Lung Cancer Screening in Asia: An Expert Consensus Report

INTRODUCTION

The incidence and mortality of lung cancer are highest in Asia compared with Europe and USA, with the incidence and mortality rates being 34.4 and 28.1 per 100,000 respectively in East Asia. Diagnosing lung cancer at early stages makes the disease amenable to curative treatment and reduces mortality. In some areas in Asia, limited availability of robust diagnostic tools and treatment modalities, along with variations in specific health care investment and policies, make it necessary to have a more specific approach for screening, early detection, diagnosis, and treatment of patients with lung cancer in Asia compared with the West.

METHOD

A group of 19 advisors across different specialties from 11 Asian countries, met on a virtual Steering Committee meeting, to discuss and recommend the most affordable and accessible lung cancer screening modalities and their implementation, for the Asian population.

RESULTS

Significant risk factors identified for lung cancer in smokers in Asia include age 50 to 75 years and smoking history of more than or equal to 20 pack-years. Family history is the most common risk factor for nonsmokers. Low-dose computed tomography screening is recommended once a year for patients with screening-detected abnormality and persistent exposure to risk factors. However, for high-risk heavy smokers and nonsmokers with risk factors, reassessment scans are recommended at an initial interval of 6 to 12 months with subsequent lengthening of reassessment intervals, and it should be stopped in patients more than 80 years of age or are unable or unwilling to undergo curative treatment.

CONCLUSIONS

Asian countries face several challenges in implementing low-dose computed tomography screening, such as economic limitations, lack of efforts for early detection, and lack of specific government programs. Various strategies are suggested to overcome these challenges in Asia.

Immunoinformatics Identification of the Conserved and Cross-Reactive T-Cell Epitopes of SARS-CoV-2 with Human Common Cold Coronaviruses, SARS-CoV, MERS-CoV and Live Attenuated Vaccines Presented by HLA Alleles of Indonesian Population

Reports on T-cell cross-reactivity against SARS-CoV-2 epitopes in unexposed individuals have been linked with prior exposure to the human common cold coronaviruses (HCCCs). Several studies suggested that cross-reactive T-cells response to live attenuated vaccines (LAVs) such as BCG (Bacillus Calmette-Guérin), OPV (Oral Polio Vaccine), and MMR (measles, mumps, and rubella) can limit the development and severity of COVID-19. This study aims to identify potential cross-reactivity between SARS-CoV-2, HCCCs, and LAVs in the context of T-cell epitopes peptides presented by HLA (Human Leukocyte Antigen) alleles of the Indonesian population. SARS-CoV-2 derived T-cell epitopes were predicted using immunoinformatics tools and assessed for their conservancy, variability, and population coverage. Two fully conserved epitopes with 100% similarity and nine heterologous epitopes with identical T-cell receptor (TCR) contact residues were identified from the ORF1ab fragment of SARS-CoV-2 and all HCCCs. Cross-reactive epitopes from various proteins of SARS-CoV-2 and LAVs were also identified (15 epitopes from BCG, 7 epitopes from MMR, but none from OPV). A majority of the identified epitopes were observed to belong to ORF1ab, further suggesting the vital role of ORF1ab in the coronaviruses family and suggesting it as a candidate for a potential universal coronavirus vaccine that protects against severe disease by inducing cell mediated immunity.

Pulmonary alveolar proteinosis with secondary Aspergillus infection: A case report

Pulmonary alveolar proteinosis (PAP) is a rare disease with mostly due to autoimmune toward granulocyte-macrophage colony-stimulating factor. In some conditions, PAP followed with secondary infection. A 34-year-old woman came with progressive shortness of breath, chronic dry cough, and mild fever. The chest High-Resolution Computed Tomography showed ground-glass opacity with septal reticulation or known as the crazy-paving pattern, and a cavity on the upper lobe of the left lung. The patient underwent bronchoscopy for diagnostic and therapeutic measures and found milky appearance bronchoalveolar lavage fluid (BALF). The serum galactomannan came out positive. Fungal infection detected from the BALF culture, Aspergillus fumigatus, hence fulfilling the diagnosis of PAP with probable invasive pulmonary aspergillosis. The patient showed clinical improvement after undergoing whole lung lavage and given anti-fungal medications.

