, the molecular mechanisms for its tumorigenesis, progression and prognosis remain unknown. As a member of the tumor necrosis factor superfamily, vascular endothelial growth inhibitor (VEGI) is involved in the development and progression of many malignant diseases. In the present study, the expression of VEGI and CD31 was examined via immunohistochemistry in non-small cell lung cancer (NSCLC) tissues obtained from 150 patients with NSCLC. The inhibitory effect of VEGI on tumor-associated blood vessel formation and growth was investigated by determining the relationship between VEGI protein expression and microvascular density (MVD). Prognostic significance was evaluated using the Kaplan-Meier method. VEGI expression was downregulated or lost in 68.7% (103/150) of patients with NSCLC, an effect that was more prevalent in adenocarcinoma (AC), 76.0% (57/75), than in squamous cell carcinoma, 61.3% (46/75). A significant negative correlation was indentified between VEGI expression and lymphovascular invasion (P=0.039) and lymph node metastasis (P=0.017) in AC tissue. Additionally, MVD was significantly lower in the VEGI-rich group compared with the VEGI-poor group. The downregulation of VEGI expression was also associated with poorer overall survival (P=0.011) in patients with AC. The present study therefore provides evidence that VEGI may be a new and effective prognostic marker of lung AC.

Effect of malignant-associated pleural effusion on endothelial viability, motility and angiogenesis in lung cancer

Malignant pleural effusion (MPE) and paramalignant pleural effusion (PPE) remain debilitating complications in lung cancer patients with poor prognosis and limited treatment options. The role of vascular endothelial cells has not been explored in the pleural environment of lung cancer. By integrating MPE and PPE as malignant-associated pleural fluid (MAPF), the current study aimed to evaluate the effect of MAPF on cell proliferation, migration and angiogenesis of HUVEC. First, increased capillaries were identified in the subpleural layer of lung adenocarcinoma. Compatible with pathological observations, the ubiquitous elevation of HUVEC survival was identified in MAPF culture regardless of the underlying cancer type, the driver gene mutation, prior treatments and evidence of malignant cells in pleural fluid. Moreover, MAPF enhanced HUVEC motility with the formation of lamellipodia and filopodia and focal adhesion complex. Tube formation assay revealed angiogenic behavior with the observation of sheet-like structures. HUVEC cultured with MAPF resulted in a significant increase in MAPK phosphorylation. Accompanied with VEGFR2 upregulation in MAPF culture, there was increased expressions of p-STAT3, HIF-1α and Nf-kB. VEGF/VEGFR2 blockade regressed endothelial migration and angiogenesis but not cell proliferation. Our data indicate the angiogenic activities of MAPF on vascular endothelial cells that revealed increased pleural capillaries in lung cancer. Targeting the VEGF/VEGFR2 pathway might modulate the angiogenic propensity of MAPF in future clinical investigations.

Ginger Extract Loaded into Chitosan Nanoparticles Enhances Cytotoxicity and Reduces Cardiotoxicity of Doxorubicin in Hepatocellular Carcinoma in Mice

This study aimed to investigate the impact of ginger extract (GE) loaded into chitosan nanoparticles (CNPs) in enhancing cytotoxicity and reducing cardiotoxicity of doxorubicin (DXN) in hepatocellular carcinoma (HCC) induced mice. DXN and GE were loaded into CNPs and cytotoxicity of loaded and unloaded drugs against HepG2 cells was evaluated. HCC was induced in male albino mice by injection of diethylnitrosamine (DINA). Mice were divided into eight groups (n = 15): (1) normal control, (2) DINA, (3) CNPs, (4) free DXN, (5) CNPs DXN, (6) free GE, (7) CNPs GE, and (8) CNPs DXN + CNPs GE. Both GE and DXN loaded into CNPs showed a greater decline in cell viability of HepG2 cells than the unloaded forms. GE CNPs displayed pronounced anticancer activity In Vivo through apoptosis, greater down-regulation of multidrug resistance 1, enhancement of anti-oxidant activity and depletion of vascular endothelial growth factor content in liver tissues. GE CNPs in combination with DXN CNPs showed nearly normal hepatic lobule architecture and the greatest increase in apoptotic cell count. Co-treatment group had decreased cardiac malondialdehyde, tumor necrosis factor-α and serum activity of creatine kinase and lactate dehydrogenase. Combination of GE CNPs and DXN CNPs might be a potentially effective therapeutic approach for HCC.

