Prognosis of recurrence after complete resection in early-stage non-small cell lung cancer

Prevalence of EGFR Mutations in Vietnamese Patients with Resected Early Stage Non-Small Cell Lung Cancer: EARLY-EGFR Study

Introduction

Comprehensive profiling of mutations in the EGFR gene is vital for selecting patients eligible for EGFR targeted therapies.

Methods

We investigated the prevalence of EGFR mutations and treatment patterns in patients with early stage non-small cell lung cancer (NSCLC) in Vietnam as a part of EARLY-EGFR (Clinical Trial Identifier: NCT04742192), a global, real-world study. Consecutive patients with surgically resected stage IA-IIIB, non-squamous NSCLC were diagnosed from August 2021 to June 2022 and were prospectively enrolled from November 2021 to July 2022.

Results

A total 200 patients (age: median [range], 60.0 [30.0-80.0] years) were enrolled from 3 centers; 56.0% were males and 64.0% never smoked. The prevalence of EGFR mutations was 51.0% (102/200) including deletions in exon-19 (49.0%) and exon-21 L858R mutations (33.3%). Females (73.9%, 65/88), patients aged ≥60 years (52.5%, 53/101), nonsmokers (61.2%, 63/103) and those with stage I (55.8%, 67/120) had higher prevalence of EGFR mutations. Multivariate analysis (adjusted odds ratio [aOR]) showed EGFR mutations to be significantly associated (p < 0.05) with female gender (aOR = 5.90), age ≥60 years (aOR = 1.05), and stage III disease (vs stage I) (aOR = 0.30).

Conclusion

These results underscore the need for EGFR testing early in management algorithm of NSCLC in Vietnam to identify patients eligible for targeted therapy in concordance with international guidelines.

Calcium Sulfide Nanoclusters Trigger DNA Damage and Induce Cell Cycle Arrest in Non-Small-Cell Lung Adenocarcinoma Cells

Lung cancer remains the most common malignancy independent of sex. Here, we focused on unraveling the molecular mechanisms of CaS nanoclusters inducing cytotoxicity by investigating DNA damage, the cell cycle, oxidative stress, and cellular repair mechanisms in non-small-cell lung carcinoma (NSCLC) cells compared to healthy lung fibroblasts. Our previous studies have demonstrated the therapeutic potential of calcium sulfide (CaS) nanostructures in skin and breast cancer models, leading to a significant reduction in cancer cell proliferation. However, how CaS nanoclusters enhance their therapeutic effects on cancer cells while minimizing damage to healthy cells remains unknown. Our results show that CaS nanoclusters, once dissociated into Ca2+ and H2S in an acidic microenvironment, selectively allow extracellular calcium to enter, leading to an increase in free calcium entry, triggering oxidative stress and limiting DNA repair mechanisms in NSCLC. Furthermore, CaS nanoclusters selectively arrest NSCLC cells in the G0-G1 and S phases of the cell cycle without affecting healthy cells' cycles. Here, we also show that the selective effects of CaS nanoclusters on lung adenocarcinoma are less likely to be regulated by intrinsic apoptotic or mitochondrial pathways. They are, rather, caused by an increase in Ca2+ and ROS, causing double-stranded DNA breakages. This selectivity for malignant cells is pH-dependent because it occurs in the acidic microenvironment characteristic of these cells. Overall, this is the first piece of evidence that CaS disrupts genomic stability, prevents the replication of damaged cells, and ultimately influences cell fate decisions such as cell cycle arrest or cell death including mitotic catastrophe and necroptotic simultaneous events.

Prognostic potential of integrated morphologic and metabolic parameters of pre-therapeutic [18F]FDG-PET/CT regarding progression-free survival (PFS) and overall survival (OS) in NSCLC-patients

PURPOSE

This study aimed to evaluate the prognostic potential of pre-therapeutic [18F]FDG-PET/CT variables regarding prediction of progression-free survival (PFS) and overall survival (OS) in NSCLC-patients.

METHOD

NSCLC-patients who underwent pre-therapeutic [18F]FDG-PET/CT were retrospectively analyzed. The following imaging features were collected from the primary tumor: tumor size, tumor density, central necrosis, spicules and SUVmax. For standardization, an indexSUVmax was calculated (SUVmax primary tumor/SUVmax liver). Descriptive statistics and correlations of survival time analyses for PFS and OS were calculated using the Kaplan-Meier method and Cox regression including a hazard ratio (HR). A value of p < 0.05 was set as statistically significant. The 95%-confidence intervals (CI) were calculated. The median follow-up time was 63 (IQR 27-106) months.