Immunoinformatics Analysis of SARS-CoV-2 ORF1ab Polyproteins to Identify Promiscuous and Highly Conserved T-Cell Epitopes to Formulate Vaccine for Indonesia and the World Population

SARS-CoV-2 and its variants caused the COVID-19 pandemic. Vaccines that target conserved regions of SARS-CoV-2 and stimulate protective T-cell responses are important for reducing symptoms and limiting the infection. Seven cytotoxic (CTL) and five helper T-cells (HTL) epitopes from ORF1ab were identified using NetCTLpan and NetMHCIIpan algorithms, respectively. These epitopes were generated from ORF1ab regions that are evolutionary stable as reflected by zero Shannon's entropy and are presented by 56 human leukocyte antigen (HLA) Class I and 22 HLA Class II, ensuring good coverage for the Indonesian and world population. Having fulfilled other criteria such as immunogenicity, IFNγ inducing ability, and non-homology to human and microbiome peptides, the epitopes were assembled into a vaccine construct (VC) together with β-defensin as adjuvant and appropriate linkers. The VC was shown to have good physicochemical characteristics and capability of inducing CTL as well as HTL responses, which stem from the engagement of the vaccine with toll-like receptor 4 (TLR4) as revealed by docking simulations. The most promiscuous peptide 899WSMATYYLF907 was shown via docking simulation to interact well with HLA-A*24:07, the most predominant allele in Indonesia. The data presented here will contribute to the in vitro study of T-cell epitope mapping and vaccine design in Indonesia.

Leading women in respiratory medicine: Letter from Indonesia

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Urinary Cotinine and Nicotine Dependence Levels in Regular Male Electronic Cigarette Users

OBJECTIVE

Found in plasma, urine, and saliva, cotinine can be used as a biomarker for nicotine in electronic cigarette (e-cig) users. Nicotine is addictive and causes dependence. Thus, it becomes a problem in smoking cessation programs. This study aimed to determine the relationship between urinary cotinine (UCot) and nicotine dependence levels in regular male e-cig users.

MATERIALS AND METHODS

This cross-sectional study consecutively included regular male e-cig users and nonsmokers. All subjects were interviewed and had their UCot levels measured using an enzyme-linked immunosorbent assay method. The regular e-cig users completed the Penn State Nicotine Dependence Index questionnaire.

RESULTS

This study recruited 71 males aged 18-45 years divided into e-cig users and non-smokers group. The predominating characteristics in e-cig users are as follows: 23 males (67.6%) aged <30 years, the highest education of senior high school 25 (73.5%) and 25 (73.5%) subjects had occupation. The UCot levels among the e-cig users in the non-dependency group were lower than that of the medium-high dependency group (P = .008). The median value for UCot level in the regular e-cig users was higher than that of the non-smoker group (276.11 [58.01-284.15] ng/mL vs 5.21 [4.65-23.72] ng/mL, P < .001). Factors influencing the UCot levels of the e-cig users were age (P = .041), nicotine level of the e-cig liquid (P = .013), and the flavor of the e-cig liquid (eg, menthol or non-menthol; P = .040).

CONCLUSION

UCot and nicotine dependence levels in the regular male e-cig users were significantly related. Nicotine dependence was found in 76.5% of the regular male e-cig users. The UCot levels in the e-cig users were significantly higher than in the non-smokers.

Association between clinical, laboratory findings and chest CT in COVID-19 in a secondary hospital in Jakarta, Indonesia

Introduction

A new emerging infectious disease caused by SARS-CoV-2 has caused a global pandemic. Early diagnosis is essential to prevent and halt the spread of the disease, patient management and isolation. In this study, we aimed to reveal correlations between clinical and laboratory findings with chest CT.

Methods

This in an observational case series single center study in a secondary hospital in Jakarta, Indonesia. Patients were included if they had typical symptoms and positive RT-PCR for SARS-CoV-2.

Results

Forty-two patients with positive RT-PCR were included in this study. Typical CT findings were present in 33 (78.6%). We found a positive correlation between patients in whom the imaging was performed after the 4^th day of symptoms and chest CT findings (r=0.365 p<0.05). In receiver operating characteristic analysis of this parameter, the area under curve (AUC) was 0.678, and the sensitivity and specificity were 0.96 and 0.44, respectively.

Conclusions

Early diagnosis of COVID-19 is essential to promptly isolate and treat suspected patients. Utilization of chest CT to help diagnosis in this pandemic era needs to be considered by healthcare facilities especially if RT-PCR is limited.

Correlation between Domestic Cigarette Smoke Exposure and Respiratory Complaints, Hospitalization and School Absence due to Respiratory Complains in the Indonesian Elementary School-Aged Children

Background:

Over 43 million Indonesian children who are exposed to cigarette smoke are at risk of having health hazard and morbidities.

Aims:

The aim of this study is to identify the correlation between cigarette smoke exposure and respiratory complaints, hospitalization, as well as school absence due to respiratory complaints in elementary school-aged Indonesian children.

