Lung cancer surgery: an up to date

Real-time lung extraction from synthesized x-rays improves pulmonary image-guided radiotherapy

Objective.Lung tumors can be obscured in x-rays, preventing accurate and robust localization. To improve lung conspicuity for image-guided procedures, we isolate the lungs in the anterior-posterior (AP) x-rays using a lung extraction network (LeX-net) that virtually removes overlapping thoracic structures, including ribs, diaphragm, liver, heart, and trachea.Approach.73 965 thoracic 3DCTs and 106 thoracic 4DCTs were included. The 3D lung volume was extracted using an open-source lung volume segmentation model. AP digitally reconstructed radiographs (DRRs) of the full anatomy CT and extracted lungs were computed as the input and reference to train a network (LeX-net) to generate lung-extracted DRRs (LeX-net DRRs) from full anatomy DRRs, which adopted a Swin-UNet model with conditional GAN. Subsequently, the trained LeX-net on 3DCT was applied to 4DCT-derived DRRs. Lung tumor tracking was then performed on DRRs using a template-matching method on a holdoff 4DCT test set of 79 patients whose gross tumor volumes were smaller than 20 cm3.Main results. LeX-net successfully isolated the lungs in DRRs, achieving an SSIM of 0.9581 ± 0.0151 and a PSNR of 30.78 ± 2.50 on the testing set of 3DCT-derived DRRs. Its performance declined slightly when applied to the 4DCT but maintained useable lung-only 2D views. On the challenging test set including cases of organ overlap, high tumor mobility, and small tumor size, the individual tumor tracking error for LeX-net DRRs was 0.97 ± 0.86 mm, significantly lower than that of 3.13 ± 5.82 mm using the full anatomy DRRs. LeX-net improved success rates of using 5 mm, 3 mm, and 1 mm tracking windows from 88.1%, 80.0%, and 58.7% to 98.1%, 94.2%, and 73.8%, respectively.Significance. LeX-net removes overlapping anatomies and enhances visualization of the lungs in x-rays. The model trained using 3DCTs is generalizable to 4DCT-derived DRRs, achieving significantly improved tumor tracking outcome.

Assessment of printed lung cancer surgery patient education materials in the United States

Objective

Well-designed patient education materials (PEMs) increase health literacy, which has been linked to better surgical patient outcomes. The quality of lung cancer surgery PEMs is unknown, however. Here we assessed printed lung cancer surgery PEMs for readability, understandability, actionability, and accessibility.

Methods

Various lung cancer programs throughout the United States were contacted for their lung cancer surgery PEMs. The readability of the received materials was calculated using 6 readability tests. Four thoracic surgeon-advanced practice practitioner dyads scored the PEMs for understandability, actionability, and accessibility using the Patient Education Material Assessment Tool and the Accessibility Assessment Tool, with the recommended minimum threshold of 70%. One-sample t tests were performed to compare each parameter against its recommended threshold.

Results

Out of 34 institutions contacted, 18 (52.9%) provided PEMs. The average reading level of the PEMs ranged from 7th grade to 11th grade, significantly exceeding the recommended 6th grade health literacy threshold (P < .01). Although mean understandability (73.7 ± 13.2%) and actionability (70.2 ± 17.8%) scores were not significantly different from the minimum threshold, and the mean accessibility score (81.8 ± 13.5%) was significantly higher than the threshold (P < .05), there was wide variation in the scores. Most PEMs scored well in organization and writing but lacked other features that can enhance patient understanding, such as visual aids and summaries.

Conclusions

PEMs are written at reading levels that are too advanced for patients. Although PEMs scored well in understandability, actionability, and accessibility, analysis of individual items revealed the need for improvement, including the use of shorter sentences, more visual aids and summaries, and expansion of language translations.

Effect of Preoperative Home-Based Exercise Training on Quality of Life After Lung Cancer Surgery: A Multicenter Randomized Controlled Trial

BACKGROUND

Preoperative exercise training is recommended for improvement of clinical outcomes after lung cancer (LC) surgery. However, its effectiveness in preventing postoperative decline in quality of life (QoL) remains unknown. This study investigated the effect of preoperative home-based exercise training (PHET) on QoL after LC surgery.

METHODS

Patients awaiting LC resection were randomized to PHET or a control group (CG). The PHET program combined aerobic and resistance exercise, with weekly telephone supervision. Primary outcome was QoL-assessed with the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire C30 (QLQ-C30) at baseline, before surgery, and 1 month after surgery. The secondary outcomes were hospital length of stay and physical performance. The main analysis included a factorial repeated-measures analysis of variance. Additionally, the proportion of patients experiencing clinical deterioration from baseline to post-surgery was assessed.

RESULTS

The study included 41 patients (68.1 ± 9.3 years; 68.3% male) in the intention-to-treat analysis (20 PHET patients, 21 CG patients). A significant group × time interaction was observed for global QoL (p = 0.004). Between-group differences in global QoL were statistically and clinically significant before surgery (mean difference [MD], 13.5 points; 95% confidence interval [CI], 2.4-24.6; p = 0.019) and after surgery (MD, 12.4 points; 95% CI, 1.3-23.4; p = 0.029), favoring PHET. Clinical deterioration of global QoL was reported by 71.4% of the CG patients compared with 30 % of the PHET patients (p = 0.003). Between-group differences in favor of PHET were found in pain and appetite loss as well as in physical, emotional and role functions after surgery (p < 0.05). Compared with CG, PHET was superior in improving preoperative five-times sit-to-stand and postoperative exercise capacity (p < 0.05). No between-group differences in other secondary outcomes were observed.

CONCLUSION

The study showed that PHET can effectively prevent the decline in QoL after LC surgery.