Multiplexed molecular profiling of lung cancer with malignant pleural effusion using next generation sequencing in Chinese patients

Lung cancer is the most common type of cancer and the leading cause of cancer-associated death worldwide. Malignant pleural effusion (MPE), which is observed in ~50% of advanced non-small cell lung cancer (NSCLC) cases, and most frequently in lung adenocarcinoma, is a common complication of stage III-IV NSCLC, and it can be used to predict a poor prognosis. In the present study, multiple oncogene mutations were detected, including 17 genes closely associated with initiation of advanced lung cancer, in 108 MPE samples using next generation sequencing (NGS). The NGS data of the present study had broader coverage, deeper sequencing depth and higher capture efficiency compared with NGS findings of previous studies on MPE. In the present study, using NGS, it was demonstrated that 93 patients (86%) harbored EGFR mutations and 62 patients possessed mutations in EGFR exons 18-21, which are targets of available treatment agents. EGFR L858R and exon 19 indel mutations were the most frequently observed alterations, with frequencies of 31 and 25%, respectively. In 1 patient, an EGFR amplification was identified and 6 patients possessed a T790M mutation. ALK + EML4 gene fusions were identified in 6 patients, a ROS1 + CD74 gene fusion was detected in 1 patient and 10 patients possessed a BIM (also known as BCL2L11) 2,903-bp intron deletion. In 4 patients, significant KRAS mutations (G12D, G12S, G13C and A146T) were observed, which are associated with resistance to afatinib, icotinib, erlotinib and gefitinib. There were 83 patients with ERBB2 mutations, but only two of these mutations were targets of available treatments. The results of the present study indicate that MPE is a reliable specimen for NGS based detection of somatic mutations.

A randomized clinical study to compare intrapleural infusion with intravenous infusion of bevacizumab in the management of malignant pleural effusion in patients with non-small-cell lung cancer

BACKGROUND

To compare the efficiency and toxicity of bevacizumab by intrapleural or intravenous infusion in the management of malignant pleural effusion in patients with non-small-cell lung cancer (NSCLC).

METHODS

Sensitizing mutation negative NSCLC patients with malignant pleural effusion were randomized into two groups in 1:1 ratio. The pleural effusion was completely drained in 24 hours; one group received intrapleural infusion and the second group received intravenous infusion of bevacizumab at a dose of 7.5 mg per kg bodyweight. The serum vascular endothelial growth factor (VEGF) was tested before and 72 hours after injection of bevacizumab. Computerized tomography (CT) scan to evaluate pleural effusions was carried out at four weeks for each patient and their survival followed-up.

RESULTS

A total of 67 patients were screened and 43 enrolled into the study. The response rate was 80% (16 of 20) in the intrapleural group and 66.7% (14 of 21) in the intravenous group. The median duration of response (DoR) of pleural effusion was 4.50 months and 3.70 months, respectively. The median serum VEGF level at 72 hours decreased 67.25% in the intrapleural group and 57.19% in the intravenous group compared to baseline level (P = 0.276). The median serum VEGF level at 72 hours decreased 52.02% compared to baseline level in patients' DoR less than three months and 68.33% in patients' DoR longer than three months, respectively (P = 0.014). The main side effects noted were mild to moderate hypertension, proteinuria and epistaxis.

CONCLUSIONS

Bevacizumab intrapleural infusion had higher efficiency and higher safety than intravenous infusion in the management of malignant pleural effusion caused by NSCLC. The decreased level of serum VEGF at 72 hours after bevacizumab treatment was closely related to the response rate and duration of the response of pleural effusion.

Effect of bevacizumab against cystic components of brain tumors

Background

Bevacizumab improves symptoms via reducing the peritumoral edema and/or normalizing blood brain barrier, and occasionally via reducing the tumor size. However, the effect against active cystic components has not been documented yet.

Materials and Methods

Between 2008 and 2018, 139 patients with primary or metastatic brain tumors were treated with bevacizumab (BEV) in our institution. The images and symptoms before and after administration of BEV were examined, and changes in size of cysts were evaluated as follows: CR (complete disappearance), PR (reduction by ≥50%), MR (reduction by ≥25%), SD (size change <25%), PD (increase by ≥25%). The effect of BEV on tumor itself was determined according to Response Assessment in Neuro‐Oncology criteria.

Results

Of the 139 patients, 21 (15.1%) had cystic components. The best responses of cysts to BEV treatment were as follows: CR 6, PR 7, MR 4, SD 4. The group of patients with progressively increasing cysts prior to BEV treatment had significant cyst size reduction compared to stable cyst size groups, at initial imaging after BEV (mean 62.6% vs 22.5%, P = .0055) and at best response timing (mean 76.3% vs 32.8%, P = .0050). Patients with cysts showed significant improvement in symptoms after the treatment with BEV compared to patients without cysts (P = .0033). However, response rate was not different between patients with or without cysts. Overall survival after starting BEV was not different between glioblastoma patients with or without cysts.