Materials and Methods:

A cross-sectional study was conducted in nonsmoking elementary school-aged children. Participants were categorized into the exposed and unexposed groups based on the report of their parents. Questionnaire-retrieved data were analyzed to identify the correlation between cigarette smoke exposure and respiratory complaints, hospitalization, as well as school absence due to respiratory complaints in elementary school-aged children.

Results:

A total of 128 study participants of nonsmoking children aged 6–12 years (mean 9.8 ± standard deviation 1.6 years) were categorized into 64 children exposed and 64 children unexposed to domestic cigarette smoking. There was a significant correlation between smoking exposure and cough episodes as well as upper respiratory infection in children within the past 12 months. A cough episode of ≥3 times/year was found more prevalent in exposed children compared to the unexposed children (26.6% vs. 9.4%; P < 0.05). Cough ≥3 times/year was found in 50% of children exposed to cigarette smoke of a smoker with a smoking habit of >10 cigarettes/day. There was a correlation between cigarette smoke exposure and hospitalization frequency of ≥1 time(s)/year due to respiratory complaints in children (P < 0.05).

Conclusion:

Cigarette smoke exposure is correlated with complaints of cough, upper respiratory tract infection, and hospitalization due to respiratory complaints in children.

Urinary Cotinine Level in Indonesian Children Exposed to Domestic Cigarette Smoke

BACKGROUND

Cotinine is a major metabolite of nicotine, and its urinary level is an indicator of exposure to cigarette smoke. The present study was aimed at identifying the urinary cotinine level in Indonesian children who were exposed and not exposed to domestic cigarette smoke.

METHODS

The study was a cross-sectional study in elementary school-aged children who had not smoked. The subjects were categorized into an exposed group and unexposed group based on their exposure status. Data were obtained from a questionnaire and random urinary samples measured using enzyme-linked immunosorbent assay.

RESULTS

There were a total of 128 subjects, including 64 children in the exposed group and 64 children in the unexposed group. The median level of cotinine in all subjects was 17.95 ng/ml (with a range of 0.1-158.3 ng/ml). The urinary cotinine level in the exposed group was higher than the unexposed group (median: 30.1 ng/ml vs. 8.45 ng/ml; P < 0.000). There was a correlation between urinary cotinine levels in children exposed to cigarette smoke and the number of cigarettes smoked by the smokers at home (P < 0.05). The optimal cut-off points of urinary cotinine levels in children, which was utilized to evaluate cigarette smoke exposure, was 17.95 ng/ml (81% sensitivity; 81% specificity; P < 0.000).

CONCLUSION

The urinary cotinine level in children exposed to cigarette smoke is higher than children who are not exposed to domestic cigarette smoke. The urinary cotinine level can be used as a noninvasive marker to evaluate cigarette smoke exposure in children.

Circulating Tumor Cell and Cell-free Circulating Tumor DNA in Lung Cancer

Circulating tumor cells (CTCs) are tumor cells that are separated from the primary site or metastatic lesion and disseminate in blood circulation. CTCs are considered to be part of the long process of cancer metastasis. As a 'liquid biopsy', CTC molecular examination and investigation of single cancer cells create an important opportunity for providing an understanding of cancer biology and the process of metastasis. In the last decade, we have seen dramatic development in defining the role of CTCs in lung cancer in terms of diagnosis, genomic alteration determination, treatment response and, finally, prognosis prediction. The aims of this review are to understand the basic biology and to review methods of detection of CTCs that apply to the various types of solid tumor. Furthermore, we explored clinical applications, including treatment monitoring to anticipate therapy resistance as well as biomarker analysis, in the context of lung cancer. We also explored the potential use of cell-free circulating tumor DNA (ctDNA) in the genomic alteration analysis of lung cancer.

Implications of Insulin-like Growth Factor 1 Receptor Activation in Lung Cancer

Insulin-like growth factor 1 receptor (IGF1R) has been intensively investigated in many preclinical studies using cell lines and animal models, and the results have provided important knowledge to help improve the understanding of cancer biology. IGF1R is highly expressed in patients with lung cancer, and high levels of circulating insulin-like growth factor 1 (IGF1), the main ligand for IGF1R, increases the risk of developing lung malignancy in the future. Several phase I clinical trials have supported the potential use of an IGF1R-targeted strategy for cancer, including lung cancer. However, the negative results from phase III studies need further attention, especially in selecting patients with specific molecular signatures, who will gain benefits from IGF1R inhibitors with minimal side effects. This review will discuss the basic concept of IGF1R in lung cancer biology, such as epithelial-mesenchymal transition (EMT) induction and cancer stem cell (CSC) maintenance, and also the clinical implications of IGF1R for lung cancer patients, such as prognostic value and cancer therapy resistance.

