Advances in lung adenocarcinoma classification: a summary of the new international multidisciplinary classification system (IASLC/ATS/ERS)

Development and Validation of a Risk Stratification Model of Pulmonary Ground-Glass Nodules Based on Complementary Lung-RADS 1.1 and Deep Learning Scores

Purpose

To assess the value of novel deep learning (DL) scores combined with complementary lung imaging reporting and data system 1.1 (cLung-RADS 1.1) in managing the risk stratification of ground-glass nodules (GGNs) and therefore improving the efficiency of lung cancer (LC) screening in China.

Materials and Methods

Overall, 506 patients with 561 GGNs on routine computed tomography images, obtained between January 2017 and March 2021, were enrolled in this single-center, retrospective Chinese study. Moreover, the cLung-RADS 1.1 was previously validated, and the DL algorithms were based on a multi-stage, three-dimensional DL-based convolutional neural network. Therefore, the DL-based cLung-RADS 1.1 model was created using a combination of the risk scores of DL and category of cLung-RADS 1.1. The recall rate, precision, accuracy, per-class F1 score, weighted average F1 score (F1_weighted), Matthews correlation coefficient (MCC), and area under the curve (AUC) were used to evaluate the performance of DL-based cLung-RADS 1.1.

Results

The percentage of neoplastic lesions appeared as GGNs in our study was 95.72% (537/561) after long-period follow-up.Compared to cLung-RADS 1.1 model or DL model, The DL-based cLung-RADS 1.1 model achieved the excellent performance with F1 scores of 95.96% and 95.58%, F1_weighted values of 97.49 and 96.62%, accuracies of 92.38 and 91.77%, and MCCs of 32.43 and 37.15% in the training and validation tests, respectively. The combined model achieved the best AUCs of 0.753 (0.526–0.980) and 0.734 (0.585–0.884) for the training and validation tests, respectively.

Conclusion

The DL-based cLung-RADS 1.1 model shows the best performance in risk stratification management of GGNs, which demonstrates substantial promise for developing a more effective personalized lung neoplasm management paradigm for LC screening in China.

Combined Radiomic and Visual Assessment for Improved Detection of Lung Adenocarcinoma Invasiveness on Computed Tomography Scans: A Multi-Institutional Study

Objective

The timing and nature of surgical intervention for semisolid abnormalities are dependent upon distinguishing between adenocarcinoma-in-situ (AIS), minimally invasive adenocarcinoma (MIA), and invasive adenocarcinoma (INV). We sought to develop and evaluate a quantitative imaging method to determine invasiveness of small, ground-glass lesions on computed tomography (CT) chest scans.

Methods

The study comprised 268 patients from 4 institutions with resected (<=3 cm) semisolid lesions with confirmed histopathological diagnosis of MIA/AIS or INV. A total of 248 radiomic texture features from within the tumor nodule (intratumoral) and adjacent to the nodule (peritumoral) were extracted from manually annotated lung nodules of chest CT scans. The datasets were randomly divided, with 40% of patients used for training and 60% used for testing the machine classifier (Training D_Train, N=106; Testing, D_Test, N=162).

Results

The top five radiomic stable features included four intratumoral (Laws and Haralick feature families) and one peritumoral feature within 3 to 6 mm of the nodule (CoLlAGe feature family), which successfully differentiated INV from MIA/AIS nodules with an AUC of 0.917 [0.867-0.967] on D_Train and 0.863 [0.79-0.931] on D_Test. The radiomics model successfully differentiated INV from MIA cases (<1 cm AUC: 0.76 [0.53-0.98], 1-2 cm AUC: 0.92 [0.85-0.98], 2-3 cm AUC: 0.95 [0.88-1]). The final integrated model combining the classifier with the radiologists’ score gave the best AUC on D_Test (AUC=0.909, p<0.001).

Conclusions

Addition of advanced image analysis via radiomics to the routine visual assessment of CT scans help better differentiate adenocarcinoma subtypes and can aid in clinical decision making. Further prospective validation in this direction is warranted.

Feasibility and Safety of Neoadjuvant Alectinib in Pulmonary Invasive Mucinous Adenocarcinoma with ALK Rearrangement: Case Report and Literature Review

Background

Pulmonary invasive mucinous adenocarcinoma (IMA) is a rare variant of lung adenocarcinoma that rarely shows anaplastic lymphoma kinase (ALK) rearrangement. Alectinib (tyrosine kinase inhibitors) has been listed as category 1 recommendations for advanced ALK + NSCLC first-line therapy due to low toxicity and excellent efficacy, and its median progression-free survival is 34.8 months. Here, we report a case of a patient with ALK-rearranged lung IMA who showed favorable results to neoadjuvant alectinib.

Case

A 67-year-old man with no history of smoking was diagnosed with clinical stage as IIIB invasive mucinous adenocarcinoma based on clinical symptoms, chest CT and pathological findings. The anaplastic lymphoma kinase (ALK) fusion status was assessed by real-time PCR. After acquiring informed consent from the patient, we offered neoadjuvant alectinib at a dosage of 150 mg twice per day for three cycles (84 days), all lesions were undetectable on chest CT. Later, a thoracoscopic left lobectomy was performed. The postoperative pathological showed that a small amount of tumor cells remained, and the TNM stage was downstaged as T1aN0M0 IA.

