Clinical and Prognostic Significance of Glutathione Peroxidase 2 in Lung Adenocarcinoma

BACKGROUND

Glutathione peroxidase 2 (GPX2) is an antioxidant enzyme with an important role in tumor progression in various cancers. However, the clinical significance of GPX2 in lung adenocarcinoma has not been clarified.

METHODS

Quantitative reverse transcription polymerase chain reaction (qRT-PCR) was used to analyze GPX2 mRNA expression. Then, we conducted immunohistochemistry (IHC) to assess GPX2 expression in specimens acquired from 351 patients with lung adenocarcinoma who underwent surgery at Kyushu University from 2003 to 2012. We investigated the association between GPX2 expression and clinicopathological characteristics and further analyzed the prognostic relevance.

RESULTS

qRT-PCR revealed that GPX2 mRNA expression was notably higher in tumor cells than in normal tissues. IHC revealed that high GPX2 expression (n = 175, 49.9%) was significantly correlated with male sex, smoking, advanced pathological stage, and the presence of pleural, lymphatic, and vascular invasion. Patients with high GPX2 expression exhibited significantly shorter recurrence-free survival (RFS) and overall survival. Multivariate analysis identified high GPX2 expression as an independent prognostic factor of RFS.

CONCLUSIONS

GPX2 expression was significantly associated with pathological malignancy. It is conceivable that high GPX2 expression reflects tumor malignancy. Therefore, high GPX2 expression is a significant prognostic factor of poor prognosis for completely resected lung adenocarcinoma.

MUC1-C Is a Common Driver of Acquired Osimertinib Resistance in NSCLC

INTRODUCTION

Osimertinib is an irreversible EGFR tyrosine kinase inhibitor approved for the first-line treatment of patients with metastatic NSCLC harboring EGFR exon 19 deletions or L858R mutations. Patients treated with osimertinib invariably develop acquired resistance by mechanisms involving additional EGFR mutations, MET amplification, and other pathways. There is no known involvement of the oncogenic MUC1-C protein in acquired osimertinib resistance.

METHODS

H1975/EGFR (L858R/T790M) and patient-derived NSCLC cells with acquired osimertinib resistance were investigated for MUC1-C dependence in studies of EGFR pathway activation, clonogenicity, and self-renewal capacity.

RESULTS

We reveal that MUC1-C is up-regulated in H1975 osimertinib drug-tolerant persister cells and is necessary for activation of the EGFR pathway. H1975 cells selected for stable osimertinib resistance (H1975-OR) and MGH700-2D cells isolated from a patient with acquired osimertinib resistance are found to be dependent on MUC1-C for induction of (1) phospho (p)-EGFR, p-ERK, and p-AKT, (2) EMT, and (3) the resistant phenotype. We report that MUC1-C is also required for p-EGFR, p-ERK, and p-AKT activation and self-renewal capacity in acquired osimertinib-resistant (1) MET-amplified MGH170-1D #2 cells and (2) MGH121 Res#2/EGFR (T790M/C797S) cells. Importantly, targeting MUC1-C in these diverse models reverses osimertinib resistance. In support of these results, high MUC1 mRNA and MUC1-C protein expression is associated with a poor prognosis for patients with EGFR-mutant NSCLCs.

CONCLUSIONS

Our findings reveal that MUC1-C is a common effector of osimertinib resistance and is a potential target for the treatment of osimertinib-resistant NSCLCs.

Usefulness of free subcutaneous fat pads for refractory secondary pneumothorax due to lung cancer

Surgical treatment for a pneumothorax involves resection of the pulmonary pleural fistula, and closure of the fistula or coverage of the fistula using pericardial fat pads or an intercostal muscle flap. In some cases, however, these treatments are difficult because of thickened pleura or dense pleural adhesions in the thoracic cavity. We report two cases of refractory secondary pneumothorax due to lung cancer that were successfully treated using free subcutaneous fat pads to cover the pulmonary pleural fistulas. Both patients had advanced lung cancer, and each developed a pneumothorax after chemotherapy or the administration of osimertinib. Each had a prolonged air leak despite chest tube drainage. We harvested a free subcutaneous fat pad around the thoracotomy site and sutured it to cover the fistula. After the operation, the air leak disappeared immediately, and the chest tube was removed from each patient on postoperative day 2. Computed tomography at 2 or 4 months postoperatively demonstrated that the free subcutaneous fat pads were still present with no sign of pneumothorax. Application of free subcutaneous fat pads to cover a persistent pulmonary pleural fistula is useful for the treatment of secondary pneumothorax due to lung cancer.

Comparison of radiological and pathological tumor sizes in resected non-small cell lung cancer

OBJECTIVES

In non-small cell lung cancer (NSCLC), T factor plays an important role in determining staging. The present study aimed to determine the validity of preoperative evaluation of clinical T (cT) factor by comparing radiological and pathological tumor sizes.