Lung cancer staging now and in the future

For a long time lung cancer was associated with a fatalistic approach by healthcare professionals. In recent years, advances in imaging, improved diagnostic techniques and more effective treatment modalities are reasons for optimism. Accurate lung cancer staging is vitally important because treatment options and prognosis differ significantly by stage. The staging algorithm should include a contrast computed tomography (CT) of the chest and the upper abdomen including adrenals, positron emission tomography/CT for staging the mediastinum and to rule out extrathoracic metastasis in patients considered for surgical resection, endosonography-guided needle sampling procedure replacing mediastinoscopy for near complete mediastinal staging, and brain imaging as clinically indicated. Applicability of evidence-based guidelines for staging of lung cancer depends on the available expertise and level of resources and is directly impacted by financial issues. Considering the diversity of healthcare infrastructure and economic performance of Asian countries, optimal and cost-effective use of staging methods appropriate to the available resources is prudent. The pulmonologist plays a central role in the multidisciplinary approach to lung cancer diagnosis, staging and management. Regional respiratory societies such as the Asian Pacific Society of Respirology should work with national respiratory societies to strive for uniform standards of care. For developing countries, a minimum set of care standards should be formulated. Cost-effective delivery of optimal care for lung cancer patients, including staging within the various healthcare systems, should be encouraged and most importantly, tobacco control implementation should receive an absolute priority status in all countries in Asia.

OX40 ligand expressed by DCs costimulates NKT and CD4+ Th cell antitumor immunity in mice

The exceptional immunostimulatory capacity of DCs makes them potential targets for investigation of cancer immunotherapeutics. We show here in mice that TNF-alpha-stimulated DC maturation was accompanied by increased expression of OX40 ligand (OX40L), the lack of which resulted in an inability of mature DCs to generate cellular antitumor immunity. Furthermore, intratumoral administration of DCs modified to express OX40L suppressed tumor growth through the generation of tumor-specific cytolytic T cell responses, which were mediated by CD4+ T cells and NKT cells. In the tumors treated with OX40L-expressing DCs, the NKT cell population significantly increased and exhibited a substantial level of IFN-gamma production essential for antitumor immunity. Additional studies evaluating NKT cell activation status, in terms of IFN-gamma production and CD69 expression, indicated that NKT cell activation by DCs presenting alpha-galactosylceramide in the context of CD1d was potentiated by OX40 expression on NKT cells. These results show a critical role for OX40L on DCs, via binding to OX40 on NKT cells and CD4+ T cells, in the induction of antitumor immunity in tumor-bearing mice.

Dendritic cells modified to express fractalkine/CX3CL1 in the treatment of preexisting tumors

Fractalkine (CX3CL1) is a unique membrane-bound CX3C chemokine that serves as a potent chemoattractant for lymphocytes. The hypothesis of this study is that dendritic cells (DC) genetically modified ex vivo to overexpress fractalkine would enhance the T cell-mediated cellular immune response with a consequent induction of anti-tumor immunity to suppress tumor growth. To prove this hypothesis, established tumors of different mouse cancer cells (B16-F10 melanoma, H-2b, and Colon-26 colon adenocarcinoma, H-2d) were treated with intratumoral injection of bone marrow-derived DC that had been modified in vitro with an RGD fiber-mutant adenovirus vector expressing mouse fractalkine (Ad-FKN). In both tumor models tested, treatment of tumor-bearing mice with Ad-FKN-transduced DC gave rise to a significant suppression of tumor growth along with survival advantages in the treated mice. Immunohistochemical analysis of tumors treated with direct injection of Ad-FKN-transduced DC demonstrated that the treatment prompted CD8+ T cells and CD4+ T cells to accumulate in the tumor milieu, leading to activation of immune-relevant processes. Consistent with the finding, the intratumoral administration of Ad-FKN-transduced DC evoked tumor-specific cytotoxic T lymphocytes, which ensued from in vivo priming of Th1 immune responses in the treated host. In addition, the anti-tumor effect provided by intratumoral injection of Ad-FKN-transduced DC was completely abrogated in CD4+ T cell-deficient mice as well as in CD8+ T cell-deficient mice. These results support the concept that genetic modification of DC with a recombinant fractalkine adenovirus vector may be a useful strategy for cancer immunotherapy protocols.