Conclusion

To our knowledge, this is the first case discussing the treatment of ALK-rearranged IMA of the lung with neoadjuvant alectinib. Alectinib is an effective ALK inhibitor, and in cases of lung adenocarcinoma with ALK rearrangement, alectinib treatment is a reasonable and priority option. Neoadjuvant alectinib may be clinically feasible and well tolerated in locally advanced NSCLC.

Survival and Treatment of Lung Cancer in Taiwan between 2010 and 2016

Background: Lung cancer is the leading cause of cancer-related death, and its incidence is still growing in Taiwan. This study investigated the prognostic factors of overall survival between 2010 and 2016 in Taiwan. Methods: Data from 2010 to 2016 was collected from the Taiwan Cancer Registry (TCR). The characteristics and overall survival of 71,334 lung cancer patients were analyzed according to the tumor, node, metastasis (TNM) 7th staging system. Univariate and multivariate analysis were performed to identify the prognostic factors. Results: The five-year overall survival (n = 71,334) was 25.0%, and the median survival was 25.3 months. The five-year overall survival of patients receiving any kind of treatment (n = 65,436; 91.7%) and surgical resection (n = 20,131; 28.2%) was 27.09% and 69.93%, respectively. The clinical staging distribution was as follows: stage IA (9208, 12.9%), stage IB (4087, 5.7%), stage IIA (1702, 2.4%), stage IIB (1454, 2.0%), stage IIIA (5309, 7.4%), stage IIIB (6316, 8.9%), stage IV (41458, 58.1%). Age, sex, Charlson comorbidity index, cell type, clinical T, clinical N, clinical M, grading and treatment strategy are independent prognostic factors in the multivariate analysis. Conclusion: The outcome for lung cancer patients was still poor. The identification of prognostic factors could facilitate in choosing treatment strategies and designing further randomized clinical trials.

Identification of Tumor Microenvironment-Related Prognostic lncRNAs in Lung Adenocarcinoma

Background

Lung adenocarcinoma (LUAD) is the most common type of lung cancer and is a severe threat to human health. Although many therapies have been applied to LUAD, the long-term survival rate of patients remains unsatisfactory. We aim to find reliable immune microenvironment-related lncRNA biomarkers to improve LUAD prognosis.

Methods

ESTIMATE analysis was performed to evaluate the degree of immune infiltration of each patient in TAGA LUAD cohort. Correlation analysis was used to identify the immune microenvironment-related lncRNAs. Univariate cox regression analysis, LASSO analysis, and Kaplan Meier analysis were used to construct and validate the prognostic model based on microenvironment-related lncRNAs.

Results

We obtained 1,178 immune microenvironment-related lncRNAs after correlation analysis. One hundred and eighty of them are independent prognostic lncRNAs. Sixteen key lncRNAs were selected by LASSO method. This lncRNA-based model successfully predicted patients’ prognosis in validation cohort, and the risk score was related to pathological stage. Besides, we also found that TP53 had the highest frequency mutation in LUAD, and the mutation of TP53 in the high-risk group, which was identified by our survival model, has a poor prognosis. lncRNA-mRNA co-expression network further suggested that these lncRNAs play a vital role in the prognosis of LUAD.

Conclusion

Here, we filtered 16 key lncRNAs, which could predict the survival of LUAD and may be potential biomarkers and therapeutic targets.

2020 Innovation-Based Optimism for Lung Cancer Outcomes

Lung cancer is the leading cause of cancer death in both males and females in the U.S. and worldwide. Owing to advances in prevention, screening/early detection, and therapy, lung cancer mortality rates are decreasing and survival rates are increasing. These innovations are based on scientific discoveries in imaging, diagnostics, genomics, molecular therapy, and immunotherapy. Outcomes have improved in all histologies and stages. This review provides information on the clinical implications of these innovations that are practical for the practicing physicians, especially oncologists of all specialities who diagnose and treat patients with lung cancer. IMPLICATIONS FOR PRACTICE: Lung cancer survival rates have improved because of new prevention, screening, and therapy methods. This work provides a review of current standards for each of these areas, including targeted and immunotherapies. Treatment recommendations are provided for all stages of lung cancer.

The promises and challenges of early non-small cell lung cancer detection: patient perceptions, low-dose CT screening, bronchoscopy and biomarkers

Lung cancer survival statistics are sobering with survival ranking among the poorest of all cancers despite the addition of targeted therapies and immunotherapies. However, improvements in tools for early detection hold promise. The Nederlands–Leuvens Longkanker Screenings Onderzoek (NELSON) trial recently corroborated the findings from the previous National Lung Screening Trial low‐dose Computerised Tomography (NLST) screening trial in reducing lung cancer mortality. Biomarker research and development is increasing at pace as the molecular life histories of lung cancers become further unravelled. Low‐dose CT screening (LDCT) is effective but targets only those at the highest risk and is burdensome on healthcare. An optimally designed CT screening programme at best will only detect a low proportion of overall lung cancers as only those at very high‐risk meet screening criteria. Biomarkers that help risk stratify suitable patients for LDCT screening, and those that assist in determining which LDCT detected nodules are likely to represent malignant disease are needed. Some biomarkers have been proposed as standalone lung cancer diagnosis tools. Bronchoscopy technology is improving, with better capacity to identify and obtain samples from early lung cancers. Clinicians need to be aware of each early lung cancer detection method’s inherent limitations. We anticipate that the future of early lung cancer diagnosis will involve a synergistic, multimodal approach, combining several early detection methods.