Systematic analysis of expression profiles of HMGB family members for prognostic application in non-small cell lung cancer

Background: Lung cancer is a significant challenge to human health. Members of the high mobility group (HMG) superfamily (HMGB proteins) are implicated in a wide variety of physiological and pathophysiological processes, but the expression and prognostic value of HMGB family members in non-small cell lung cancer (NSCLC) have not been elucidated.

Methods: In this study, ONCOMINE, UALCAN, GEPIA, Kaplan–Meier Plotter, starBase, OncomiR databases, and GeneMANIA were utilized to evaluate the prognostic significance of HMGB family members in NSCLC.

Results: HMGB2/3 expression levels were higher in NSCLC patients. HMGB1 expression was higher in lung squamous cell carcinoma (LUSC) and was lower in lung adenocarcinoma (LUAD) tissue than in normal lung tissue. HMGB2 expression was related to cancer stage. Increased HMGB1 mRNA expression levels were associated with improved lung cancer prognosis, including overall survival (OS), first-progression survival (FP), and post-progression survival (PPS). There was no significant association between HMGB2 levels and prognostic indicators. HMGB3 expression was associated with poorer OS. GeneMANIA and GO/KEGG pathway analysis showed that HMGB family members mainly associated with chromosome condensation, regulation of chromatin organization, and nucleosome binding in NSCLC. HMGBs expression were closely correlated with infiltrating levels of specific types of immune cells in NSCLC, especially Th2 cells, Th17 cells, and mast cells. hsa-miR-25-3p, hsa-miR-374a-3p, and hsa-miR-93-5p were significantly positively correlated with HMGB1, HMGB2, and HMGB3, respectively. However, hsa-miR-30a-5p was predicted to significantly negatively regulate HMGB3 expression.

Conclusion: Our study revealed that HMGB1 is positively related to the improved prognosis in NSCLC, and demonstrate that HMGB3 might be a risk factor for poorer survival of NSCLC patients.

A Prediction Model for Postoperative Pulmonary Complication in Pulmonary Function-Impaired Patients Following Lung Resection

PURPOSE

Most patients with lung cancer have impaired pulmonary function. Single pulmonary function parameters have been suggested as good indices for predicting postoperative pulmonary complications (PPC). The purpose of this retrospective study was to construct a prediction model, including more than one pulmonary function parameter, for better prediction of PPC in patients with lung cancer and impaired pulmonary function.

PATIENTS AND METHODS

Our database of patients who underwent lung resection for non-small cell lung cancer was reviewed and those with impaired pulmonary function were enrolled. Clinical data, including PPC, were recorded. Univariate and logistic regression analyses were applied to explore potential predictors and a prediction model constructed based on the results of logistic regression.

RESULTS

Patients with impaired pulmonary function (n = 124) were enrolled. Most patients were male, current smokers, >60 years old, and had adenocarcinoma and mild ventilatory dysfunction or diffusion dysfunction. In univariate analysis, we identified six pulmonary function parameters that differed significantly between the PPC and non-PPC groups. Receiver operating characteristic curves were used to determine the best cutoff values. In logistic regression, only forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC%), peak expiratory flow (PEF%), and post predictive operation (ppo)-FEV1% remained significant. Based on these results, we constructed a prediction model for PPC including FEV1/FVC%, PEF%, and ppo-FEV1%, which had an good diagnostic performance of, with 76.7% sensitivity and 67.6% specificity.

CONCLUSION

Our prediction model, including the pulmonary function parameters, FEV1/FVC%, PEF%, and ppo-FEV1%, shows excellent performance for predicting PPC in patients with lung cancer and impaired pulmonary function following resection, and has potential for wide application in clinical practice.

The Clinical Value of Pulmonary Rehabilitation in Reducing Postoperative Complications and Mortality of Lung Cancer Resection: A Systematic Review and Meta-Analysis

Background: Pulmonary rehabilitation is one meaningful way of improving exercise tolerance and pulmonary function. Thus, it may reduce the postoperative complications and mortality of pulmonary resection. Hence, we refreshed the data and conducted this systemic analysis.

Method: We searched Pubmed, Web of Science, and EMBASE using “lung OR pulmonary” AND “operation OR resection OR surgery” AND “rehabilitation or exercise.” The cut-off date was September 30, 2020. The publications were filtrated, and data were extracted from all selected studies by two reviewers. Review Manger 5.1 and the fixed or random regression model were used for calculating the pooled odds ratio (OR).

Result: Finally, 13 publications were enrolled in this study. Among them, five publications reported mortality, nine reported postoperative complications, and seven reported postoperative pulmonary complications. The pooled OR of mortality was 1.32 [95% confidence interval (CI): 0.54–3.23] for the pulmonary rehabilitation group, the pooled OR of postoperative complications was 0.62 (95% CI: 0.49–0.79) for the pulmonary rehabilitation group, and the pooled OR of postoperative pulmonary complications was 0.39 (95% CI: 0.27–0.56) for the pulmonary rehabilitation group. Subgroup analysis revealed the perioperative pulmonary rehabilitation was the most important part.

Conclusion: Pulmonary rehabilitation may not affect the mortality of pulmonary resection patients, however, it could decrease the number of postoperative complications, especially pulmonary complications. Perioperative pulmonary rehabilitation was the most important part of the program.

The status of WIF1 methylation in cell-free DNA is associated with the insusceptibility for gefitinib in the treatment of lung cancer

BACKGROUND

Targeted cancer therapy has shed light on the treatment of tumor, especially for patients with non-small cell lung cancer. However, only a limited portion of NSCLC patients carrying specific mutations showed an ideal drug response. In addition, DNA methylation status showed a great potential for cancer detection and prognosis prediction.