METHODS

Data for 1,799 patients with primary NSCLC who underwent curative surgery were investigated. The concordance between cT and pathological T (pT) factors was analyzed. Furthermore, we compared groups with an increase or decrease of ≥ 20% and groups with an increase or decrease of < 20% in the size change between preoperative radiological and pathological diameters.

RESULTS

The mean sizes of the radiological solid components and the pathological invasive tumors were 1.90 cm and 1.99 cm, respectively, correlation degree = 0.782. The group with increased pathological invasive tumor size (≥ 20%) compared with the radiologic solid component was significantly more likely female, consolidation tumor ratio (CTR) ≤ 0.5, and within cT1. Multivariate logistic analysis identified CTR < 1, cT ≤ T1, and adenocarcinoma as independent risk factors for increased pT factor.

CONCLUSION

The radiological invasive area of tumors with cT1, CTR < 1, or adenocarcinoma on preoperative CT may be underestimated compared with pathological invasive diameter.

Lobectomy for Pulmonary Arteriovenous Fistula in a Patient With Rendu-Osler-Weber Disease: A Case Report

BACKGROUND

Rendu-Osler-Weber disease (Osler's disease) is the most common cause of pulmonary arteriovenous fistula. We report a case of pulmonary arteriovenous fistula associated with Osler's disease that was treated by lobectomy.

CASE REPORT

A 44-year-old man with Osler's disease presented with respiratory distress. Computed tomography showed a pulmonary arteriovenous fistula, which had a 26-mm-long diameter in S6 of the left lung. Transcatheter treatment had a high risk of recurrence, and surgery was indicated. The pulmonary arteriovenous fistula was found at the beginning of A6. A6 and the basilar artery were cut together with a stapler. The postoperative course was uneventful, and respiratory distress symptoms improved with no recurrence.

CONCLUSION

We report a case of pulmonary arteriovenous fistula caused by Osler's disease treated by lobectomy. Although transcatheter treatment is the mainstream treatment for pulmonary arteriovenous fistulas, surgical resection may be effective depending on the size of the lesion.

Granzyme B (GZMB)-Positive Tumor-Infiltrating Lymphocytes in Lung Adenocarcinoma: Significance as a Prognostic Factor and Association with Immunosuppressive Proteins

BACKGROUND

Granzyme B (GZMB) is a serine protease produced by cytotoxic lymphocytes that reflects the activity of anti-tumor immune responses in tumor-infiltrating lymphocytes (TILs); however, the prognostic significance of GZMB+ TILs in lung adenocarcinoma is poorly understood.

METHODS

We analyzed 273 patients with pathological stage (pStage) I-IIIA lung adenocarcinoma who underwent surgery at Kyushu University from 2003 to 2012. We evaluated GZMB+ TIL counts by immunohistochemistry. We set the cut-off values at 12 cells/0.04 mm2 for GZMB+ TILs and divided the patients into GZMB-High (n = 171) and GZMB-Low (n = 102) groups. Then, we compared the clinicopathological characteristics of the two groups and clinical outcomes. Programmed cell death ligand-1 (PD-L1) and indoleamine 2,3-dioxygenase 1 (IDO1) expression in tumor cells was also evaluated, and combined prognostic analyses of GZMB+ TILs with PD-L1 or IDO1 were performed.

RESULTS

GZMB-Low was significantly associated with pStage II-III, PD-L1 positivity, and IDO1 positivity. Disease-free survival (DFS) and overall survival (OS) in the GZMB-Low group were significantly worse than in the GZMB-High group. In multivariable analysis, GZMB-Low was an independent prognostic factor for both DFS and OS. Furthermore, combined prognostic analyses of GZMB+ TILs with PD-L1 or IDO1 showed that GZMB-Low with high expression of these immunosuppressive proteins had the worst prognosis.

CONCLUSIONS

We analyzed GZMB+ TIL counts in lung adenocarcinoma and elucidated its prognostic significance and association with PD-L1 and IDO1. GZMB+ TIL counts might reflect the patient's immunity against cancer cells and could be a useful prognostic marker of lung adenocarcinoma.

Impact of Chronic Obstructive Pulmonary Disease on the Long-term Prognosis of Patients Undergoing Lobectomy for Non-small-cell Lung Cancer: A Propensity Score-matched Analysis

BACKGROUND/AIM

Recent advances in surgery, such as thoracoscopic surgery, have made it possible to treat patients with chronic obstructive pulmonary disease (COPD) more safely than before. This study evaluated the short- and long-term prognosis of lobectomy in non-small cell lung cancer (NSCLC) patients with COPD.

PATIENTS AND METHODS

This retrospective, propensity-matched, cohort analysis was conducted from January 2014 to December 2018. Among 441 patients who underwent lobectomy for NSCLC, 158 (35.8%) had a preoperative diagnosis of COPD. Propensity-matched analysis, incorporating preoperative variables, was used to compare postoperative hospital stay and complications, and long-term prognosis between the groups.