RESULTS

This study included a total of 82 patients (25 women, 57 men; mean age: 66 ± 9 years). IndexSUVmax (PFS: HR = 1.0, CI: 1.0-1.1, p = 0.49; OS: HR = 1.0, CI: 0.9-1.2, p = 0.41), tumor size (PFS: HR = 1.0, CI: 0.9-1.0, p = 0.08; OS: HR = 1.0, CI: 0.9-1.0, p = 0.07), tumor density (PFS: HR = 0.9, CI: 0.6-1.4, p = 0.73; OS: HR = 0.3; CI: 0.1-1.1; p = 0.07), central necrosis (PFS: HR = 1.0, CI: 0.6-1.8, p = 0.98; OS: HR = 0.6, CI: 0.2-1.9, p = 0.40) and spicules (PFS: HR = 1.0, CI: 0.6-1.9, p = 0.91; OS: HR = 1.3, CI: 0.4-3.7, p = 0.65) did not significantly affect PFS and OS in the study population. An optimal threshold value for the indexSUVmax was determined by ROC analysis and Youden's index. There was no significant difference in PFS with an indexSUVmax-threshold of 3.8 (13 vs. 27 months; p = 0.45) and in OS with an indexSUVmax-threshold of 4.0 (113 vs. 106 months; p = 0.40).

CONCLUSIONS

SUVmax and morphologic parameters from pre-therapeutic [18F]FDG-PET/CT were not able to predict PFS and OS in NSCLC-patients.

Clinical Significance of Dual-Block Elastic Stain Evaluating Visceral Pleural Invasion in Peripheral Non-Small Cell Lung Cancer

Visceral pleural invasion (VPI) is a critical component in the staging of peripheral non-small cell lung carcinoma (NSCLC). We aim to investigate whether dual-block elastic stain increases visceral pleural invasion positivity compared with single-block elastic stain. We further analyze the potential predictors of visceral pleural invasion. 8419 peripheral NSCLC patients (including 6008 patients with tumor size≤3 cm in stage I) were divided into a cohort using one paraffin block (single-block group, n = 5184) and a cohort using dual paraffin blocks (dual-block group, n = 3235) for elastic stain. The VPI-positive rate demonstrated by the dual-block elastic stains group was significantly higher than that of the single-block elastic stain group (17.7% (573/3235) versus 9.1% (474/5184), respectively, P < .001). The presence of visceral pleural invasion in T1 (≤3 cm) patients detected by single- and dual-block elastic stain was 6.3% (235/3730) and 12.0% (273/2278), respectively (P < .001). 5.7% of T1 patients (stage IA) were additionally upstaged to T2a (stage IB) by dual-block elastic stain. However, the incidence of visceral pleural invasion in pT2a patients showed no significant difference between the single-block group and the dual-block group (16.8% vs. 17.1%, P = .916). Lymphovascular invasion, lymph node metastasis, dedifferentiated carcinomas, the presence of spread through airspaces (STAS) and a poorly differentiated adenocarcinomatous growth pattern could be significant predictors of visceral pleural invasion (P < .001). Our results indicate that using dual-block elastic stain identifies more visceral pleural invasion positive T1 NSCLC patients who are upstaged to T2a, and who could benefit from optimal management post-operatively. The application of dual-block elastic stain is an efficient and practical method to detect visceral pleural invasion status.

Economic Burden of Recurrence in Completely Resected Stage IB-IIIA Non-Small Cell Lung Cancer: A Retrospective Study Using Nationwide Claims Data of South Korea

INTRODUCTION

Although many patients with early stage non-small cell lung cancer (NSCLC) experience recurrence despite complete resection, few studies have reported on the corresponding economic burden. This study aimed to understand the economic impact of recurrence by measuring healthcare costs and resource utilization in patients with recurrent stage IB-IIIA NSCLC.

METHODS

Using Health Insurance Review and Assessment claims data from South Korea, we included patients who underwent complete resection for stage IB-IIIA NSCLC during the index period (January 1, 2012, to October 31, 2018). Patients who experienced recurrence were matched with those who did not using 1:1 propensity score (PS) matching. The mean healthcare costs and resource utilization were analyzed from the date of complete resection to the last claims for cancer treatment. A generalized linear model (GLM) was used to estimate the impact of covariates on healthcare costs. A difference-in-difference (DID) analysis was conducted to analyze the healthcare costs between the two groups before and after recurrence.

RESULTS

Patients with recurrence incurred higher healthcare costs, particularly in outpatient settings. The cost of targeted therapy and immune checkpoint inhibitors primarily contributed to cost differences, and medication costs increased over time after complete resection. Patients with recurrence were also hospitalized more frequently (9.3 vs. 5.0, p < 0.0001) for a longer period (74 days vs. 42 days, p < 0.0001) than those without recurrence. GLM analysis showed that the total cost was 2.31-fold higher in patients with recurrence (95% confidence interval: 2.19-2.44). The DID analysis showed significantly increased total costs in patients with recurrence (β = 26,269, p < 0.0001), which was mostly attributed to medication costs (β = 17,951, p < 0.0001).

CONCLUSION

Recurrence of completely resected NSCLC leads to a substantial increase in healthcare costs and resource utilization. The results of this study show the economic burden of recurrence, which may help future economic analyses and resource allocation.

Anesthetic and analgesic techniques and perioperative inflammation may affect the timing of recurrence after complete resection for non-small-cell lung cancer

Introduction

It has been widely recognized that both surgery and anesthesia may increase the risk of cancer recurrence by inducing an inflammatory response and immunosuppression in various cancer operations. The present study explored using hazard curves how anesthetic and analgesic techniques regarding the host inflammation status affect the risk of recurrence over time in patients with non-small-cell lung cancer (NSCLC).