METHODS

Bisulfite sequencing was performed to analyze the DNA methylation of WIF1 promoter in cfDNA and tumor tissue samples collected from NSCLC patients. PFS and OS analyses were carried out to evaluate the prognosis of gefitinib treatment in patients with differential levels of WIF1 DNA methylation. Quantitative real-time PCR was used to analyze the expression of WIF1 mRNA, while immunohistochemistry was performed to assess the expression of WIF1 protein. Furthermore, ELISA was carried out to evaluate the WIF1 activity in plasma.

RESULTS

The DNA methylation level of WIF1 promoter was lower in the cfDNA of NSCLC patients with a complete or partial response to gefitinib, and NSCLC patients with hypomethylated WIF1 showed better PFS and OS. The DNA methylation of WIF1 promoter in the resected tumor tissues was consistent with WIF1 DNA methylation in cfDNA, indicating that cfDNA was mainly derived from lung cancer tissues. As a result, the expression of WIF1 in tissue samples and the WIF1 activity in plasma was inhibited in patients with hypermethylated WIF1. Moreover, the cell viability of gefitinib-resistant cells was decreased by the suppressed WIF1 methylation in vitro. And the expression level of WIF1 mRNA was higher in gefitinib-resistant cells overexpressing ALKBH5, a known suppressor of WIF1 methylation.

CONCLUSION

In summary, the findings of this study demonstrated that the level of WIF1 methylation in cfDNA was associated with the insusceptibility of gefitinib in the treatment of lung cancer.

Multimodal soft tissue markers for bridging high-resolution diagnostic imaging with therapeutic intervention

Diagnostic imaging often outperforms the surgeon's ability to identify small structures during therapeutic procedures. Smart soft tissue markers that translate the sensitivity of diagnostic imaging into optimal therapeutic intervention are therefore highly warranted. This paper presents a unique adaptable liquid soft tissue marker system based on functionalized carbohydrates (Carbo-gel). The liquid state of these markers allows for high-precision placement under image guidance using thin needles. Based on step-by-step modifications, the image features and mechanical properties of markers can be optimized to bridge diagnostic imaging and specific therapeutic interventions. The performance of Carbo-gel is demonstrated for markers that (i) have radiographic, magnetic resonance, and ultrasound visibility; (ii) are palpable and visible; and (iii) are localizable by near-infrared fluorescence and radio guidance. The study demonstrates encouraging proof of concept for the liquid marker system as a well-tolerated multimodal imaging marker that can improve image-guided radiotherapy and surgical interventions, including robotic surgery.

Immunoscore Predicts Survival in Early-Stage Lung Adenocarcinoma Patients

Background: The lung cancer staging system is insufficient for a comprehensive evaluation of patient prognosis. We constructed a novel immunoscore model to predict patients with high risk and poor survival.

Method: Immunoscore was developed based on z-score transformed enrichment score of 11 immune-related gene sets of 109 immune risk genes. The immunoscore model was trained in lung adenocarcinoma cohort from The Cancer Genome Atlas (TCGA-LUAD) (n = 400), and validated in other two independent cohorts from Gene Expression Omnibus (GEO), GSE31210 (n = 219) and GSE68465 (n = 356). Meta-set (n = 975) was formed by combining all training and testing sets.

Result: High immunoscore conferred worse prognosis in all sets. It was an independent prognostic factors in multivariate Cox analysis in training, testing and meta-set [hazard ratio (HR) = 2.96 (2.24–3.9), P < 0.001 in training set; HR = 1.99 (1.21–3.26), P = 0.006 in testing set 1; HR = 1.48 (1.69–2.39), P = 0.005 in testing set 2; HR = 2.01 (1.69–2.39), P < 0.001 in meta-set]. Immunoscore-clinical prognostic signature (ICPS) was developed by integrating immunoscore and clinical characteristic, and had higher C-index than immunoscore or stage alone in all sets [0.72 (ICPS) vs. 0.7 (immunoscore) or 0.59 (stage) in training set; 0.75 vs. 0.72 or 0.7 in testing set 1; 0.65 vs. 0.61 or 0.62 in testing set 2; 0.7 vs. 0.66 or 0.64 in meta-set]. Genome analysis revealed that immunoscore was positively correlated with tumor mutation burden (R = 0.22, P < 0.001). Besides, high immunoscore was correlated with high proportion of carcinoma-associated fibroblasts (R = 0.32, P < 0.001) in tumor microenvironment but fewer CD8+ cells infiltration (R = −0.28, P < 0.001).

Conclusion: The immunoscore and ICPS are potential biomarkers for evaluating patient survival. Further investigations are required to validate and improve their prediction accuracy.

Investigating the significance of tumor-infiltrating immune cells for the prognosis of lung squamous cell carcinoma

Objective

Increasing evidence has indicated an association between immune cells infiltration in LSCC and clinical outcome. The aim of this research was tantamount to comprehensively investigate the effect of 22 tumor infiltrating immune cells (TIICs) on the prognosis of LSCC patients.

Methods

In our research, the CIBERSORT algorithm was utilized to calculate the proportion of 22 TIICs in 502 cases from the TCGA cohort. Cases with a CIBERSORT P-value of <0.05 were kept for further study. Using the CIBERSORT algorithm, we first investigated the difference of immune infiltration between normal tissue and LSCC in 22 subpopulations of immune cells. Kaplan-Meier analysis was used to analyze the effect of 22 TIICs on the prognosis of LSCC. An immune risk score model was constructed based on TIICs correlated with LSCC-related recurrence. Multivariate cox regression analysis was used to investigate whether the immune risk score was an independent factor for prognosis prediction of LSCC. Nomogram was under construction to comprehensively predict the survival rate of LSCC.