RESULTS

Propensity matching estimated 145 patients in each group. There was no difference between the two groups for length of postoperative hospital stay (12 vs. 11 days, p=0.306). Postoperative complications were more frequent in the COPD group (24.1%) than in the non-COPD group (16.6%), but the difference was not significant (p=0.108). The 5-year overall survival rate was 86.2% in the COPD group and 82.1% in the non-COPD group after matching (p=0.580). The corresponding 5-year recurrence-free survival rate was 72.8% in the COPD group and 67.2% in the non-COPD group after matching (p=0.601).

CONCLUSION

In case of Global Initiative for Chronic Obstructive Lung Disease (GOLD) I/II classification, COPD did not significantly worsen the prognosis of patients with NSCLC after lobectomy.

Transducin Beta-Like 2 is a Potential Driver Gene that Adapts to Endoplasmic Reticulum Stress to Promote Tumor Growth of Lung Adenocarcinoma

BACKGROUND

Endoplasmic reticulum (ER) stress has a close relation with cancer progression. Blocking the adaptive pathway of ER stress could be an anticancer strategy. Here, we identified an ER stress-related gene, Transducin beta-like 2 (TBL2), an ER-localized type I transmembrane protein, on increased chromosome 7q as a candidate driver gene of lung adenocarcinoma (LUAD).

METHODS

The association between TBL2 mRNA expression and prognostic outcomes and clinicopathological factors was analyzed using The Cancer Genome Atlas (TCGA) datasets of LUAD and lung squamous cell carcinoma (LUSC). Localization of TBL2 in tumor tissues was observed by immunohistochemical staining. Gene set enrichment analysis (GSEA) was conducted using TCGA dataset. In vitro cell proliferation assays were performed using TBL2 knockdown LUAD cells, LUSC cells, and LUAD cells overexpressing TBL2. Apoptosis and ATF4 expression (ER stress marker) were evaluated by western blotting.

RESULTS

TBL2 was overexpressed in LUAD and LUSC cells. Multivariate analysis indicated high TBL2 mRNA expression was an independent poor prognostic factor of LUAD. GSEA revealed high TBL2 expression was positively correlated to the ER stress response in LUAD. TBL2 knockdown attenuated LUAD cell proliferation under ER stress. TBL2 inhibited apoptosis in LUAD cells under ER stress. TBL2 knockdown reduced ATF4 expression under ER stress.

CONCLUSIONS

TBL2 may be a novel driver gene that facilitates cell proliferation, possibly by upregulating ATF4 expression followed by adaptation to ER stress, and it is a poor prognostic biomarker of LUAD.

MicroRNA-326 negatively regulates CD155 expression in lung adenocarcinoma

Treatment with immune checkpoint inhibitors induces a durable response in some patients with non-small-cell lung cancer, but eventually gives rise to drug resistance. Upregulation of CD155 expression is implicated as one mechanism of resistance to programmed death receptor-1 (PD-1)/PD-1 ligand (PD-L1) inhibitors, and it is therefore important to characterize the mechanisms underlying regulation of CD155 expression in tumor cells. The aim of this study was to identify microRNAs (miRNAs) that might regulate CD155 expression at the posttranscriptional level in lung cancer. Comprehensive miRNA screening with target prediction programs and a dual-luciferase reporter assay identified miR-346, miR-328-3p, miR-326, and miR-330-5p as miRNAs that bind to the 3'-UTR of CD155 mRNA. Forced expression of these miRNAs suppressed CD155 expression in lung cancer cell lines. Immunohistochemical staining of CD155 in tissue specimens from 57 patients with lung adenocarcinoma revealed the median tumor proportion score for CD155 to be 68%. The abundance of miR-326 in these specimens with a low level of CD155 expression was significantly greater than in specimens with a high level (p < 0.005). Our results thus suggest that miR-326 negatively regulates CD155 expression in lung adenocarcinoma and might therefore play a role in the development of resistance to PD-1/PD-L1 inhibitors.

Development of artificial intelligence prognostic model for surgically resected non-small cell lung cancer

There are great expectations for artificial intelligence (AI) in medicine. We aimed to develop an AI prognostic model for surgically resected non-small cell lung cancer (NSCLC). This study enrolled 1049 patients with pathological stage I-IIIA surgically resected NSCLC at Kyushu University. We set 17 clinicopathological factors and 30 preoperative and 22 postoperative blood test results as explanatory variables. Disease-free survival (DFS), overall survival (OS), and cancer-specific survival (CSS) were set as objective variables. The eXtreme Gradient Boosting (XGBoost) was used as the machine learning algorithm. The median age was 69 (23-89) years, and 605 patients (57.7%) were male. The numbers of patients with pathological stage IA, IB, IIA, IIB, and IIIA were 553 (52.7%), 223 (21.4%), 100 (9.5%), 55 (5.3%), and 118 (11.2%), respectively. The 5-year DFS, OS, and CSS rates were 71.0%, 82.8%, and 88.7%, respectively. Our AI prognostic model showed that the areas under the curve of the receiver operating characteristic curves of DFS, OS, and CSS at 5 years were 0.890, 0.926, and 0.960, respectively. The AI prognostic model using XGBoost showed good prediction accuracy and provided accurate predictive probability of postoperative prognosis of NSCLC.