Material and Methods

Clinicopathological data from patients who underwent complete pulmonary resection with pathological I–IIIB stage NSCLC from 2010 to 2020 were collected. The inflammation-based scores, including the C-reactive protein-to-albumin ratio (CAR), systemic immune-inflammation index (SII), Glasgow prognostic score (GPS), and modified GPS (mGPS), were calculated before surgery, and hazard curves indicating the changes in hazards over time were evaluated.

Results

A total of 396 patients were eligible for the analysis. The median follow-up was 42.3 months. In total, 118 patients (29.8%) experienced recurrence, and 66.9% of those occurred within 24 months after surgery. According to the multivariate Cox regression analysis, volatile anesthesia (VA) (hazard ratio [HR], 1.69; 95% confidence interval [CI], 1.05–2.71), and elevated CAR (HR, 1.88; 95% CI, 1.18–2.99) were associated with a worse recurrence-free survival. The resulting hazard curve revealed that a delayed peak of recurrence was present in patients with a low CAR in the VA group and in those with intravenous flurbiprofen axetil administration in the propofol-based total intravenous anesthesia group (30 and 24 months after surgery, respectively).

Discussion

Choosing anesthetic and analgesic techniques while taking inflammation-based scores into account may be useful for reducing the risk of and/or delaying recurrence in patients undergoing resection for NSCLC.

Ground Glass Opacity and Adjuvant Chemotherapy in Pathological Stage IB-IIA Lung Adenocarcinoma

Background

The prognostic value of ground glass opacity (GGO) in stage IA non-small cell lung cancer (NSCLC) has been widely recognized. However, studies investigating its value in the related stage IB-IIA lung adenocarcinoma (LUAD) remains lacking. The impact of adjuvant chemotherapy (ACT) on pathological stage IB-IIA LUAD is also controversial.

Materials and Methods

We retrospectively reviewed the clinical records of 501 patients with pathological stage IB-IIA LUAD at the Sun Yat-sen University Cancer Center from January 2008 to June 2018. We calculated and compared survival curves using the Kaplan-Meier test and log-rank test. Cox regression models were performed to determine independent prognostic factors of disease-free survival (DFS) and overall survival (OS). We established nomograms to predict the OS and DFS of LUAD patients. Calibration and receiver operator characteristic curves were conducted to assess the predictive performance of two nomograms. Based on the nomogram, we identified candidate patients that may most benefit from ACT after surgery.

Results

The number of patients with pure solid, part GGO, and pure GGO nodules was 240, 242, and 19, respectively, and 125 patients who received ACT. Patients with consolidation-to-tumor ratio (CTR) <0.75 had longer OS (P = 0.026) and DFS (P = 0.003). Pathological tumor size and at least 10 lymph nodes (LNs) resection were independent prognostic factors of both OS and DFS. CTR <0.75 was positively associated with DFS. The C-index of nomograms predicting individual OS and DFS was 0.660 and 0.634, respectively. Based on the nomogram for OS, ACT was found to be a positive prognostic indicator of OS (P = 0.031, HR = 0.5141, 95% CI 0.281-0.942) in patients with nomogram total points ≥5.

Conclusion

CTR <0.75 is associated with a better DFS in patients with stage IB-IIA LUAD. Nomograms developed by integrating pathological tumor size, at least 10 LNs resection, and CTR ≥0.75 for predicting individual OS and DFS displayed a good predictive capacity and clinical value, which were also proved to be a useful tool for selecting patients most benefiting from ACT.

SUVmax to tumor perimeter distance: a robust radiomics prognostic biomarker in resectable non-small cell lung cancer patients

OBJECTIVE

The purpose of this study was to evaluate the prognostic value of novel geometric variables obtained from pre-treatment [¹⁸F]FDG PET/CT with respect to classical ones in patients with non-small cell lung cancer (NSCLC).

METHODS

Retrospective study including stage I-III NSCLC patients with baseline [¹⁸F]FDG PET/CT. Clinical, histopathologic, and metabolic parameters were obtained. After tumor segmentation, SUV and volume-based variables, global texture, sphericity, and two novel parameters, normalized SUVpeak to centroid distance (nSCD) and normalized SUVmax to perimeter distance (nSPD), were obtained. Early recurrence (ER) and short-term mortality (STM) were used as end points. Univariate logistic regression and multivariate logistic regression with respect to ER and STM were performed.

RESULTS

A cohort of 173 patients was selected. ER was detected in 49/104 of patients with recurrent disease. Additionally, 100 patients died and 53 had STM. Age, pathologic lymphovascular invasion, lymph nodal infiltration, TNM stage, nSCD, and nSPD were associated with ER, although only age (aOR = 1.06, p = 0.002), pathologic lymphovascular invasion (aOR = 3.40, p = 0.022), and nSPD (aOR = 0.02, p = 0.018) were significant independent predictors of ER in multivariate analysis. Age, lymph nodal infiltration, TNM stage, nSCD, and nSPD were predictors of STM. Age (aOR = 1.05, p = 0.006), lymph nodal infiltration (aOR = 2.72, p = 0.005), and nSPD (aOR = 0.03, p = 0.022) were significantly associated with STM in multivariate analysis. Coefficient of variation (COV) and SUVmean/SUVmax ratio did not show significant predictive value with respect to ER or STM.