Synchronous multiple primary lung cancers with shared EGFR mutation but differential imaging findings and pathological subtypes: A case report

Lung cancer is a leading cause of cancer mortality worldwide. As the incidence of lung cancer increases in recent years, the number of patients diagnosed with synchronous multiple primary lung cancers (SMPLC) is also rising. SMPLC diagnosis is often made based on the clinical course, imaging findings, and histologic and molecular features. Standard lobectomy is the main therapeutic modality for SMPLC. Because maximum retention of lung function is essential, sublobectomy is also a commonly used surgical strategy when appropriate. The question is how to optimize the sequence of lobectomy and sublobectomy for patients with SMPLC. Thoracoscope lobectomy for the primary lesion plus sublobectomy for the secondary lesions is the most commonly used approach. Here we present a case of SMPLC with sublobectomy followed by lobectomy.

Molecular differences across invasive lung adenocarcinoma morphological subgroups

Background

Lung adenocarcinomas (ADCs) show heterogeneous morphological patterns that are classified into five subgroups: lepidic predominant, papillary predominant, acinar predominant, micropapillary predominant and solid predominant. The morphological classification of ADCs has been reported to be associated with patient prognosis and adjuvant chemotherapy response. However, the molecular mechanisms underlying the morphology differences among different subgroups remain largely unknown.

Methods

Using the molecular profiling data from The Cancer Genome Atlas (TCGA) lung ADC (LUAD) cohort, we studied the molecular differences across invasive ADC morphological subgroups.

Results

We showed that the expression of proteins and mRNAs, but not the gene mutations copy number alterations (CNA), were significantly associated with lung ADC morphological subgroups. In addition, expression of the FOXM1 gene (which is negatively associated with patient survival) likely plays an important role in the morphological differences among different subgroups. Moreover, we found that protein abundance of PD-L1 were associated with the malignancy of subgroups. These results were validated in an independent cohort.

Conclusions

This study provides insights into the molecular differences among different lung ADC morphological subgroups, which could lead to potential subgroup-specific therapies.

The role of monoamine oxidase A in HPV-16 E7-induced epithelial-mesenchymal transition and HIF-1α protein accumulation in non-small cell lung cancer cells

Our previous studies have found that human papillomavirus (HPV)-16 E7 oncoprotein promotes epithelial-mesenchymal transition (EMT) and hypoxia-inducible factor-1α (HIF-1α) protein accumulation in non-small cell lung cancer (NSCLC) cells and monoamine oxidase A (MAOA) is highly expressed in NSCLC tissues. Here, we further explored the role of MAOA in HPV-16 E7-induced EMT and HIF-1α protein accumulation in A549 and NCI-H460 NSCLC cells. Our results showed that HPV-16 E7 enhanced MAOA expression in NSCLC cells. Additionally, MAOA knockout inhibited HPV-16 E7-induced migration, invasion, and EMT, and significantly reduced HPV-16 E7-induced ROS generation and HIF-1α protein accumulation via promoting its degradation. Furthermore, MAOA knockout suppressed HPV-16 E7-induced ERK1/2 activation. In vivo, MAOA knockout inhibited tumor growth, metastasis, and the expression of EMT-related markers and HIF-1α proteins induced by HPV-16 E7 in NCI-H460 NSCLC subcutaneous xenograft and in situ intrapulmonary models of nude mice. Taken together, our findings provide evidence that MAOA plays a key role in EMT and HIF-1α protein accumulation induced by HPV-16 E7 in NSCLC cells, suggesting that MAOA may be a potential therapeutic target for HPV-related NSCLC.

Heterogeneity of Glucose Transport in Lung Cancer

Increased glucose uptake is a known hallmark of cancer. Cancer cells need glucose for energy production via glycolysis and the tricarboxylic acid cycle, and also to fuel the pentose phosphate pathway, the serine biosynthetic pathway, lipogenesis, and the hexosamine pathway. For this reason, glucose transport inhibition is an emerging new treatment for different malignancies, including lung cancer. However, studies both in animal models and in humans have shown high levels of heterogeneity in the utilization of glucose and other metabolites in cancer, unveiling a complexity that is difficult to target therapeutically. Here, we present an overview of different levels of heterogeneity in glucose uptake and utilization in lung cancer, with diagnostic and therapeutic implications.