Results

The results of the different analysis showed that except of memory B cells, naive CD4+T cells, T cells and activated NK cells, the remaining immune cells all had differential infiltration in normal tissues and LSCC (p < 0.05). Kaplan-Meier analysis revealed two immune cells statistically related to LSCC-related recurrence, including activated mast cells and follicular helper T cells. Immune risk score model was constructed based on three immune cells including resting memory CD4+T cells, activated mast cells and follicular helper T cells retained by forward stepwise regression analysis. The Kaplan-Meier curve indicated that patients in the high-risk group linked to poor outcome (P = 8.277e−03). ROC curve indicated that the immune risk score model was reliable in predicting recurrence risk (AUC = 0.614). Multivariate cox regression analysis showed that the immune risk score model was just an independent factor for prognosis prediction of LSCC (HR = 2.99, 95% CI [1.65–5.40]; P = 0.0002). The nomogram model combined immune risk score and clinicopathologic parameter score to predict 3-year survival in patients with LSCC.

Conclusions

Collectively, tumor-infiltrating immune cells play a major role in the prognosis of LSCC.

Yiqi Chutan Tang Reduces Gefitinib-Induced Drug Resistance in Non-Small-Cell Lung Cancer by Targeting Apoptosis and Autophagy

High incidence and mortality rates for non-small-cell lung cancer (NSCLC) lead to low survival rates. Epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKI) are commonly first prescribed for NSCLC patients with EGFR mutations. However, most patients with sensitizing EGFR mutations become resistant to EGFR-TKI after 9-13 months treatment. Yiqi Chutan Tang (YQCT) has been prescribed as a treatment to this issue for over 20 years. In this report, high-performance liquid chromatography (HPLC) analysis, flow cytometry, western blot analysis, and functional annotation analysis were applied to uncover the molecular mechanisms of YQCT. Our results show the application of YQCT reduces gefitinib-induced drug resistance, induces slight cell cycle arrest, enhances gefitinib-induced apoptosis, and activates the autophagy. These results indicate that at the molecular level YQCT can reduce drug resistance and improve anti-cancer effects when associated with gefitinib, which could be a result of enhancement of apoptosis and autophagy in the EGFR-TKI resistant cells of NSCLC. This research provides a new treatment strategy for patients with EGFR-TKI resistance in NSCLC. © 2019 The Authors. Cytometry Part A published by Wiley Periodicals, Inc. on behalf of International Society for Advancement of Cytometry.

Down Regulation of the Expression of ELMO3 by COX2 Inhibitor Suppresses Tumor Growth and Metastasis in Non-Small-Cell Lung Cancer

Non-small cell lung cancer (NSCLC) is one of the most common malignancies. Studies have shown that engulfment and cell motility 3 (ELMO3) is highly expressed in NSCLC and can be used as a novel biomarker, but its underlying mechanism remains to be explored. The aim of this study was to investigate the mechanism by which ELMO3 may be down-regulated by COX-2 inhibitors to inhibit NSCLC. NSCLC tissue and adjacent normal lung tissue from 24 patients were used to detect the mRNA and protein expression of ELMO3, COX-2, and other related proteins by Western blot, RT-PCR, and Immunohistochemical analysis. Lewis Lung carcinoma (LLC) cells were used to investigate the effects and the mechanism of siELMO3 and COX-2 inhibitor. C57BL/6 mice inoculated with LLC cells by subcutaneous (s.c.) injection were used to detect the in vivo effects of cox-2 inhibitor. The expression of ELMO3 and cyclooxygenase-2 (COX-2) in human NSCLC tissues was significantly increased compared with that in the adjacent normal tissues. ELMO3 exhibited a positive correlation with COX-2 expression. Moreover, knockdown of ELMO3 suppressed the epithelial-mesenchymal transition (EMT), adhesion, and metastasis of Lewis lung carcinoma (LLC) cells. Importantly, Parecoxib, a selective inhibitor of COX-2, significantly reduced the expression of ELMO3 and EMT in LLC cells and LLC-bearing mice. Furthermore, it could inhibit the growth, adhesion and metastasis of LLC cells in vitro. Our results demonstrate that down regulation of ELMO3 suppressed growth and metastasis of lung cancer by inhibiting EMT. Parecoxib could reduce ELMO3 expression and suppress growth and metastasis of lung cancer, which might be a useful chemotherapeutic agent for inhibiting metastasis and recurrence of NSCLC.

Prognostic Implications of Heterogeneity in Intra-tumoral Immune Composition for Recurrence in Early Stage Lung Cancer

Background: Studies in the past have identified selected immune cells that associate with different clinical outcomes in non-small cell lung cancer (NSCLC). Considering the fact that immune responses are heterogenous and that the clinical outcome could be influenced by the interplay of various immune cell types, it is imperative to evaluate multiple intra-tumoral immune cell types in the same set of patients. Objective: To evaluate the individual and combined effects of diverse intra-tumoral immune cell types on recurrence after complete surgical resection in early stage lung adenocarcinoma. Methods: We obtained NCBI GEO datasets for lung adenocarcinoma, the most prevalent histological subtype of NSCLC and re-analyzed the gene expression data of 292 patients with early stage cancer (IA/IB). CIBERSORT was used to resolve 22 immune cell types from the tumor transcriptomes. Survival analysis was carried out to assess the effect of immune cell types and genes associated with recurrence. Results: Out of the 22 cell types, a high proportion of Tregs and monocyte-macrophages in the tumors were associated with significantly increased probability of recurrence. Conversely, increased proportion of non-Treg CD4+ T cells and plasma cells were associated with a lower probability of recurrence. The higher expression of CCL20 (which can direct the migration of cells of B cell lineage), XCL1 (associated with prototypical Th1 responses) and the immunoglobulin chains IGHV4.34 and IGLV6.57 were associated with a significantly lower probability of recurrence. Importantly, the intra-tumoral immune phenotype comprising these four cell types varied among patients and differentially associated with recurrence depending on net levels of positive and negative prognostic factors. Despite a high level of intra-tumoral plasma cells, a concomitant high level of monocyte-macrophages reduced the freedom from recurrence from ~80 to ~50% at 80 months (p < 0.05). Furthermore, stratification of the patients on the basis of a score estimated from the levels of four cell types enabled the identification of patients with significantly increased probability of recurrence (~50%) after surgery. Significance: Our analysis suggests that concomitant levels of macrophages and plasma cells, in addition to the T regs and non-TregCD4+ T cells in tumors can identify patients with early stage lung cancer at greater risk of recurrence.