Modulation of host glutamine anabolism enhances the sensitivity of small cell lung cancer to chemotherapy

Small cell lung cancer (SCLC) is one of the deadliest human cancers, with a 5-year survival rate of ∼7%. Here, we performed a targeted proteomics analysis of human SCLC samples and thereby identified hypoxanthine phosphoribosyltransferase 1 (HPRT1) in the salvage purine synthesis pathway as a factor that contributes to SCLC malignancy by promoting cell survival in a glutamine-starved environment. Inhibition of HPRT1 by 6-mercaptopurine (6-MP) in combination with methotrexate (MTX), which blocks the de novo purine synthesis pathway, attenuated the growth of SCLC in mouse xenograft models. Moreover, modulation of host glutamine anabolism with the glutamine synthetase inhibitor methionine sulfoximine (MSO) in combination with 6-MP and MTX treatment resulted in marked tumor suppression and prolongation of host survival. Our results thus suggest that modulation of host glutamine anabolism combined with simultaneous inhibition of the de novo and salvage purine synthesis pathways may be of therapeutic benefit for SCLC.

Prognostic Impact of Central Nervous System Recurrence After Surgery in Patients With Epidermal Growth Factor Receptor Mutation-positive Non-small-cell Lung Cancer

BACKGROUND/AIM

Adjuvant therapy using third-generation tyrosine kinase inhibitors (TKI) demonstrated improved central nervous system (CNS) disease-free survival after surgery in patients with epidermal growth factor receptor (EGFR) mutation-positive lung cancer. However, the prognostic impact of CNS recurrence in surgical patients remains unknown. We evaluated the effect of CNS recurrence on post-recurrence survival (PRS) in patients with postoperatively recurrent NSCLC.

PATIENTS AND METHODS

We assessed the prognostic impact of CNS recurrence using a cohort from a prospective observational study (Kyushu University Lung Surgery Group Study 2: KLSS-2). Based on data from 340 patients in whom EGFR mutations were assessed among 498 total patients in the KLSS-2 cohort, factors related to CNS recurrence and prognosis after postoperative recurrence were analyzed.

RESULTS

We noted no marked differences in the presence of EGFR mutations (p=0.14) between patients with CNS recurrence and those without CNS recurrence. Among the patients tested for EGFR mutations with stage IV recurrences (n=219), survival analysis of patients with EGFR mutations showed that the CNS group had a significantly poorer PRS than the no-CNS group (MST: 36.8 vs. 43.9 months, p=0.035). In multivariate survival analysis of stage IV EGFR mutation-positive cases, recurrence in multiple organs and recurrence of brain metastases were independent poor prognostic factors (hazard ratio=2.2, p=0.029; hazard ratio=3.2, p=0.0006, respectively).

CONCLUSION

Postoperative CNS recurrence was associated with a poor prognosis among patients with EGFR mutation-positive lung cancer in the period when third-generation EGFR-TKIs were not available. In EGFR mutation-positive lung cancer, prevention of CNS recurrence after surgery may improve post-recurrence prognosis.

Impact of the pretreatment prognostic nutritional index on the survival after first-line immunotherapy in non-small-cell lung cancer patients

BACKGROUND

Immunotherapy has become a standard-of-care for patients with non-small-cell lung cancer (NSCLC). Although several biomarkers, such as programmed cell death-1, have been shown to be useful in selecting patients likely to benefit from immune checkpoint inhibitors (ICIs), more useful and reliable ones should be investigated. The prognostic nutritional index (PNI) is a marker of the immune and nutritional status of the host, and is derived from serum albumin level and peripheral lymphocyte count. Although several groups reported its prognostic role in patients with NSCLC receiving a single ICI, there exist no reports which have demonstrated its role in the first-line ICI combined with or without chemotherapy.

MATERIALS AND METHODS

Two-hundred and eighteen patients with NSCLC were included in the current study and received pembrolizumab alone or chemoimmunotherapy as the first-line therapy. Cutoff value of the pretreatment PNI was set as 42.17.

RESULTS

Among 218 patients, 123 (56.4%) had a high PNI (≥42.17), while 95 (43.6%) had a low PNI (<42.17). A significant association was observed between the PNI and both the progression-free survival (PFS; hazard ratio [HR] =  0.67, 95% confidence interval [CI]: 0.51-0.88, p =  0.0021) and overall survival (OS; HR = 0.46, 95% CI: 0.32-0.67, p < 0.0001) in the entire population, respectively. The multivariate analysis identified the pretreatment PNI as an independent prognosticator for the PFS (p =  0.0011) and OS (p  < 0.0001), and in patients receiving either pembrolizumab alone or chemoimmunotherapy, the pretreatment PNI remained an independent prognostic factor for the OS (p = 0.0270 and 0.0006, respectively).