Adenocarcinoma of the Lung Presenting with Intrapulmonary Miliary Metastasis

Miliary mottling on imaging is usually infectious in etiology and is less commonly seen with metastatic cancers. The cancers that are reported to cause miliary metastases include secondaries from cancers of the thyroid, kidney, trophoblasts, etc. Here, we report a case of a 63-year-old female who presented with prolonged cough and shortness of breath and whose imaging showed diffuse bilateral miliary nodules. Bronchoscopy with a transbronchial biopsy confirmed the diagnosis as adenocarcinoma of the lung with intrapulmonary miliary metastasis. Treatment with a combination of pemetrexed and carboplatin was not helpful and cancer had spread diffusely across the lung on repeat imaging after three months. It is essential to consider this clinical presentation as a separate subtype, with specific treatment protocols as compared to primary adenocarcinoma of the lung.

CT and clinical characteristics that predict risk of EGFR mutation in non-small cell lung cancer: a systematic review and meta-analysis

INTRODUCTION

To systematically analyze CT and clinical characteristics to find out the risk factors of epidermal growth factor receptor (EGFR) mutation in non-small cell lung cancer (NSCLC). Then the significant characteristics were used to set up a mathematic model to predict EGFR mutation in NSCLC.

MATERIALS AND METHODS

PubMed, Web of Knowledge and EMBASE up to August 17, 2018 were systematically searched for relevant studies that investigated the evidence of association between CT and clinical characteristics and EGFR mutation in NSCLC. After study selection, data extraction, and quality assessment, the pooled odds ratios (ORs) were calculated. Then from May 2017 to August 2018, all NSCLC received EGFR mutation examination and CT examination in our hospital were chosen to test the prediction model by receiver operating characteristic (ROC) curves.

RESULTS

Seventeen original studies met the inclusion criteria. The results showed that the ORs of ground-glass opacity (GGO), air bronchogram, pleural retraction, vascular convergence, smoking history, female gender were, respectively, 1.93 (P = 0.003), 2.09 (P = 0.03), 1.59 (P < 0.01), 1.61 (P = 0.001), 0.28 (P < 0.01), 0.35 (P < 0.01). The result of speculation, cavitation/bubble-like lucency, lesion shape, margin, pathological stage were, respectively, 1.19 (P = 0.32), 0.99 (P = 0.97), 0.82 (P = 0.42), 1.02 (P = 0.90), 0.77 (P = 0.30). 121 NSCLC received EGFR mutation test were included to test the prediction model. The mathematical model based on the results of meta-analysis was: 0.74 × air bronchogram + 0.46 × pleural retraction + 0.48 × vascular convergence - 1.27 × non-smoking history - 1.05 × female. The area under the ROC curve was 0.68.

CONCLUSION

Based on the current evidence, GGO presence, air bronchogram, pleural retraction, vascular convergence were significant risk factors of EGFR mutation in NSCLC. And the prediction model can help to predict EGFR mutation status.

Detection of pulmonary ground-glass opacity based on deep learning computer artificial intelligence

Background

A deep learning computer artificial intelligence system is helpful for early identification of ground glass opacities (GGOs).

Methods

Images from the Lung Image Database Consortium and Image Database Resource Initiative (LIDC-IDRI) database were used in AlexNet and GoogLeNet to detect pulmonary nodules, and 221 GGO images provided by Xinhua Hospital were used in ResNet50 for detecting GGOs. We used computed tomography image radial reorganization to create the input image of the three-dimensional features, and used the extracted features for deep learning, network training, testing, and analysis.

Results

In the final evaluation results, we found that the accuracy of identification of lung nodule could reach 88.0%, with an F-score of 0.891. In terms of performance and accuracy, our method was better than the existing solutions. The GGO nodule classification achieved the best F-score of 0.87805. We propose a preprocessing method of red, green, and blue (RGB) superposition in the region of interest to effectively increase the differentiation between nodules and normal tissues, and that is the innovation of our research.

Conclusions

The method of deep learning proposed in this study is more sensitive than other systems in recent years, and the average false positive is lower than that of others.

Gefitinib for Epidermal Growth Factor Receptor Activated Osteoarthritis Subpopulation Treatment

Osteoarthritis (OA) is a leading cause of physical disability among aging populations, with no available drugs able to efficiently restore the balance between cartilage matrix synthesis and degradation. Also, OA has not been accurately classified into subpopulations, hindering the development toward personalized precision medicine. In the present study, we identified a subpopulation of OA patients displaying high activation level of epidermal growth factor receptor (EGFR). With Col2a1-creER^T2; Egfr^f/f mice, it was found that the activation of EGFR, indicated by EGFR phosphorylation (pEGFR), led to the destruction of joints. Excitingly, EGFR inhibition prohibited cartilage matrix degeneration and promoted cartilage regeneration. The Food and Drug Administration (FDA)-approved drug gefitinib could efficiently inhibit EGFR functions in OA joints and restore cartilage structure and function in the mouse model as well as the clinical case report. Overall, our findings suggested the concept of the EGFR activated OA subpopulation and illustrated the mechanism of EGFR signaling in regulating cartilage homeostasis. Gefitinib could be a promising disease-modifying drug for this OA subpopulation treatment.

Effect of invasive mucinous adenocarcinoma on lung cancer-specific survival after surgical resection: a population-based study

Background

In 2015, the World Health Organization (WHO) announced a new classification of lung tumors. Mucinous bronchioloalveolar adenocarcinomas were reclassified as invasive mucinous adenocarcinomas (IMAs). Due to the rarity or this tumor type, conflicting clinical outcomes have been reported based on small patient numbers.