[Advances in Surgical Approach and Resection of Non-small Cell Lung Cancer]

随着疾病谱的改变，肺癌的发病率和死亡率在全球范围内一直居高不下，自从外科干预被应用于肺癌的治疗，其地位日益提高，目前以外科手术为主的综合治疗已成为肺癌治疗的首选方案，外科手术入路和术式种类繁多，并且新的技术不断出现，本文拟总结不同手术方式和手术入路的研究进展。随着手术软硬件技术的发展和微创理念深入人心，胸腔镜微创手术较传统开胸手术为肺癌患者带来了更多的福音，手术方式的改变也可更大限度保留肺组织，提高患者的生存质量，相信随着各类手术适应证和手术方式的进一步规范，微创胸腔镜手术会给肺癌患者带来更多的益处。

Keratin 17 Promotes Lung Adenocarcinoma Progression by Enhancing Cell Proliferation and Invasion

Backgrounds

Lung adenocarcinoma (LAC) accounts for the majority of lung cancer, which is the leading cause of cancer-related mortality worldwide. Keratin 17 (KRT17) was reported to promote the tumor development of skin tumor and oral cancer. The aim of this study was to investigate the expression and function of KRT17 in LAC.

Material/Methods

Immunohistochemical staining and quantitative PCR were performed to explore the expression of KRT17 in both LAC tissues and adjacent normal liver tissues. Chi-square test, univariate analysis, and multivariate analysis were conducted to statistically evaluate the clinical significance of KRT17 in LAC. Proliferation, migration, and invasion capacities of LAC cells were assessed after overexpression or silencing KRT17.

Results

Both the RNA and protein levels of KRT17 were up-regulated in LAC tissues compared to normal lung tissues. High expression of KRT17 was correlated with advanced TNM stage and poor overall survival. Moreover, KRT17 was identified as a novel independent prognostic factor for LAC patients. Cellular studies showed that KRT17 can enhance the proliferation, migration, and invasion capacities of LAC cells, thereby promoting tumor progression.

Conclusions

High expression of KRT17 is frequent in LAC tissues, which promotes tumor proliferation and invasion, and is correlated with a poor overall survival. Targeting KRT17 may be a novel direction for LAC drug development.

Gram-negative bacteria facilitate tumor progression through TLR4/IL-33 pathway in patients with non-small-cell lung cancer

Non-small-cell lung cancer (NSCLC) accounts for the most cases in clinical lung cancer patients. Patients with NSCLC are often diagnosed in advanced stage and frequently infected with gram-negative bacteria. Pulmonary infection with gram-negative bacteria is the most frequent postoperative complication in NSCLC patients. While accumulating evidence indicate an involvement of gram-negative bacteria in NSCLC progression, the underlying mechanisms remain largely unknown. Herein, we explored the effect of gram-negative bacteria on tumor progression using tumor cells from NSCLC patients. We observed that infection with gram-negative bacteria predicted advanced stages and decreased time interval to recurrence of NSCLC patients. Incubation of NSCLC cells with gram-negative bacteria promoted their growth and metastasis. Mechanistically, gram-negative bacteria activated Toll-like receptor 4 (TLR4) signaling in NSCLC cells, leading to increased mRNA and protein expression of interleukin 33 (IL-33) through MyD88-dependent pathway. Knockdown of IL-33 abrogated the contribution of gram-negative bacteria to NSCLC progression by regulating cancer metabolic activities and stem cell properties. In NSCLC patients, higher TLR4 expression was associated with increased IL-33 expression, Ki-67 proliferation index and CD133 expression in those with gram-negative bacterial infection. These findings shed new light on the molecular mechanisms underlie gram-negative bacteria mediated tumor progression and provide clues for innovative therapeutic explorations for NSCLC patients.

Discrimination of Malignant versus Benign Mediastinal Lymph Nodes Using Diffusion MRI with an IVIM Model

OBJECTIVES

To investigate the value of an intravoxel incoherent motion (IVIM) diffusion model for discriminating malignant versus benign mediastinal lymph nodes (MLN).

METHODS

Thirty-five subjects with enlarged MLN were scanned at 1.5 Tesla. Diffusion-weighted imaging was performed with eight b-values. IVIM parameters D, D*, and f, as well as apparent diffusion coefficient (ADC) from a mono-exponential model were obtained. 91 nodes (49 malignant and 42 benign) were analysed with pathologic (n=90) or radiologic (n=1) confirmations. Receiver operating characteristic (ROC) analysis was used to evaluate the diagnostic performance.

RESULTS

The mean values of D, ADC, and f for the malignant group were significantly lower than those for the benign group (p<0.001), while D* showed no significant difference (p=0.281). In the ROC analysis, the combination of D and f produced the largest area under the curve (0.953) compared to ADC or other individual IVIM parameters, leading to the best specificity (92.9%) and diagnostic accuracy (90.1%).

CONCLUSION

This study demonstrates that the combination of IVIM parameters can improve differentiation between malignant and benign MLN as compared to using ADC alone.

KEY POINTS

• Diffusion MRI is useful for non-invasively discriminating malignant versus benign lymph nodes. • A mono-exponential model is not adequate to characterise diffusion process in lymph nodes. • IVIM model is advantageous over mono-exponential model for assessing lymph node malignancy. • Combination of IVIM parameters improves differentiation of malignant versus benign lymph nodes.