CONCLUSION

The geometric variables, nSCD and nSPD, are robust biomarkers of the poorest outcome prediction of patients with NSCLC with respect to classical PET variables.

KEY POINTS

• In NSCLC patients, it is crucial to find prognostic parameters since TNM system alone cannot explain the variation in lung cancer survival. • Age, lymphovascular invasion, lymph nodal infiltration, and metabolic geometrical parameters were useful as prognostic parameters. • The displacement grade of the highest point of metabolic activity towards the periphery assessed by geometric variables obtained from [¹⁸F]FDG PET/CT was a robust biomarker of the poorest outcome prediction of patients with NSCLC.

Design and Characterization of Fibroblast Activation Protein Targeted Pan-Cancer Imaging Agent for Fluorescence-Guided Surgery of Solid Tumors

Tumor-targeted fluorescent dyes have been shown to significantly improve a surgeon's ability to locate and resect occult malignant lesions, thereby enhancing a patient’s chances of long term survival. Although several...

Risk stratification and adjuvant chemotherapy after radical resection based on the clinical risk scores of patients with stage IB-IIA non-small cell lung cancer

INTRODUCTION

Despite the heterogeneity among patients with stage IB-IIA non-small cell lung cancer (NSCLC), clinically applicable models to identify patients most suitable for receiving adjuvant chemotherapy (ACT) are limited. We aimed to develop a model for risk stratification and the individualized application of ACT.

METHODS

Between January 2008 and March 2018, patients with T2N0M0 NSCLC at Sun Yat-sen University Cancer Center were retrospectively enrolled. Survival curves were estimated by Kaplan-Meier method and compared with log-rank test. Cox regression models were used to identify prognostic factors for disease-free survival (DFS) and overall survival (OS). Propensity score matching (PSM) was implemented. Subgroup analysis was performed based on clinical risk score (CRS) value and epidermal growth factor receptor (EGFR) mutation status.

RESULTS

Of 1063 patients with T2N0 NSCLC enrolled, 272 patients received ACT. Before PSM, patients with high CRS (>1) had a significantly worse OS and DFS outcomes. In the PSM, the baseline characteristics of the 270 pairs of patients were well matched. ACT was associated with improved OS outcomes for patients with a high CRS, while ACT was associated with improved OS and DFS outcomes in patients with wild-type EGFR. The interaction analysis showed an apparent interaction effect between ACT and EGFR-activating mutations as well as chemotherapy regimens and histology.

CONCLUSIONS

The CRS can predict the prognosis of patients with stage IB-IIA NSCLC. ACT could improve the outcome of patients with a high CRS. Patients with non-squamous cell histology receiving pemetrexed plus platinum might benefit more, but not those with EGFR-activating mutations.

Postoperative Adverse Events are Associated with Oncologic Recurrence Following Curative-intent Resection for Lung Cancer

BACKGROUND

Up to 50% of patients suffer short-term postoperative adverse events (AEs) and metastatic recurrence in the long-term following curative-intent lung cancer resection. The association between AEs, particularly infectious in nature, and disease recurrence is controversial. We sought to evaluate the association of postoperative AEs on risk of developing recurrence and recurrence-free survival (RFS) following curative-intent lung resection surgery.

METHODS

All lung cancer resections at a single institution (January 2008-July 2015) were included, with prospective collection of AEs using the Thoracic Morbidity & Mortality System. Cox proportional hazards models were used to estimate the effect of AEs on recurrence, with results presented as hazard ratio (HR) with 95% confidence interval (CI). An a priori, clinically driven approach to predictor variable selection was used. Kaplan-Meier curves were used examine the relationship between AE and RFS. p < 0.05 was considered statistically significant.

RESULTS

892 patients underwent curative-intent resection. 342 (38.3%) patients experienced an AE; 69 (7.7%) patients developed infectious AEs. 17.6% (n = 157) of patients had disease recurrence after mean follow-up of 26.5 months. Severe (Grade IV) AEs were associated with increased risk of recurrence (3.40; 95% CI 1.56-7.41) and a trend to decreased RFS. Major infectious AEs were associated with increased risk of recurrence (HR 1.71; CI 1.05-2.8) and earlier time to recurrence (no infectious AE 66 months, minor infectious 41 months, major infectious 54 months; p = 0.02).

CONCLUSION

For patients undergoing curative-intent lung cancer resection, postoperative AEs associated with critical illness or major infection were associated with increased risk of oncologic recurrence.

Genetic Variants in One-Carbon Metabolism Pathway Predict Survival Outcomes of Early-Stage Non-Small Cell Lung Cancer

BACKGROUND

This study was conducted to investigate the association between genetic variants in one-carbon metabolism and survival outcomes of surgically resected non-small cell lung cancer (NSCLC).

METHODS

We genotyped 41 potentially functional variants of 19 key genes in the one-carbon metabolism pathway among 750 NSCLC patients who underwent curative surgery. The association between genetic variants and overall survival (OS)/disease-free survival (DFS) were analyzed.