Methods

Patients diagnosed as primary lung nonmucinous adenocarcinoma (NMA) or IMA from 2000 to 2014 were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. General features of each IMA were explored and the effect of histological characteristics on lung cancer-specific survival was analyzed in matched samples using the TNM staging system.

Results

The incidence of IMA among all primary lung cancer patients was 0.2% (1,783/1,154,742), and the incidence of IMA among patients with a primary resected lung adenocarcinoma was 1.5% (531/35,406). IMAs tended to be located in the lower lobe (P<0.001), be well differentiated (P<0.001), and be N0 (91.7% vs. 72.3%, P<0.001), T1 or T2 (P<0.001), and stage I tumors (P<0.001) when compared with NMAs. After matching by stages, a stratified Cox PH analysis revealed that the tumor histologic type (P=0.2) did not increase the risk of lung cancer-specific death, while advanced age (HR 1.03, P<0.001), male sex, and the need for radiation, pneumonectomy or sublobar resections increased the risk of cancer-specific death.

Conclusions

The histologic type of the tumor, whether IMA or not, did not affect lung cancer-specific survival times among patients with a primary M0 stage lung adenocarcinoma. When stratified by the TNM staging system, patents that required pneumonectomy, sublobar resection or radiation had shorter lung cancer-specific survival times.

Increased expression of monoamine oxidase A is associated with epithelial to mesenchymal transition and clinicopathological features in non-small cell lung cancer

Monoamine oxidase A (MAOA), a mitochondrial enzyme, is closely associated with neurological disorders. Recently, MAOA has been linked to the progression of prostate cancer, hepatocellular carcinoma, and cholangiocarcinoma. However, MAOA was reported to have different effects on the progression of these types of cancer, and the role of MAOA in non-small cell lung cancer (NSCLC) progression remains unclear. The present study determined the expression of MAOA and epithelial to mesenchymal transition (EMT) markers in 45 pairs of NSCLC and matched non-tumor adjacent lung tissues, and further analyzed the correlation between MAOA expression and the EMT or the development of clinicopathological features. The results demonstrated that protein and mRNA expression levels of MAOA in NSCLC tissues were higher than those observed in the matched non-tumor adjacent lung tissues. Furthermore, the increased MAOA expression in NSCLC tissues was positively correlated with N-cadherin (r=0.525, P=0.002), Slug (r=0.515, P=0.001), and Twist (r=0.448, P=0.008) expressions, but negatively correlated with E-cadherin expression (r=-0.387, P=0.01). Additionally, the elevated MAOA expression in NSCLC tissues was associated with late stage NSCLC (Z=-2.596, P=0.029) and lymph node metastases (Z=-2.378, P=0.020). These findings suggest that MAOA may have a role in promoting NSCLC progression by mediating EMT.

Hemorrhagic Brain Metastases in a Patient with Anaplastic Lymphoma Kinase (ALK)-Rearranged Invasive Mucinous Adenocarcinoma of the Lung

Patient: Female, 44

Final Diagnosis: Brain metastases from invasive mucinous adenocarcinoma of the lung

Symptoms: Coughing

Medication: —

Clinical Procedure: —

Specialty: Pulmonology

Single nucleotide polymorphisms of nucleotide excision repair pathway are significantly associated with outcomes of platinum-based chemotherapy in lung cancer

Nucleotide excision repair (NER) pathway plays critical roles in repairing DNA disorders caused by platinum. To comprehensively understand the association between variants of NER and clinical outcomes of platinum-based chemotherapy, 173 SNPs in 27 genes were selected to evaluate association with toxicities and efficiency in 1004 patients with advanced non-small cell lung cancer. The results showed that consecutive significant signals were observed in XPA, RPA1, POLD1, POLD3. Further subgroup analysis showed that GTF2H4 presented consecutive significant signals in clinical benefit among adenocarcimoma. In squamous cell carcinoma, rs4150558, rs2290280, rs8067195 were significantly associated with anemia, rs3786136 was significantly related to thrombocytopenia, ERCC5 presented consecutive significant signals in response rate. In patients receiving TP regimen, significant association presented in neutropenia, thrombocytopenia and gastrointestinal toxicity. Association with anemia and neutropenia were found in GP regimen. rs4150558 showed significant association with anemia in NP regimen. In patients > 58, ERCC5 showed consecutive significant signals in gastrointestinal toxicity. Survival analysis showed SNPs in POLD2, XPA, ERCC6 and POLE were significantly associated with progression free survival, SNPs in GTF2H4, ERCC6, GTF2HA, MAT1, POLD1 were significantly associated with overall survival. This study suggests SNPs in NER pathway could be potential predictors for clinical outcomes of platinum-based chemotherapy among NSCLC.

Software-based risk stratification of pulmonary adenocarcinomas manifesting as pure ground glass nodules on computed tomography

OBJECTIVES

To assess the performance of the "Computer-Aided Nodule Assessment and Risk Yield" (CANARY) software in the differentiation and risk assessment of histological subtypes of lung adenocarcinomas manifesting as pure ground glass nodules on computed tomography (CT).