CONCLUSION

The PNI might help clinicians appropriately identifying patients with better treatment outcomes when receiving first-line ICI therapy.

Is radical local therapy effective in postoperative recurrent EGFR-mutated non-small cell lung cancer?

BACKGROUND

Long-term survival can be achieved with radical local therapy in some cases of postoperative recurrence of non-small cell lung cancer (NSCLC). Here, we evaluated post-recurrence survival (PRS) after treatment of postoperative recurrent epidermal growth factor receptor (EGFR) mutated NSCLC and examined the effectiveness of radical local therapy.

METHODS

This multicenter prospective cohort study was conducted in 14 hospitals. The inclusion criteria for this study were patients with recurrence after radical resection for NSCLC. Information about the patient characteristics at recurrence, tumor-related variables, primary surgery, and treatment for recurrence was collected. After registration, follow-up data (e.g., treatment and survival outcomes) were obtained and analyzed.

RESULTS

From 2010 to 2015, 505 patients with recurrent NSCLC were enrolled into the study, and 154 EGFR mutation-positive cases were included. As the initial treatment for recurrence, 111 patients (72%) received chemotherapy, 14 (9%) received chemoradiotherapy, 14 (9%) received definitive radiotherapy, and seven (5%) received surgical resection. The remaining eight patients (5%) received supportive care. The median PRS and 5-year survival rates for all cases were 64 months and 53.2%, respectively. The 5-year survival rate according to the initial treatment was as follows: supportive care, 0%; chemotherapy, 53.3% and radical local therapy, 60.1%. The six patients who received radical local treatment remained recurrence-free for more than 3 years after recurrence with only initial treatment.

CONCLUSIONS

Although radical local therapy may be curative in some patients, chemotherapy including EGFR-TKI treatment is expected to provide long-term survival comparable to that of radical local therapy.

Prognostic impact of noninvasive areas in resected pathological stage IA lung adenocarcinoma

MAIN PROBLEMS

In non-small-cell lung cancer, ground-glass opacity on computed tomography imaging reflects pathological noninvasiveness and is a favorable prognostic factor. However, the significance of pathological noninvasive areas (NIAs) has not been fully revealed. In this study, we aimed to elucidate the prognostic impact of NIAs on lung adenocarcinoma.

METHODS

We analyzed 402 patients with pathological stage (p-Stage) IA lung adenocarcinoma who underwent surgery in 2013-2016 at two institutions and examined the association of the presence of NIAs with clinicopathological factors and prognosis. Furthermore, after using propensity-score matching to adjust for clinicopathological factors, such as age, sex, smoking history, pathological invasive area size, pathological T factor (p-T), p-Stage, and histological subtype (lepidic predominant adenocarcinoma [LPA] or non-LPA), the prognostic impact of NIAs was evaluated.

RESULTS

Patients were divided into NIA-present (N = 231) and NIA-absent (N = 171) groups. Multivariable analysis showed that NIA-present was strongly associated with earlier p-T, earlier p-Stage, LPA, and epidermal growth factor receptor mutation. Kaplan-Meier survival analysis showed that the NIA-present group displayed a better prognosis than the NIA-absent group in disease-free survival (DFS) and overall survival (OS) (5-year DFS 94.6% vs. 87.2%, 5-year OS 97.2% vs. 91.1%). However, after adjusting for clinicopathological factors by propensity score matching, no significant differences in prognosis were identified between the NIA-present and NIA-absent groups (5-year DFS 92.4% vs 89.6%, 5-year OS 95.6% vs 94.3%).

CONCLUSIONS

Our current study suggests that the prognostic impact of the presence of NIAs on lung adenocarcinoma is due to differences in clinicopathological factors.

Tumor plasticity and therapeutic resistance in oncogene-addicted non-small cell lung cancer: from preclinical observations to clinical implications

The identification of actionable targets in oncogene-addicted non-small cell lung cancer (NSCLC) has fueled biomarker-directed strategies, especially in advanced stage disease. Despite the undeniable success of molecular targeted therapies, duration of clinical response is relatively short-lived. While extraordinary efforts have defined the complexity of tumor architecture and clonal evolution at the genetic level, not equal interest has been given to the dynamic mechanisms of phenotypic adaptation engaged by cancer during treatment. At the clinical level, molecular targeted therapy of EGFR-mutant and ALK-rearranged tumors often results in epithelial-to-mesenchymal transition (EMT) and histological transformation of the original adenocarcinoma without the acquisition of additional genetic lesions, thus limiting subsequent therapeutic options and patient outcome. Here we provide an overview of the current understanding of the genetic and non-genetic molecular circuits governing this phenomenon, presenting current strategies and potentially innovative therapeutic approaches to interfere with lung cancer cell plasticity.