RESULTS

Among the 41 single-nucleotide polymorphisms (SNPs) analyzed, 4 SNPs (MTHFD1L rs6919680T>G and rs3849794T>C, MTR rs2853523C>A, and MTHFR rs4846049G>T) were significantly associated with survival outcomes. MTHFD1L rs6919680T>G and MTR rs2853523C>A were significantly associated with better OS (adjusted hazard ratio [aHR] = 0.73, 95% confidence interval [CI] = 0.54-0.99, p = 0.04) and worse OS (aHR = 2.14, 95% CI = 1.13-4.07, p = 0.02), respectively. MTHFD1L rs3849794T>C and MTHFR rs4846049G>T were significantly associated with worse DFS (aHR = 1.41, 95% CI = 1.08-1.83, p = 0.01; and aHR = 1.97, 95% CI = 1.10-3.53, p = 0.02, respectively). When the patients were divided according to histology, the associations were significant only in squamous cell carcinoma (SCC), but not in adenocarcinoma (AC). In SCC, MTHFD1L rs6919680T>G and MTR rs2853523C>A were significantly associated with better OS (aHR = 0.64, 95% CI = 0.41-1.00, p = 0.05) and worse OS (aHR = 2.77, 95% CI = 1.11-6.91, p = 0.03), respectively, and MTHFD1L rs3849794T>C and MTHFR rs4846049G>T were significantly associated with worse DFS (aHR = 1.73, 95% CI = 1.17-2.56, p = 0.01; and aHR = 2.78, 95% CI = 1.12-6.88, p = 0.03, respectively).

CONCLUSIONS

Our results suggest that the genetic variants in the one-carbon metabolism pathway could be used as biomarkers for predicting the clinical outcomes of patients with early-stage NSCLC.

Unusual local and distant metastases after complete resection of roentgenographically occult squamous cell carcinoma

Roentgenographically occult squamous cell carcinoma (ROSCC) was reported to have been cured after complete resection. We experienced unusual local and distant metastases after complete resection of a ROSCC of left B6 bronchus. During the operation due to the proximal bronchial stump being positive for squamous cell carcinoma (SCC), a left lower sleeve lobectomy was performed. Six years after the operation, a chest CT showed no abnormal shadows. 6 months later a PET-CT showed metastases on bilateral supraclavicular lymph nodes, mediastinal lymph nodes, and the right adrenal glands. A biopsy of the right supraclavicular lymph node revealed that it was a metastatic SCC. The possibility of recurrence from a second pulmonary SCC might still remain. A prolonged follow-up over many years is desirable for a heavy smoker with a ROSCC.

Complex Network Characterization Using Graph Theory and Fractal Geometry: The Case Study of Lung Cancer DNA Sequences

This paper discusses an approach developed for exploiting the local elementary movements of evolution to study complex networks in terms of shared common embedding and, consequently, shared fractal properties. This approach can be useful for the analysis of lung cancer DNA sequences and their properties by using the concepts of graph theory and fractal geometry. The proposed method advances a renewed consideration of network complexity both on local and global scales. Several researchers have illustrated the advantages of fractal mathematics, as well as its applicability to lung cancer research. Nevertheless, many researchers and clinicians continue to be unaware of its potential. Therefore, this paper aims to examine the underlying assumptions of fractals and analyze the fractal dimension and related measurements for possible application to complex networks and, especially, to the lung cancer network. The strict relationship between the lung cancer network properties and the fractal dimension is proved. Results show that the fractal dimension decreases in the lung cancer network while the topological properties of the network increase in the lung cancer network. Finally, statistical and topological significance between the complexity of the network and lung cancer network is shown.

Fluorescence-guided surgery of cancer: applications, tools and perspectives

Thousands of patients die each year from residual cancer that remains following cytoreductive surgery. Use of tumor-targeted fluorescent dyes (TTFDs) to illuminate undetected malignant tissue and thereby facilitate its surgical resection shows promise for reducing morbidity and mortality associated with unresected malignant disease. TTFDs can also improve i) detection of recurrent malignant lesions, ii) differentiation of normal from malignant lymph nodes, iii) accurate staging of cancer patients, iv) detection of tumors during robotic/endoscopic surgery (where tumor palpation is no longer possible), and v) preservation of healthy tissue during resection of cancer tissue. Although TTFDs that passively accumulate in a tumor mass provide some tumor contrast, the most encouraging TTFDs in human clinical trials are either enzyme-activated or ligand-targeted to tumor-specific receptors.

Prognostic factors in operated T3 non-small cell lung cancer: A retrospective, single-center study of 129 patients

Background

This study aims to investigate the prognostic factors that affect survival rates and durations in patients with T3 non-small cell lung cancer who underwent surgery.

Methods

A total of 129 patients with T3 n on-small c ell l ung c ancer (125 males, 4 females; mean age 60±9.3 years; range 23 to 80 years) who were performed surgery in our clinic between January 1997 and December 2013 were evaluated retrospectively in terms of age, gender, type of resection, tumor histopathology, tumor, node and metastasis staging, lymph node invasion, chemotherapy and radiotherapy, and recurrence.