METHODS

64 surgically resected and histologically proven adenocarcinomas manifesting as pure ground-glass nodules on CT were assessed using CANARY software, which classifies voxel-densities into three risk components (low, intermediate, and high risk). Differences in risk components between histological adenocarcinoma subtypes were analysed. To determine the optimal threshold reflecting the presence of an invasive focus, sensitivity, specificity, negative predictive value, and positive predictive value were calculated.

RESULTS

28/64 (44%) were adenocarcinomas in situ (AIS); 26/64 (41%) were minimally invasive adenocarcinomas (MIA); and 10/64 (16%) were invasive ACs (IAC). The software showed significant differences in risk components between histological subtypes (P<0.001-0.003). A relative volume of 45% or less of low-risk components was associated with histological invasiveness (specificity 100%, positive predictive value 100%).

CONCLUSIONS

CANARY-based risk assessment of ACs manifesting as pure ground glass nodules on CT allows the differentiation of their histological subtypes. A threshold of 45% of low-risk components reflects invasiveness in these groups.

KEY POINTS

• CANARY-based risk assessment allows the differentiation of their histological subtypes. • 45% or less of low-risk component reflects histological invasiveness. • CANARY has potential role in suspected adenocarcinomas manifesting as pure ground-glass nodules.

Associations between radiologist-defined semantic and automatically computed radiomic features in non-small cell lung cancer

Tumor phenotypes captured in computed tomography (CT) images can be described qualitatively and quantitatively using radiologist-defined "semantic" and computer-derived "radiomic" features, respectively. While both types of features have shown to be promising predictors of prognosis, the association between these groups of features remains unclear. We investigated the associations between semantic and radiomic features in CT images of 258 non-small cell lung adenocarcinomas. The tumor imaging phenotypes were described using 9 qualitative semantic features that were scored by radiologists, and 57 quantitative radiomic features that were automatically calculated using mathematical algorithms. Of the 9 semantic features, 3 were rated on a binary scale (cavitation, air bronchogram, and calcification) and 6 were rated on a categorical scale (texture, border definition, contour, lobulation, spiculation, and concavity). 32-41 radiomic features were associated with the binary semantic features (AUC = 0.56-0.76). The relationship between all radiomic features and the categorical semantic features ranged from weak to moderate (|Spearmen's correlation| = 0.002-0.65). There are associations between semantic and radiomic features, however the associations were not strong despite being significant. Our results indicate that radiomic features may capture distinct tumor phenotypes that fail to be perceived by naked eye that semantic features do not describe and vice versa.

Radiological and Clinical Features associated with Epidermal Growth Factor Receptor Mutation Status of Exon 19 and 21 in Lung Adenocarcinoma

The exon 19 and 21 in Epidermal Growth Factor Receptor (EGFR) mutation are the most common subtype of lung adenocarcinoma, and the strongest predictive biomarker for progression-free survival and tumor response. Although some studies have shown differences in radiological features between cases with and without EFGR mutations, they lacked necessary stratification. This article is to evaluate the association of CT features between the wild type and the subtype (exon 19 and 21) of EGFR mutations in patients with lung adenocarcinoma. Of the 721 finally included patients, 132 were positive for EGFR mutation in exon 19, 140 were positive for EGFR mutation in exon 21, and 449 were EGFR wild type. EGFR mutation in exon 19 was associated with a small-maximum diameter (28.51 ± 14.07) (p < 0.0001); sex (p < 0.0001); pleural retraction (p = 0.0034); and the absence of fibrosis (p < 0.0001), while spiculated margins (p = 0.0095), subsolid density (p < 0.0001) and no smoking (p < 0.0001) were associated with EGFR mutation in exon 21. Receiver Operating Characteristic (ROC) curves suggested that the maximum Area Under the Curve (AUC) was related to the female gender (AUC = 0.636) and the absence of smoking (AUC = 0.681). This study demonstrated the radiological and clinical features could be used to prognosticate EGFR mutation subtypes in exon 19 and 21.

[The new TNM classification for lung tumors : Changes and the assessment of multiple tumor foci]

Recently a new TNM classification for tumors of the lung was published, encompassing some relevant changes, for example how to deal with multiple lung tumors. This article comprehensively describes respective changes. Furthermore, background information on how the new TNM classification was built and what should be done in the future to further improve prognosis and outcome prediction is reviewed.

Pulmonary nodules in a patient with rheumatoid arthritis: Which diagnostic approach is the most appropriate?

BACKGROUND

Pulmonary nodular excavation should firstly evoke tuberculosis or necrosis broncho-pulmonary tumor, particularly: epidermoid carcinoma. The case discussed here illustrated these difficulties in patients with rheumatoid arthritis (RA).

CASE PRESENTATION

A 63-year-old woman was presented with a-three-year history of RA and a recent discovery of an excavated pulmonary nodule. Initial investigations focused on a rheumatoid origin. The evolution of the disease was worrisome and surgical exploration was deemed mandatory. The result was the discovery of a nodule of a malignant nature.

CONCLUSION

In this paper, we discussed the excavation of the pulmonary nodule, its diagnoses and management of the difficulties we encountered.