Conservative treatment for residual lung congestion after left upper trisegmentectomy: a case report

Background

Currently, segmentectomy is the procedure of choice in approximately 10% of lung cancer surgeries in Japan. However, complications are often observed in that procedure. In particular, residual pulmonary congestion after segmentectomy often leads to surgical intervention.

Case Description

We report a case of improved congestion in the residual lung after left upper trisegmentectomy (LUTS) with conservative treatment under careful observation. A 65-year-old man was diagnosed with bilateral lung cancer and initially underwent LUTS. On the next day after surgery, blood sputum was observed. Computed tomography (CT) showed consolidation in the lingual region of the left lung and stenosis of V4+5 in the left lung. The cause of the congestion was thought to be an isolated segment with part of the remaining S3 and a thin V4+5 with poor flow. Because pulmonary torsion or necrosis of the residual lung was not observed, conservative treatment with antibiotics under careful follow-up by CT was chosen. The pulmonary congestion and inflammatory reaction gradually improved, and the patient was discharged home on the 26th day after surgery.

Conclusions

We experienced a case of residual pulmonary congestion after LUTS that resolved with conservative treatment. Careful follow-up of the patient's general condition and imaging studies are considered to be important.

Prognostic Impact of C-Reactive Protein-to-Lymphocyte Ratio in Non-small Cell Lung Cancer: A Propensity Score-Matching Analysis

BACKGROUND

Many inflammatory and nutritional markers have been used to predict prognosis in lung cancer. The C-reactive protein (CRP)-to-lymphocyte ratio (CLR) is a useful prognostic factor in various cancers. However, the prognostic value of preoperative CLR in patients with non-small cell lung cancer (NSCLC) remains to be established. We examined the significance of the CLR compared with known markers.

METHODS

A total of 1380 surgically resected NSCLC patients treated at two centers were recruited and divided into derivation and validation cohorts. After CLRs were calculated, patients were classified into high and low CLR groups based on the cutoff value determined by receiver operating characteristics curve analysis. Subsequently, we determined the statistical associations of the CLR with clinicopathological factors and prognosis and further analyzed its prognostic impact by propensity-score matching.

RESULTS

Of all the inflammatory markers examined, CLR yielded the highest area-under-the-curve value. The prognostic impact of CLR remained significant after propensity-score matching. Prognosis was significantly worse in the high-CLR group than in the low-CLR group (5-year, disease-free survival [DFS]: 58.1% vs. 81.9%, P < 0.001; 5-year overall survival [OS]: 72.1% vs. 91.2%, P < 0.001). The results were confirmed in the validation cohorts. Multivariable analysis also showed high CLR as an independent factor for both DFS and OS (DFS: hazard ratio [HR] 1.42, P = 0.027; OS: HR 1.95, P = 0.0037).

CONCLUSIONS

Preoperative CLR is a useful marker for predicting the prognosis of NSCLC patients who have undergone surgery.

Skeletal muscle area predicts the outcomes of non-small-cell lung cancer after trimodality therapy

OBJECTIVES

Sarcopenia correlates with poor prognosis in various malignancies. However, the prognostic significance of sarcopenia remains to be determined in patients with non-small-cell lung cancer who undergo surgery after receiving neoadjuvant chemoradiotherapy (NACRT).

METHODS

We retrospectively reviewed the patients with stage II/III non-small-cell lung cancer who underwent surgery following NACRT. The paravertebral skeletal muscle area (SMA) (cm2) at the 12th thoracic vertebra level was measured. We calculated the SMA index (SMAI) as SMA/squared height (cm2/m2). Patients were divided into low and high SMAI groups, and the association of SMAI with clinicopathological factors and prognosis was assessed.

RESULTS

The patients' [men, 86 (81.1%)] median age was 63 (21-76) years. There were 106 patients including 2 (1.9%), 10 (9.4%), 74 (69.8%), 19 (17.9%) and 1 (0.9%) patients with stage IIA, IIB, IIIA, IIIB and IIIC, respectively. Of the patients, 39 (36.8%) and 67 (63.2%) were classified in the low and the high SMAI groups, respectively. Kaplan-Meier analysis showed that the low group had a significantly shorter overall survival and disease-free survival than the high group. Multivariable analysis identified low SMAI as an independent poor prognostic factor for overall survival.

CONCLUSIONS

Pre-NACRT SMAI correlates with poor prognosis; therefore, assessing sarcopenia based on pre-NACRT SMAI may help determine optimal treatment strategies and suitable nutritional and exercise interventions.