Conclusion

Bevacizumab is effective against progressively increasing cysts. Although cysts reduction effect and tumor response and/or overall survival are independent, BEV may be effective in patients who are symptomatic due to cyst enlargement.

Malignant Pleural Effusion and Its Current Management: A Review

Malignant pleural effusion (MPE) is an exudative effusion with malignant cells. MPE is a common symptom and accompanying manifestation of metastatic disease. It affects up to 15% of all patients with cancer and is the most common in lung, breast cancer, lymphoma, gynecological malignancies and malignant mesothelioma. In the last year, many studies were performed focusing on the pathophysiological mechanisms of MPE. With the advancement in molecular techniques, the importance of tumor-host cell interactions is becoming more apparent. Additionally, the process of pathogenesis is greatly affected by activating mutations of EGFR, KRAS, PIK3CA, BRAF, MET, EML4/ALK and RET, which correlate with an increased incidence of MPE. Considering all these changes, the authors aim to present a literature review of the newest findings, review of the guidelines and pathophysiological novelties in this field. Review of the just recently, after seven years published, practice guidelines, as well as analysis of more than 70 articles from the Pubmed, Medline databases that were almost exclusively published in indexed journals in the last few years, have relevance and contribute to the better understanding of the presented topic. MPE still presents a severe medical condition in patients with advanced malignancy. Recent findings in the field of pathophysiological mechanisms of MPE emphasize the role of molecular factors and mutations in the dynamics of the disease and its prognosis. Treatment guidelines offer a patient-centric approach with the use of new scoring systems, an out of hospital approach and ultrasound. The current guidelines address multiple areas of interest bring novelties in the form of validated prediction tools and can, based on evidence, improve patient outcomes. However, the role of biomarkers in a clinical setting, possible new treatment modalities and certain specific situations still present a challenge for new research.

[Progress of Bevacizumab in Malignant Pleural Effusion Caused by Non-small Cell Lung Cancer]

Lung cancer is the most commonly diagnosed cancer worldwide. Malignant pleural effusion (MPE) caused by advanced lung cancer seriously affect the patients' quality of life and prognosis. The management of MPE includes thoracentesis, pleurodesis, indwelling pleural catheters and drug perfusion in pleural cavity. Vascular endothelial growth factor (VEGF) and its receptor are a group of important ligands and receptors that affect angiogenesis. They are the main factors controlling angiogenesis, and they play an important role in the formation of MPE. Bevacizumab is a recombinant humanized VEGF monoclonal antibody, competitively binding to endogenous VEGF receptor. Bevacizumab can inhibit new blood vessel formation, reduce vascular permeability, prevent pleural effusion accumulation and slow the growth of cancers. This review aims to discuss the progress of bevacizumab in the treatment of MPE caused by non-small cell lung cancer (NSCLC), and explore the clinical application, efficacy, safety and future direction of bevacizumab.
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Malignant pleural effusion as a predictor of the efficacy of anti-PD-1 antibody in patients with non-small cell lung cancer

Background

The aim of this study was to evaluate the usefulness of the presence of malignant pleural effusion (MPE) as a negative predictor of anti‐PD‐1 antibody efficacy.

Methods

A retrospective review of patients with advanced or recurrent non‐small cell lung cancer treated with an anti‐PD‐1 antibody between December 2015 and March 2018 at the National Cancer Center Hospital, Japan, was conducted. Progression‐free survival (PFS) and overall survival (OS) were compared between patients with and without MPE. Additional survival analysis according to PD‐L1 expression status was conducted. Univariate and multivariate analyses were performed.

Results

A total of 252 patients were identified before the commencement of anti‐PD‐1 antibody treatment: 33 with MPE and 219 without MPE. PFS and OS were significantly shorter in patients with MPE than in patients without MPE (median PFS 3.0 vs. 5.8 months, hazard ratio [HR] 1.7, P = 0.014; median OS 7.9 vs. 15.8 months, HR 2.1, P = 0.001). In patients with PD‐L1 expression in ≥ 1% of their tumor cells, the PFS of patients with MPE was significantly shorter than of patients without MPE (median PFS 3.1 vs. 6.5 months, HR 2.0, 95% confidence interval 1.0–3.5; P = 0.021). The presence of MPE was independently associated with a shorter PFS and OS in multivariate analysis.

Conclusion

The presence of MPE in patients administered an anti‐PD‐1 antibody is associated with shorter PFS and OS, regardless of the presence of PD‐L1 expression ≥ 1% of tumor cells.