Utility of Cluster of Differentiation 5 and Cluster of Differentiation 117 Immunoprofile in Distinguishing Thymic Carcinoma from Pulmonary Squamous Cell Carcinoma: A Study on 1800 Nonsmall Cell Lung Cancer Cases

Background

Mediastinum harbors a mixed bag of neoplastic lesions with varied therapeutic and prognostic implications. Distinguishing pulmonary squamous cell carcinoma from thymic carcinoma is a challenging task owing to rather nonspecific clinicoradiological features and a considerable overlap in histomorphological features. Thus, we evaluated the diagnostic utility of cluster of differentiation 5 (CD5) and CD117 immunohistochemical markers in distinguishing these tumors.

Materials and Methods

The archives of department of histopathology were retrospectively reviewed from June 2012 to May 2016. Formalin-fixed paraffin-embedded blocks of 1800 cases diagnosed as nonsmall cell lung carcinoma were retrieved, and immunohistochemical expression of CD5 and CD117 was evaluated in these cases.

Results

Adenocarcinoma (980; 54.44%) was the most common histological subtype of lung carcinoma observed in our study. CD117 was positive in 171 out of 1800 cases (9.5%) of which 120 cases (70.17%) were adenocarcinoma, followed by 40 cases (23.4%) of squamous cell carcinoma. Immunoreactivity for CD5 was observed in 209 cases (11.61%), 200 (95.7%) cases of which were diagnosed as adenocarcinoma. None of the cases diagnosed as squamous cell carcinoma on histomorphology showed CD5 immunoexpression.

Conclusion

While thymic squamous cell carcinomas are well known for CD5 and CD117 coexpression, none of the cases of squamous cell carcinoma arising in lung express CD5. These markers are a diagnostic tool to distinguish a primary lung squamous cell carcinoma from thymic carcinoma, particularly in the setting of a central pulmonary lesion with mediastinal involvement.

Clinicopathological and immunohistochemical features of lung invasive mucinous adenocarcinoma based on computed tomography findings

Background

We performed an analysis to clarify differences in clinicopathological and molecular features of lung invasive mucinous adenocarcinoma (IMA) based on computed tomography (CT) findings and their impact on prognosis.

Patients and methods

On the basis of CT findings, we divided lung IMA into three subtypes: solid, bubbling, and pneumonic. We then investigated differences in clinicopathological characteristics, prognosis, and the expressions of well-identified biomarkers, including cyclooxygenase-2 (Cox-2), excision repair cross-complementation group 1 (ERCC1), ribonucleotide reductase M1 (RRM1), class III beta-tubulin, thymidylate synthase (TS), secreted protein acidic and rich in cysteine (SPARC), programmed cell death-1 ligand-1 (PD-L1), and epidermal growth factor receptor mutation, among the three subtypes.

Results

A total of 29 patients with resected lung IMA were analyzed. Compared with the solid or bubbling type, the pneumonic type had a higher proportion of symptoms, a larger tumor size, a higher pathological stage, and a significantly worse prognosis. The immunohistochemical findings tended to show high expression of RRM1, class III beta-tubulin, and Cox-2 in the tumor and of SPARC in the stroma, but not of ERCC1, TS, and PD-L1 in the tumor. None of the biomarkers with high expression levels in the tumor were prognostic biomarkers, but the expression of SPARC in the stroma was correlated with a poor outcome.

Conclusion

Clinical and pathological features, in conjunction with molecular data, indicate that IMA should be divided into different subgroups. In our results, the pneumonic type was correlated with a significantly worse outcome. Further studies should be performed to confirm our conclusion and to explore its molecular implications.

The expression of SALL4 is significantly associated with EGFR, but not KRAS or EML4-ALK mutations in lung cancer

BACKGROUND

Lung cancer is the leading cause of cancer-related deaths worldwide; unfortunately, its prognosis is still very poor. Therefore, developing the target molecular is very important for lung cancer diagnosis and treatment, especially in the early stage. With this in view, spalt-like transcription factor 4 (SALL4) is considered a potential biomarker for diagnosis and prognosis in cancers, including lung cancer.

METHODS

In order to better investigate the association between the expression of SALL4 and driver genes mutation, 450 histopathologically diagnosed patients with lung cancer and 11 non-cancer patients were enrolled to test the expression of SALL4 and the status of driver genes mutation. This investigation included epidermal growth factor receptor (EGFR), kirsten rat sarcoma viral oncogene homolog (KRAS), and a fusion gene of the echinoderm microtubule-associated protein-like 4 (EML4) and the anaplastic lymphoma kinase (ALK).

RESULTS

The results of the study showed that females harbored more EGFR mutation in adenocarcinoma (ADC). The mutation rate of KRAS and EML4-ALK was about 5%, and the double mutations of EGFR/EML4-ALK were higher than EGFR/KRAS. In the expression analysis, the expression of SALL4 was much higher in cancer tissues than normally expected, especially in tissues that carried EGFR mutation (P<0.05), however, there were no significant differences between different mutation types. Likewise, there were no significant differences between expression of SALL4 and KRAS and EML4-ALK mutations.