Smoking enhances the expression of angiotensin-converting enzyme 2 involved in the efficiency of severe acute respiratory syndrome coronavirus 2 infection

Smoking is one of the risk factors most closely related to the severity of coronavirus disease 2019 (COVID-19). However, the relationship between smoking history and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infectivity is unknown. In this study, we evaluated the ACE2 expression level in the lungs of current smokers, ex-smokers, and nonsmokers. The ACE2 expression level of ex-smokers who smoked cigarettes until recently (cessation period shorter than 6 months) was higher than that of nonsmokers and ex-smokers with a long history of nonsmoking (cessation period longer than 6 months). We also showed that the efficiency of SARS-CoV-2 infection was enhanced in a manner dependent on the angiotensin-converting enzyme 2 (ACE2) expression level. Using RNA-seq analysis on the lungs of smokers, we identified that the expression of inflammatory signaling genes was correlated with ACE2 expression. Notably, with increasing duration of smoking cessation among ex-smokers, not only ACE2 expression level but also the expression levels of inflammatory signaling genes decreased. These results indicated that smoking enhances the expression levels of ACE2 and inflammatory signaling genes. Our data suggest that the efficiency of SARS-CoV-2 infection is enhanced by smoking-mediated upregulation of ACE2 expression level.

Surgical resection of a tuberculoma in the diaphragm: a case report

BACKGROUND

Extrapulmonary tuberculosis commonly affects the lymphatic system, nervous system, and gastrointestinal system. Tuberculous infection in the muscle is very rare. Moreover, tuberculous infection in the diaphragm is extremely rare. We herein report a case of tuberculomas in the diaphragm and posterior mediastinum that were successfully diagnosed and treated.

CASE PRESENTATION

We encountered a 62-year-old woman with a tuberculoma in the diaphragm. The patient presented with mild dyspnea. Computed tomography showed a mass in the left diaphragm, focal thickening of the posterior mediastinum, and multiple nodules in the lungs. Positron emission tomography-computed tomography showed increased uptake in the left diaphragm mass and thickening of the posterior mediastinum; therefore, we considered the masses to be malignant and planned surgical resection. However, the patient was diagnosed with tuberculosis from a sputum culture, and she was treated with anti-tuberculous therapy. The masses in the diaphragm and posterior mediastinum had become enlarged after 6 months of anti-tuberculous therapy; therefore, the patient underwent resection of both masses. Tuberculous infection was histologically confirmed in each lesion. She was pathologically diagnosed with tuberculous abscesses in the diaphragm and posterior mediastinum and began treatment with anti-tuberculosis drugs.

CONCLUSIONS

Preoperative diagnosis of a tuberculoma in the diaphragm is usually difficult, and surgical intervention is important for both diagnosis and treatment.

Involvement of growth differentiation factor 15 in paradoxical relationship between body mass index and mortality in patients with suspected or known coronary artery disease; The ANOX Study

Background

Obesity is a well-established risk factor for type 2 diabetes mellitus, hypertension and dyslipidemia, leading to coronary artery disease (CAD). Nevertheless, body mass index (BMI) is inversely associated with cardiovascular (CV) mortality in patients with cardiac disorders, termed “obesity paradox”. However, the underlying mechanism remains unclear.

Purpose

To clarify important factors involved in the pathogenesis of obesity paradox.

Methods

Using data from a multicenter, prospective cohort of 2,418 patients with suspected or known CAD enrolled in the ANOX study, we assessed the relationship between BMI at baseline and the incidence of CV death over 3 years, and investigated the involvement of several endocrine factors which were previously reported to have some roles in obesity and heart diseases, such as adiponectin, N-terminal pro-brain natriuretic peptide (NT-proBNP) and growth differentiation factor 15 (GDF-15), in the relationship between BMI and CV death.

Results

In Kaplan-Meier analyses, the lower quartiles of BMI and the higher quartiles of adiponectin levels were paradoxically associated with the higher cumulative incidence of CV death. To clarify the important factors involved in the paradoxical association between BMI or adiponectin and mortality, we first investigated independent determinants for BMI and adiponectin levels respectively, using multiple stepwise regression analyses among many clinical factors, and then narrow down the prognostic factors commonly associated with BMI and adiponectin, which were age, hemoglobin and NT-proBNP. Interestingly, circulating levels of GDF15 were significantly correlated with NT-proBNP levels, and the presence of anemia raised the gradient of the correlation line in a scatter plot (without anemia, r=0.139, p&lt;0.0001; with anemia, r=0.228, p&lt;0.0001). Moreover, the highest GDF15 quartile showed significantly lower BMI and higher adiponectin levels compared to the lower quartiles (p&lt;0.001 and p&lt;0.001, respectively, by Student t-test). In Cox proportional hazard models, hazard ratios (HRs) of BMI (per 1-unit increase) were 0.90 (95% confidence interval [CI], 0.85–0.96) for CV death. Additional adjustment for hemoglobin, NT-proBNP, adiponectin or GDF15 diminished the statistical significance (HR, 0.92 [95% CI, 0.87–0.99], 0.95 [0.89–1.01], 0.92 [0.87–0.99], or 0.93 [0.87–0.99], respectively).