Results

During the evaluation, while 61 patients (47.3%) were alive, 68 (52.7%) had lost their lives. One-, two- and five-year survival rates of the study population were 79.8%, 56.9% and 23.2%, respectively. Mean duration of survival was 41.5±4.0 months (range 33.7-49.4 months). Patient's age or tumor histopathology did not affect the duration of survival. Overall duration of survival was significantly longer in patients of stage IIB, patients who had low stages of lymph node invasion, who were performed lobectomy, who received chemotherapy or radiotherapy or who were without recurrence (p<0.05 for each). Multivariate regression analysis revealed that lymph node invasion, presence of recurrence or pneumonectomy, or failure to have been administered chemotherapy increased mortality risk significantly (hazard ratios 0.217, 3.369, 2.791 and 2.254, respectively).

Conclusion

Our findings revealed that lymph node invasion, presence of recurrence or pneumonectomy, or failure to have been administered chemotherapy are poor prognostic factors in T₃ non-small cell lung cancer. Prognostic factors should be taken into consideration during treatment and follow-up periods of patients with T₃ non-small cell lung cancer.

Post surgery circulating free tumor DNA is a predictive biomarker for relapse of lung cancer

Cancer cells release DNA fragments into plasma as circulating free DNA (cfDNA). However, quantitative measurement of tumor-derived DNA in cfDNA remains challenge. The purpose of this study was to quantitatively assess tumor-derived DNA in lung cancer patients. By optimizing competitive allele-specific TaqMan PCR (CAST-PCR), we assessed the copy number of mutated Kirsten rat sarcoma viral oncogene homolog (KRAS) and epidermal growth factor receptor (EGFR) alleles in the pre/post surgery plasma of 168 lung cancer patients. An absolute quantitative PCR method was developed to assess the number of total cfDNA. All mutations detected in tumors were also found in the plasma after surgery. At the time of 30 days after surgery, EGFR mutation of circulating cell-free DNA was detected only in two patients who recurred in 4 months after surgery. Compared to that of normal control at 30 days after surgery, five patients who recurred in 4 months had significantly higher circulating cell-free DNA (P < 0.001), whereas six patients who recurred after 4 months (P = 0.207) and five patients without recurrence (P = 0.901) demonstrated significantly lower circulating cell-free DNA. Our findings suggest that cfDNA analysis in plasma is an alternative and supplement to tissue analysis and hold promise for clinical application. Stratification of patients according to cfDNA levels at 30 days after surgery might be helpful in selecting lung cancer patients for adjuvant therapy after surgery.

Optimal delivery of follow-up care following pulmonary lobectomy for lung cancer

Introduction

The rationale for oncologic surveillance following pulmonary lobectomy is to detect recurrent disease or a second primary lung cancer early enough so that an intervention can increase survival and/or improve quality of life. Therefore, we reviewed literature for international guidelines and reorganized these useful factors associated with non-small-cell lung cancer (NSCLC) recurrence as remedies in postoperative follow-up.

Method

The population of interest for this review was patients who had been treated with complete resection for primary NSCLC and were in follow-up.

Result

Guidelines on follow-up care for NSCLC vary internationally. Because of the production of progressive medical modalities, the current follow-up care should be corrected.

Conclusion

The specific follow-up schedule for computed tomography imaging may be more or less frequent, depending upon risk factors for recurrence. Many different predictors of postoperative recurrence may help to optimize the patient selection for specified surveillance guidelines and personalized adjuvant therapies to prevent possibly occult micrometastases and to get a better outcome.

Design, Synthesis, and Evaluation of a Neurokinin-1 Receptor-Targeted Near-IR Dye for Fluorescence-Guided Surgery of Neuroendocrine Cancers

The neurokinin-1 receptor (NK1R) is implicated in the growth and metastasis of many tumors, including cancers of the brain (e.g., gliomas, glioblastomas, and astrocytomas), skin (e.g., melanomas), and neuroendocrine tissues (cancers of the breast, stomach, pancreas, larynx, and colon). Because overexpression of NK1R has been reported in most of these malignancies, we have undertaken designing an NK1R-targeted near-infrared (NIR) fluorescent dye for fluorescence-guided surgeries of these cancers. We demonstrate here that an NK1R-binding ligand linked to the NIR dye LS288 selectively accumulates in NK1R-expressing tumor xenografts with high affinity (Kd = 13 nM), allowing intraoperative imaging of these cancers in live mice. Because tumor accumulation is nearly quantitatively blocked by excess unlabeled ligand, and because NK1R-negative tumors and normal tissues display virtually no uptake, we conclude that the observed tumor retention is NK1R-mediated. Results on the synthesis, in vitro characterization, and animal testing of NK1R-targeted NIR dye are presented.

Lung cancer screening: Should we be excluding people with previous malignancy?

The National Lung Screening Trial (NLST) was a large, randomized, controlled study showing a 20% reduction of lung cancer mortality and 7% reduction of all cause mortality using annual low dose computed tomography (LDCT) in a high risk population. NLST excluded people with a previous history of cancer treatment within the past 5 years and all people with a history lung cancer. The aim of this work is to review how lung cancer screening trials addressed the confounding effect of previous malignancy. We also review the subsequent recommendations by the United States Preventative Task Force Services, multiple professional societies and the Center for Medicaid and Medicare Services which defer either to NLST criteria or, clinician judgment or refrain from asserting any recommendation on the topic, respectively. Implications of lung cancer screening in the setting of previous malignancies, specifically lung, head and neck, esophageal, gastric, breast, colorectal cancer and lymphoma are also discussed. With lung cancer screening, an antecedent malignancy introduces the possibility of discovering metastasis as well as lung cancer. In some circumstances diagnosis and treatment of oligometastatic disease may confer a survival benefit. The survival benefit of treating either lung cancer or oligometastatic disease as result of lung cancer screening has yet to be determined. Further studies are needed to determine the role of lung cancer screening in the setting of previous malignancy.