CONCLUSIONS

SALL4 is up regulated in lung cancer specimens and harbors EGFR mutation; this finding indicates that SALL4 expression may be relevant with EGFR, which could provide a new insight to lung cancer therapy. The mechanism needs further investigation and analysis.

Former smokers with non-small-cell lung cancers: a comprehensive investigation of clinicopathologic characteristics, oncogenic drivers, and prognosis

The aim of this present investigation was to evaluate the clinicopathologic characteristics, oncogenic drivers, and prognosis of former smokers with non‐small‐cell lung cancer (NSCLC), and to compare them with those of the current and never smokers. This investigation was a single‐institution retrospective study of 2289 NSCLC patients, who were classified as former, current, or never smokers. A collection was made of the clinicopathological characteristics, spectra of well‐identified driver genes and survival rates. The survival rates were compared using log‐rank test, and independent prognostic factors, identified using Cox regression analysis. Of 2289 NSCLC patients, 257 (11.2%) were former smokers; 868 (37.9%), current smokers; and 1164 (50.9%), never smokers. Compared with the current, the former were characterized by older age at diagnosis (64.3y vs. 59.9y; P < 0.001), earlier TNM stage (stage I, 47.9% vs. 39.5%; P = 0.017), fewer solid predominance in adenocarcinomas (16.2% vs. 29.5%; P = 0.005), and more EGFR mutation (33.2% vs. 20.7%; P < 0.001) but less KRAS mutation (6.7% vs. 11.9%, P = 0.041). No statistically significant survival differences were observed between the former and current. However, the light former smokers presented favorable overall survival when compared with the light current and heavy former or current (the light former vs. the heavy former, P = 0.028; the light former vs. the light current, P = 0.048; and the light former vs. the heavy current, P = 0.048). Our findings suggest that the former smokers with NSCLCs can have distinctive clinicopathologic characteristics, oncogenic drivers, and prognosis, and they, especially the light former, can benefit from smoking cessation.

Differential diagnostic value of CD5 and CD117 expression in thoracic tumors: a large scale study of 1465 non-small cell lung cancer cases

Background

Thoracic pathologists are frequently faced with tissue specimens from intrathoracic/mediastinal tumors. Specifically the differentiation between thymic and pulmonary squamous cell carcinomas (SqCC) can be challenging. In order to clarify the differential diagnostic value of CD5 and CD117 in this setting, we performed a large scale expression study of both markers in 1465 non-small cell lung cancer (NSCLC) cases.

Methods

Tissue microarrays of formalin-fixed paraffin-embedded resection specimens of 1465 NSCLC were stained with antibodies against CD117 and CD5. Positivity of both markers was correlated with clinicopathological variables.

Results

CD117 was positive in 145 out of 1457 evaluable cases (9.9 %) and CD5 was positive in 133 out of 1427 evaluable cases (9.3 %). 28 cases (1.9 %) showed coexpression of CD117 and CD5. Among the 145 cases that were positive for CD117, 97 (66.8 %) were adenocarcinomas (ADC), 34 (23.4 %) were SqCC, 5 (3.4 %) were adenosquamous carcinomas (ADSqCC), 8 (5.5 %) were large cell carcinomas (LC), and one (0.6 %) was a pleomorphic carcinoma (PC). In the CD5 positive group consisting of 133 cases, 123 (92.4 %) were ADC, 0 (0 %) were SqCC, 4 (3.0 %) were ADSqCC, 3 (2.2 %) LC and 3 (2.2 %) were PC. None of the 586 SqCC showed expression of CD5. No association of CD117- or CD5 positivity to patients’ age, pathological stages or to T-, N-, or M- categories was observed.

Conclusions

A substantial subset of NSCLC exhibit positivity of CD117 and CD5. Since CD5 expression was not observed in pulmonary SqCC, but is expressed in the majority of thymic squamous cell carcinomas, the application of this immunomarker is a valuable tool in the differential diagnosis of thoracic neoplasms.

Electronic supplementary material

The online version of this article (doi:10.1186/s13000-015-0441-7) contains supplementary material, which is available to authorized users.

Clinical features and mutation status of EGFR, KRAS, BRAF, EML4-ALK and ROS1 between surgical resection samples and non surgical resection samples in lung cancer

BACKGROUND

Target therapy is the first-line treatment in lung cancer. The testing of driver gene mutations is crucial for decision of treatment. Many lung cancer patients are in advanced grade, and lose the chance of operation.

METHODS

The tissue used to perform mutation testing is only from biopsy. In order to analysis the difference between surgical resection samples (SRSs) and non-surgical resection samples (NSRSs), 1,357 surgical tissues and 145 biopsy samples histopathologically diagnosed with lung cancer were collected to detect the mutation status of EGFR, KRAS, BRAF, EML4-ALK and ROS1 in this study.

RESULTS

There were no significant differences of age, gender, and histological type between the two group patients we collected; however, the significant difference was present in grade. More early stage patients were in the surgical group, but more advanced stage lung cancer patients were in non surgical group. In the mutation analysis, we also found no significant differences in all driver genes we detected between the two groups.

CONCLUSIONS

Both surgical resection samples and biopsy samples could be used to perform the testing the driver gene mutation.