Shikonin enhances Adriamycin antitumor effects by inhibiting efflux pumps in A549 cells

Shikonin (SHK) is a natural naphthoquinone pigment isolated from Lithospermum erythrorhizon, that has been reported to suppress the growth of a number of cancer cell types. Adriamycin (AD) is typically used as an effective anticancer agent; however, it has the propensity to induce drug resistance. The aim of the present study was to investigate the effects of SHK alone and in combination with AD on lung adenocarcinoma cells and the underlying molecular mechanisms of their effects. Colony formation, MTT and propidium iodide staining assays demonstrated that the co-treatment of A549 cells with SHK and AD significantly decreased cell viability and potently induced apoptosis. The mitochondrial membrane potential was assessed using 5,5', 6,6'-tetrachloro-1,1',3,3'-tetraethyl-benzimidazolylcarbocyanine iodide staining and fluorescence microscopy. Cells co-treated with SHK and AD exhibited marked mitochondrial membrane damage. In addition, co-treatment with SHK and AD significantly reduced ATP levels in A549 cells compared with the control. Western blot analysis revealed that SHK enhanced the antitumor effects of AD by inhibiting the expression of ATP-binding cassette transporters. These results suggest that the inhibition of glycolysis could be an effective approach for lung cancer treatment. Therefore, SHK has the potential to be used as an anticancer agent in the treatment of lung adenocarcinoma, and thus warrants further investigation and development.

Clinicopathological and prognostic significance of Oct-4 expression in patients with non-small cell lung cancer: a systematic review and meta-analysis

BACKGROUND

Octamer-binding transcription factor 4 (Oct-4) has been identified to participate in the tumorigenicity and malignancy of non-small cell lung cancer (NSCLC). However, its definite prognostic roles in NSCLC still remain a debate. Therefore, we conducted this meta-analysis to evaluate the prognostic value of Oct-4 expression in NSCLC and its relationship to some major clinicopathological characteristics.

METHODS

A comprehensive literature retrieval was performed in PubMed, EMBASE and the Web of Science to identify the full-text articles that met our eligibility criteria. Odds ratio (OR) with 95% confidence interval (CI) severed as the summarized statistics for clinicopathological assessments, and hazard ratio (HR) with 95% CI served as the summarized statistics for prognostic assessments. Q-test and I(2)-statistic were used to evaluate the level of heterogeneity. Potential publication bias was detected by both Begg's test and Egger's test.

RESULTS

There were 16 retried articles with 1,363 NSCLC cases included into this meta-analysis. Oct-4 expression was found to be significantly associated with the unfavorable outcomes for differentiation degree (OR: 3.065; 95% CI: 1.568-5.957; P=0.001), TNM stage (OR: 3.695; 95% CI: 2.252-6.063; P<0.001) and lymphatic metastasis (OR: 2.372; 95% CI: 1.504-3.742; P<0.001), but not associated with the histological subtypes, gender, age and smoking status. Oct-4 expression was also significantly associated with the poor prognosis of NSCLC (HR: 3.030; 95% CI: 2.283-4.021; P<0.001). The prognostic roles of Oct-4 expression in NSCLC still remained statistically reliable in the subgroups stratified by statistical analysis, patients' origins, positively-stained sites and histological subtypes.

CONCLUSIONS

Our meta-analysis indicates that Oct-4 can serve as a strong biomarker predicting the poor clinicopathological and prognostic characteristics of NSCLC. More high-quality studies based on a large sample size will be very helpful to further validate and modify our findings in the future.

Resveratrol overcomes gefitinib resistance by increasing the intracellular gefitinib concentration and triggering apoptosis, autophagy and senescence in PC9/G NSCLC cells

Gefitinib (Gef) provides clinical benefits to non-small cell lung cancer (NSCLC) patients with activating EGFR mutations. However, acquired resistance (AR) is a major obstacle to effective Gef therapy. This study demonstrated that resveratrol (Res) could synergize with Gef to inhibit the proliferation of Gef-resistant NSCLC cells. The underlying mechanisms of synergism were investigated, and the results showed that cotreatment with Gef and Res could inhibit EGFR phosphorylation by increasing intracellular Gef accumulation through the impairment of Gef elimination from PC9/G cells. Consistently, CYP1A1 and ABCG2 expression were inhibited. Meanwhile, the cotreatment significantly induced cell apoptosis, autophagy, cell cycle arrest and senescence accompanied by increased expression of cleaved caspase-3, LC3B-II, p53 and p21. Further studies revealed that autophagy inhibition enhanced apoptosis and abrogated senescence while apoptosis inhibition had no notable effect on cell autophagy and senescence during cotreatment with Gef and Res. These results indicated that in addition to apoptosis, senescence promoted by autophagy contributes to the antiproliferation effect of combined Gef and Res on PC9/G cells. In conclusion, combined treatment with Gef and Res may represent a rational strategy to overcome AR in NSCLC cells.

DDMC-p53 gene therapy with or without cisplatin and microwave ablation

Lung cancer remains the leading cause of death in cancer patients. Severe treatment side effects and late stage of disease at diagnosis continue to be an issue. We investigated whether local treatment using 2-diethylaminoethyl-dextran methyl methacrylate copolymer with p53 (DDMC-p53) with or without cisplatin and/or microwave ablation enhances disease control in BALBC mice. We used a Lewis lung carcinoma cell line to inoculate 140 BALBC mice, which were divided into the following seven groups; control, cisplatin, microwave ablation, DDMC-p53, DDMC-p53 plus cisplatin, DDMC-p53 plus microwave, and DDMC-p53 plus cisplatin plus microwave. Microwave ablation energy was administered at 20 W for 10 minutes. Cisplatin was administered as 1 mL/mg and the DDMC-p53 complex delivered was 0.5 mL. Increased toxicity was observed in the group receiving DDMC-p53 plus cisplatin plus microwave followed by the group receiving DDMC-p53 plus cisplatin. Infection after repeated treatment administration was a major issue. We conclude that a combination of gene therapy using DDMC-p53 with or without cisplatin and microwave is an alternative method for local disease control. However, more experiments are required in a larger model to identify the appropriate dosage profile.