Risk Factors for Local and Distant Recurrence After Surgical Treatment in Patients With Non-Small-Cell Lung Cancer

INTRODUCTION

The purpose of this study was to identify independent perioperative and pathologic variables associated with non-small-cell lung cancer (NSCLC) recurrence after complete surgical resection.

PATIENTS AND METHODS

A retrospective examination was performed of a prospectively maintained database of patients who underwent resection for NSCLC from January 2009 to January 2014 at a multi-institution. Clinicopathologic variables were evaluated for their influence on frequency of recurrence. Cox proportional regression hazard model analysis examined the association of recurrence in NSCLC.

RESULTS

Of these patients, 2816 (19.3%) experienced recurrence of primary cancer. Local or distant recurrence was found in 20.5% and 79.5% of patients, respectively. Median follow-up was 27.9 months (range, 11.4-66.0 months). The analysis indicated independent effects of the following risk factors on the risk of recurrence: age 64-90 years (hazard ratio [HR], 1.136; 95% confidence interval [CI] 1.024-1.261), histologic type adenocarcinoma (HR, 1.117; 95% CI 1.005-1.24), blood vessel invasion (HR, 1.236; 95% CI, 1.124-1.359), lymphatic vessel invasion (HR, 1.287; 95% CI, 1.176-1.409), visceral pleural invasion (HR, 1.641; 95% CI, 1.215-2.218), N1 disease (HR, 1.142; 95% CI, 0.99-1.316), N2 disease (HR, 1.596; 95% CI, 1.271-1.649), tumor size of 20-30 mm (HR, 1.235; 95% CI, 1.081-1.41), 30-50 mm (HR, 1.544; 95% CI, 1.33-1.792), 50-70 mm (HR, 1.521; 95% CI, 1.275-1.815), and 70-100 mm (HR, 1.71; 95% CI, 1.385-2.11), pneumonectomy (HR, 1.08; 95% CI, 0.97-1.203), and sublobar resection (HR, 1.762; 95% CI, 1.537-2.019).

CONCLUSION

In the largest series reported to date on postresection recurrence of NSCLC, increasing pathologic stage, advanced age, pneumonectomy, sublobar resection, lymphatic and blood vessel invasion, and visceral pleural invasion were independently associated with local and distant recurrence.

Prognostic Factors for Survival After Recurrence in Patients With Completely Resected Lung Adenocarcinoma: Important Roles of Epidermal Growth Factor Receptor Mutation Status and the Current Staging System

Epidermal growth factor receptor (EGFR) status and pathological stage (p-stage) were shown to be essential prognostic factors for estimating survival after recurrence of lung adenocarcinoma. In patients with EGFR mutations, those with early p-stage tumors showed better survival after disease recurrence than those with advanced p-stage tumors. The EGFR mutation status and p-stage could also prompt the design of clinical trials on adjuvant therapy for patients after complete surgical resection.

BACKGROUND

The current staging system and epidermal growth factor receptor (EGFR) mutation status are key factors for predicting survival. However, the significance of these factors as predictors of survival after disease recurrence (PRS) has not been sufficiently elucidated. The objective of this study was to investigate the clinicopathological factors, particularly the EGFR mutation status and pathological stage (p-stage), which affect PRS in patients with completely resected lung adenocarcinoma.

PATIENTS AND METHODS

We retrospectively reviewed the data of 198 consecutive lung adenocarcinoma patients with disease recurrence who previously underwent complete surgical resection in our hospital.

RESULTS

Of the 198 patients, 117 were examined for EGFR mutations (mutants). Mutants were detected in 57 patients (28.7%). The patients with mutants had a significantly better 3-year PRS (3y-PRS) rate (68.6%) than those with an EGFR wild type (WT) status (51.7%) or an unknown (UN) status (27.0%). The 3y-PRS rates for p-stage I to II (p-I-II) and p-stage III (p-III) were 52.5% and 29.3%, respectively. Multivariate survival analysis showed that the EGFR mutation status and p-stage had significant associations with favorable PRS. The 3y-PRS rate for mutants/p-I-II (81.4%) was significantly better than that for mutants/p-III (48.0%). Conversely, there was no significant difference between mutants/p-III and WT/UN/p-I-II (3y-PRS: 40.7%) or between mutants/p-III and WT/UN/p-III (3y-PRS: 24.4%).

CONCLUSION

EGFR status and p-stage were shown to be essential prognostic factors for estimating PRS. In patients with mutants, those with early p-stage tumors showed better PRS than those with advanced p-stage tumors.

Prognostic factors for surgically managed patients with stage II non-small cell lung cancer

BACKGROUND

To investigate the prognostic factors in surgically managed patients with stage II non-small cell lung cancer.