Involvement of fractalkine/CX3CL1 expression by dendritic cells in the enhancement of host immunity against Legionella pneumophila

Legionnaires' disease is clinically manifested as severe pneumonia caused by Legionella pneumophila. However, the dendritic cell (DC)-centered immunological framework of the host defense against L. pneumophila has not been fully delineated. For this study, we focused on a potent chemoattractant for lymphocytes, fractalkine/CX3CL1, and observed that the fractalkine expression of DCs was somewhat up-regulated when they encountered L. pneumophila. We therefore hypothesized that fractalkine expressed by Legionella-capturing DCs is involved in the induction of T-cell-mediated immune responses against Legionella, which would be enhanced by a genetic modulation of DCs to overexpress fractalkine. In vivo immunization-challenge experiments demonstrated that DCs modified with a recombinant adenovirus vector to overexpress fractalkine (AdFKN) and pulsed with heat-killed Legionella protected immunized mice from a lethal Legionella infection and that the generation of in vivo protective immunity depended on the host lymphocyte subsets, including CD4(+) T cells, CD8(+) T cells, and B cells. Consistent with this, immunization with AdFKN/Legionella/DC induced significantly higher levels of serum anti-Legionella antibodies of several isotypes than those induced by control immunizations. Further analysis of spleen cells from the immunized mice indicated that the AdFKN/Legionella/DC immunization elicited Th1-dominated immune responses to L. pneumophila. These observations suggest that fractalkine may play an important role in the DC-mediated host defense against intracellular pathogens such as L. pneumophila.

Antitumor immune response by CX3CL1 fractalkine gene transfer depends on both NK and T?cells

The CX3C chemokine fractalkine (CX3CL1) exists as both a membrane-bound form promoting firm cell-cell adhesion and a soluble form chemoattracting leukocytes expressing its receptor CX3CR1. When adenoviral vector expressing mouse fractalkine (AdFKN) was transduced to the tumor cells, fractalkine was expressed as both membrane-bound form on the tumor cells and soluble form in the supernatant in vitro. Intratumoral injection of AdFKN (1 x 10(9)PFU/tumor) into C26 and B16F10 tumors resulted in marked reduction of tumor growth compared to control (C26: 86.5%, p<0.001; B16F10: 85.5%, p<0.001). Histological examination of tumor tissues revealed abundant infiltration of NK cells, dendritic cells, and CD8(+) T lymphocytes 3 and/or 6 days after treatment with AdFKN. Splenocytes from mice treated by AdFKN developed tumor-specific cytotoxic T cells, and thereby protected from rechallenging with parental tumor cells. Antitumor effects by AdFKN were completely abrogated in both NK cell-depleted mice and CD8(-/-) mice, and partially blocked in CD4(-/-) mice. These data indicated that fractalkine mediates antitumor effects by both NK cell-dependent and T cell-dependent mechanisms. This study suggests that fractalkine can be a suitable candidate for immunogene therapy of cancer because fractalkine induces both innate and adaptive immunity.

Adenovirus Vector-Mediated in Vivo Gene Transfer of OX40 Ligand to Tumor Cells Enhances Antitumor Immunity of Tumor-Bearing Hosts

OX40 ligand (OX40L), the ligand for OX40 on activated CD4+ T cells, has adjuvant properties for establishing effective T-cell immunity, a potent effector arm of the immune system against cancer. The hypothesis of this study is that in vivo genetic engineering of tumor cells to express OX40L will stimulate tumor-specific T cells by the OX40L-OX40 engagement, leading to an induction of systemic antitumor immunity. To investigate this hypothesis, s.c. established tumors of three different mouse cancer cells (B16 melanoma, H-2b; Lewis lung carcinoma, H-2b; and Colon-26 colon adenocarcinoma, H-2d) were treated with intratumoral injection of a recombinant adenovirus vector expressing mouse OX40L (AdOX40L). In all tumor models tested, treatment of tumor-bearing mice with AdOX40L induced a significant suppression of tumor growth along with survival advantages in the treated mice. The in vivo AdOX40L modification of tumors evoked tumor-specific cytotoxic T lymphocytes in the treated host correlated with in vivo priming of T helper 1 immune responses in a tumor-specific manner. Consistent with the finding, the antitumor effect provided by intratumoral injection of AdOX40L was completely abrogated in a CD4+ T cell-deficient or CD8+ T cell-deficient condition. In addition, ex vivo AdOX40L-transduced B16 cells also elicited B16-specific cytotoxic T lymphocyte responses, and significantly suppressed the B16 tumor growth in the immunization-challenge experiment. All of these results support the concept that genetic modification of tumor cells with a recombinant OX40L adenovirus vector may be of benefit in cancer immunotherapy protocols.