Shikonin Induces Apoptosis, Necrosis, and Premature Senescence of Human A549 Lung Cancer Cells through Upregulation of p53 Expression

Shikonin, a natural naphthoquinone pigment isolated from Lithospermum erythrorhizon, has been reported to suppress growth of various cancer cells. This study was aimed to investigate whether this chemical could also inhibit cell growth of lung cancer cells and, if so, works via what molecular mechanism. To fulfill this, A549 lung cancer cells were treated with shikonin and then subjected to microscopic, biochemical, flow cytometric, and molecular analyses. Compared with the controls, shikonin significantly induced cell apoptosis and reduced proliferation in a dose-dependent manner. Specially, lower concentrations of shikonin (1-2.5 μg/mL) cause viability reduction; apoptosis and cellular senescence induction is associated with upregulated expressions of cell cycle- and apoptotic signaling-regulatory proteins, while higher concentrations (5-10 μg/mL) precipitate both apoptosis and necrosis. Treatment of cells with pifithrin-α, a specific inhibitor of p53, suppressed shikonin-induced apoptosis and premature senescence, suggesting the role of p53 in mediating the actions of shikonin on regulation of lung cancer cell proliferation. These results indicate the potential and dose-related cytotoxic actions of shikonin on A549 lung cancer cells via p53-mediated cell fate pathways and raise shikonin a promising adjuvant chemotherapeutic agent for treatment of lung cancer in clinical practice.

The new IASLC/ATS/ERS lung adenocarcinoma classification from a clinical perspective: current concepts and future prospects

The new the International Association for the Study of Lung Cancer (IASLC)/the American Thoracic Society (ATS)/the European Respiratory Society (ERS) pathologic classification of lung cancer has markedly changed the pathologic diagnosis of lung adenocarcinoma. This classification deals with many aspects that directly affect clinical practice, and opens new gateways for future research. By means of a multidisciplinary approach, it differs significantly from the former 2004 the World Health Organization (WHO) classification, which was mainly written by pathologist. The present review, in line with the consensus article, is divided in two components: the diagnosis and classification of lung adenocarcinoma in resection specimens and the diagnosis of lung cancer in small biopsies and cytology. Resection specimens are currently classified according to the predominant histologic pattern after comprehensive subtyping in 5% increments. This approach has led to the addition of new pathologic subtypes [adenocarcinoma in situ (AIS), minimally invasive adenocarcinoma (MIA) and micropapillary predominant adenocarcinoma)] and to the discontinuation of some heterogeneous entities included in the former 2004 WHO classification (mixed subtype adenocarcinoma and bronchioloalveolar carcinoma). Overall, these changes have resulted in a better stratification of lung adenocarcinoma tumors in more homogeneous morphologic, clinical and biological subgroups. Pathologic subtyping has demonstrated prognostic utility in resected stage I-III patients, and recent data support their predictive role for the benefit of adjuvant chemotherapy. Moreover, comprehensive pathologic subtyping may potentially affect TNM staging and surgical management or early-stage tumors. On the other hand, for the first time, the novel pathologic classification provides standardized terminology and diagnostic criteria of small biopsies and cytology. Criteria are proposed not only for adenocarcinoma but also for other histologies, but special emphasis was put on the distinction between adenocarcinoma and squamous-cell carcinoma due to its major clinical implications. This review outlines the main issues of the new lung adenocarcinoma classification from a clinical perspective. We describe the different pathologic subtypes in resection specimens, with their most relevant clinical implications. Further on, we address the new terminology and diagnostic criteria for lung adenocarcinomas in small specimens, oriented to their importance for the management and treatment of metastatic lung cancer patients. Finally, we discuss some unanswered questions and relevant issues for the near future.

Log odds of positive lymph nodes are superior to other measures for evaluating the prognosis of non-small cell lung cancer

BACKGROUND

To evaluate the ability of the log odds of positive lymph nodes to predict prognosis in patients with non-small cell lung cancer (NSCLC).

METHODS

Correlations between the log odds of positive lymph nodes, numbers of dissected lymph nodes, dissected lymph node stations, positive lymph nodes, positive lymph node ratio, and positive lymph node stations were retrospectively evaluated using Pearson correlation coefficients (r), survival analysis by Kaplan-Meier, Cox hazard ratio model, and log-rank tests.

RESULTS

The numbers of dissected lymph nodes, positive lymph nodes, dissected lymph node stations and positive lymph node stations significantly correlated with the log odds of positive lymph nodes (P < 0.001, P < 0.001, P = 0.002 and P < 0.001, respectively). The five-year survival ratio of postoperative patients with the log odds of positive lymph nodes <11.412 and >-1.412 were 63.9% and 32.5%, respectively (P < 0.001). According to multivariate analysis, age and log odds of positive lymph nodes are independent risk factors for overall survival (hazard ratio = 2.660, 95% confidence interval 2.114-3.346, P < 0.001). A new staging system featuring a combination of log odds of positive lymph nodes and a tumor node metastasis (TNM) staging system was established for predicting survival.

CONCLUSION

The log odds of positive lymph nodes are superior to the positive lymph node ratio and p-N-stage for predicting prognosis of NSCLC. A new staging system that combines log odds of positive lymph nodes and the current TNM staging system predicts prognosis more accurately than the TNM system alone.