MATERIAL AND METHODS

A retrospective analysis of clinical data of surgically managed 93 patients with stage II non-small cell lung cancer in our hospital between May 2005 and November 2009 was conducted, and prognostic factors that may impact the postoperative 5-year survival rate were statistically analyzed.

RESULTS

Univariable survival analysis showed that new TNM staging, total number of dissected lymph nodes, number of dissected N1 and N2 lymph nodes and N1 lymph groups, metastasis rate of N1 lymph nodes, and 10th group of lymph nodes metastatic or not, were related to the postoperative 5-year survival rate in the patients. Multivariable survival analysis showed that the metastasis rate of N1 lymph nodes and 10th group of lymph nodes metastatic or not were independent prognostic factors for the postoperative 5-year survival rate in the patients.

CONCLUSION

When patients with stage II non-small cell lung cancer are treated with surgery, the total number of dissected lymph nodes greater than 6, the number of dissected N1 lymph nodes over 5, N2 over 2, and the number of dissected N1 groups over 3, may improve their postoperative 5-year survival rate. The metastasis rate of N1 lymph nodes over 50%, and the metastasis of the 10th group of lymph nodes imply poor prognosis of the patients.

Anti-tumor effect of cactus polysaccharides on lung squamous carcinoma cells (SK-MES-1)

BACKGROUND

Cactus polysaccharides are the active components of Opuntia dillenii which have been used extensively in folk medicine. In this study, we investigate the anti-tumor effect of cactus polysaccharides on lung squamous carcinoma cells SK-MES-1.

MATERIALS AND METHODS

The inhibitory effect of Cactus polysaccharides on lung squamous carcinoma cells were detected by MTT assay. Cell cycle was determined by flow cytometry and cell apoptosis was determined by AnnexinV assay. Western-blotting was applied to detect P53 and PTEN protein expression in the cells treated with cactus polysaccharides.

RESULTS

Results showed that different concentrations of wild cactus polysaccharides prevent SK-MES-1 cells growth and induces S phase arrest. The data also revealed that cactus polysaccharides cause apoptosis in SK-MES-1 cells determined by Annexin-V assay. Furthermore, cactus polysaccharides induced growth arrest and apoptosis may be due to the increase of P53 and phosphatase and tension homolog deleted on chromosome ten (PTEN) protein.

CONCLUSION

Cactus polysaccharides have anti-tumor activity on lung squamous carcinoma cells.

Noninvasive image texture analysis differentiates K-ras mutation from pan-wildtype NSCLC and is prognostic

BACKGROUND

Non-invasive characterization of a tumor's molecular features could enhance treatment management. Quantitative computed tomography (CT) based texture analysis (QTA) has been used to derive tumor heterogeneity information, and the appearance of the tumors has been shown to relate to patient outcome in non-small cell lung cancer (NSCLC) and other cancers. In this study, we examined the potential of tumoral QTA to differentiate K-ras mutant from pan-wildtype tumors and its prognostic potential using baseline pre-treatment non-contrast CT imaging in NSCLC.

METHODS

Tumor DNA from patients with early-stage NSCLC was analyzed on the LungCarta Panel. Cases with a K-ras mutation or pan-wildtype for 26 oncogenes and tumor suppressor genes were selected for QTA. QTA was applied to regions of interest in the primary tumor. Non-parametric Mann Whitney test assessed the ability of the QTA, clinical and patient characteristics to differentiate between K-ras mutation from pan-wildtype. A recursive decision tree was developed to determine whether the differentiation of K-ras mutant from pan-wildtype tumors could be improved by sequential application of QTA parameters. Kaplan-Meier survival analysis assessed the ability of these markers to predict survival.

RESULTS

QTA was applied to 48 cases identified, 27 had a K-ras mutation and 21 cases were pan-wildtype. Positive skewness and lower kurtosis were significantly associated with the presence of a K-ras mutation. A five node decision tree had sensitivity, specificity, and accuracy values (95% CI) of 96.3% (78.1-100), 81.0% (50.5-97.4), and 89.6% (72.9-97.0); respectively. Kurtosis was a significant predictor of OS and DFS, with a lower kurtosis value linked with poorer survival.

CONCLUSIONS

Lower kurtosis and positive skewness are significantly associated with K-ras mutations. A QTA feature such as kurtosis is prognostic for OS and DFS. Non-invasive QTA can differentiate the presence of K-ras mutation from pan-wildtype NSCLC and is associated with patient survival.

Novel treatment options in stage I non-small-cell lung cancer

In the last 5 years, the current management of stage I non-small-cell lung cancer has been challenged due to novel surgical approaches and advances in radiation technology. The outcome after a sublobar resection is promising, especially for tumors less than 2 cm. Other treatment opportunities are available for high risk patients with comorbidity and impaired pulmonary function. Stereotactic ablative body radiotherapy is a good alternative treatment to surgery, especially in elderly and comorbid patients. However, randomized evidence comparing sublobar resection and stereotactic radiotherapy is presently lacking. The most recent development in radiotherapy is hadron therapy with a presumed reduced toxicity because of its peculiar physical and biological effects. Promising thermal and microwave ablative techniques are in development and have specific niche indications.