Clinical significance of serum T helper 1/T helper 2 cytokine shift in patients with non-small cell lung cancer

The aim of this study was to explore the T helper 1 (Th1)/Th2 cytokine shift and its clinical significance in the peripheral blood and tumor tissues of non-small cell lung cancer (NSCLC) patients. In total, 124 NSCLC patients who were admitted to Xinxiang Central Hospital were selected, along with 124 healthy individuals undergoing physical examination at the same hospital during this period (as controls). ELISA was conducted to detect the Th1 and Th2 cytokine levels in the peripheral blood of patients in the two groups prior to and following radical surgery treatment. In addition, the Th1 and Th2 cytokine levels in the peripheral blood of the observation group were measured following surgery to analyze the correlation between relapse and survival. Compared with the control group, interleukin 4 (IL-4) and IL-10 concentrations in the peripheral blood of the observation group, prior to and following surgery, were significantly higher, whilst IL-2 and interferon-γ (INF-γ) concentrations were significantly lower (P<0.05). In the observation group, the IL-4 and IL-10 concentrations were significantly decreased following surgery, as compared with prior to surgery (P<0.05), whilst the IL-2 and INF-γ concentrations increased significantly (P<0.05). The one- and three-year cumulative relapse frequencies of patients with postoperative IL-4 abnormalities were significantly increased compared with those in patients with normal IL-4 levels following surgery (P<0.05), and the median survival time and survival rate significantly decreased in patients with postoperative IL-4 abnormalities (P<0.05). In terms of the three-year cumulative relapse rate, median survival time, and one- and three-year cumulative survival rate, patients with postoperative IL-2, IL-10 and INF-γ level abnormalities did not present any statistical significance compared with those without such abnormalities (P>0.05). In conclusion, Th2 cytokines dominate the peripheral blood of NSCLC patients and radical surgery treatment may improve the Th1/Th2 shift in patients. Furthermore, postoperative IL-4 levels were observed to correlate with relapse and the survival rate of patients; therefore, IL-4 may be considered as an auxiliary in the postoperative diagnosis during clinical practice.

A multifactoral analysis of 1452 patients for smoking sensation. An outpatient lab experience

Smoking habit is held responsible for several respiratory and metabolic diseases. Data from 1452 patients were recorded from our outpatient laboratory. The following parameters were recorded within several follow ups of our patients; smoking habit, respiratory functions, smoking cessation questionnaires, and administered drugs. The treatment administered to smokers throughout the period of inspection seems to also have a significant effect on dependence. In fact, varelicline causes a 50% reduction in smoking dependence in regards to nicotine substitutes (odds ratio: 0.48 (0.31-0,74), p=0.001) so displaying a substantial preponderance on the choice to fight smoking dependence.

A retrospective analysis of the effect of intraoperative opioid dose on cancer recurrence after non-small cell lung cancer resection

Preclinical studies have demonstrated that opioid receptor agonists increase the rate of non-small cell lung cancer (NSCLC) growth and metastasis. Following institutional review board approval, we retrieved data on 901 patients who underwent surgery for NSCLC at MD Anderson Cancer Center. Comprehensive demographics, intraoperative data, and recurrence-free survival (RFS) and overall survival (OS) at 3 and 5 years were obtained. Cox proportional analyses were conducted to assess the association between intraoperative opioid exposure and RFS and OS. The median intraoperative fentanyl equivalents dosage was 10.15 μg/kg. The multivariate analysis by stage indicated that a trend toward significance for opioid consumption as a risk factor in stage I patients (P = 0.053). No effect was found on RFS for stage II or III patients. Alternatively, opioid consumption was a risk factor for OS for stage I patients (P = 0.036), whereas no effect was noted for stage II or III patients. Intraoperative opioid use is associated with decreased OS in stage I but not stage II–III NSCLC patients. Until randomized controlled studies explore this association further, opioids should continue to be a key component of balanced anesthesia.

Lung cancer with chest wall invasion: retrospective analysis comparing en-bloc resection and 'resection in bird cage'

Background

Invasion of the chest wall per se is not a contraindication for tumor resection in non-small cell lung cancer (NSCLC), provided there is no mediastinal lymph node or vital structure involvement. Although widely known to Brazilian surgeons, the ‘resection in bird cage’ technique has never been widely studied in terms of patient survival. Thus, the objective of this study was to evaluate the postoperative consequences and overall survival of extra-musculoperiosteal resection compared with en-bloc resection in NSCLC patients with invasion of the endothoracic fascia.

Methods

Between January 1990 and December 2009, 33 NSCLC patients with invasion of the thoracic wall who underwent pulmonary resection were retrospectively analyzed. Of the 33 patients evaluated, 20 patients underwent en-bloc resection and 13 underwent ‘resection in bird cage.’ For each patient, a retrospective case note review was made.

Results

The median age at surgery, gender, indication, rate of comorbidities, tumor size and the degree of uptake in the costal margin were similar for both groups. The rate of postoperative complications and the duration of hospitalization did not differ between the groups. Regarding the outcome variables, the disease-free interval, rate of local recurrence, metastasis-free time after surgery, overall mortality rate, mortality rate related to metastatic disease, duration following surgery in which deaths occurred, and overall survival were also similar between groups. The cumulative survival curves between the ‘resection in bird cage’ and en-bloc resection and between stages Ia + Ib and IIb + IIIa + IV were not significantly different (p = 0.68 and p = 0.64, respectively). The cumulative metastasis-free survival curves were not significantly different between the two types of surgery (p = 0.38).

Conclusions

In NSCLC patients with invasion of the endothoracic fascia, ‘resection in bird cage’ is a less aggressive procedure that yields similar results in terms of morbidity and mortality compared with en-bloc resection. Thus, ‘resection in bird cage’ meets the oncologic principles of resection and does not adversely affect the patients in terms of cure.