Conclusions

The lower BMI and the higher adiponectin levels were paradoxically associated with the higher incidence of CV death in patients with CAD. This paradox may be mediated by cardiac endocrine factors induced by cardiac stresses, including GDF-15 in addition to natriuretic peptides.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): The ANOX study is supported by a Grant-in-Aid for Clinical Research from the National Hospital Organization.

Vascular endothelial factor C and D in patients with heart failure with preserved, mildly reduced, and reduced ejection fraction: the PREHOSP-CHF study

Background

The lymphatic system has been suggested to play an important role in cardiovascular diseases including heart failure (HF). Vascular endothelial growth factor C (VEGF-C) and D (VEGF-D) are key regulators of lymphangiogenesis, and we recently reported the association of low VEGF-C with the risk of all-cause death and high VEGF-D with the risk of HF hospitalization in patients with HF.

Purpose

To investigate the association of VEGF-C and VEGF-D with prognosis in patients with HF with preserved ejection fraction (EF) (HFpEF: EF≥50%), mildly reduced EF (HFmrEF: EF, 40–49%), and reduced EF (HFrEF: EF&lt;40%).

Methods

The PREHOSP-CHF study is a multicenter prospective cohort study to determine the predictive value of angiogenesis-related biomarkers in HF. A total of 1,024 patients (mean age 75.5±12.6 years; 58.7% male) admitted to acute decompensated HF were included in the analyses. Serum levels of VEGF-C and VEGF-D, as well as N-terminal pro B-type natriuretic peptide (NT-proBNP), high sensitivity cardiac troponin-I (hs-cTnI), high sensitivity C reactive protein, were measured at the time of discharge. Patients were followed-up over two years.

Results

The numbers of HFpEF, HFmrEF, and HFrEF were 429 (41.9%), 186 (18.2%), and 409 (39.9%), respectively. HFpEF patients were older, more likely to be female, and had more hypertension, atrial fibrillation, and anemia, but less coronary artery disease. NT-proBNP and hs-cTnI levels increased with decreasing EF. VEGF-C levels decreased with increasing EF (median [interquartile range]: HFpEF, 4508 [3318–5919] pg/ml; HFmrEF, 4719 [3663–6203] pg/ml; HFrEF, 5023 [3804–6382] pg/ml), whereas VEGF-D levels were comparable among the three EF groups (HFpEF, 404.6 [293.1–560.3] pg/ml; HFmrEF, 386.0 [298.5–556.3] pg/ml; HFrEF, 414.2 [296.1–557.3] pg/ml). In multivariate stepwise logistic regression analyses, anemia and high NT-proBNP were independently associated with low VEGF-C levels, and high NT-proBNP was independently associated with high VEGF-D levels, across all the EF groups. During the follow-up, incidences of all-cause death and HF hospitalizations were similar among the three EF groups (log-rank P=0.6 for all-cause death, and log-rank P=0.3 for HF hospitalization). On multivariate Cox proportional hazard analyses including established risk factors and cardiovascular biomarkers, VEGF-C levels tended to be inversely associated with the incidence of all-cause death in patients with HFpEF and HFrEF (Figure). On the contrary, VEGF-D levels were significantly and positively associated with the incidence of HF hospitalization in patients with HFpEF, and tended to be positively associated with it in patients with HFmrEF and HFrEF (Figure).

Conclusions

Low VEGF-C was associated with the risk of all-cause death in patients with HFpEF and HFrEF, while high VEGF-D was associated with the risk of HF hospitalization especially in HFpEF.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Grant-in-Aid for Clinical Research from the National Hospital Organization

Associations of soluble fms-like tyrosine kinase-1 with cardiovascular events and stroke in patients with atrial fibrillation and suspected or known coronary artery disease: the EXCEED-J study

Background

Atrial fibrillation (AF) increases the risk of stroke. Soluble fms-like tyrosine kinase-1 (sFlt-1), a vascular endothelial growth factor (VEGF) antagonist, has been suggested as a marker of endothelial dysfunction, which are associated with both AF and coronary artery disease (CAD). Recently, we demonstrated that sFlt-1 is independently associated with major adverse cardiovascular (CV) events (MACE) in patients with suspected or known CAD. However, the prognostic utility of sFlt-1 in patients with AF remains unknown.

Methods

Using data from a multicenter, prospective cohort of 3255 patients with suspected or known CAD, we investigated whether AF modifies the prognostic utility of sFlt-1. Heparin-free serum levels of sFlt-1, N-terminal pro-brain natriuretic peptide, high-sensitivity cardiac troponin-I, high-sensitivity C-reactive protein, cystatin C, neutrophil gelatinase-associated lipocalin, VEGF, and placental growth factor were measured in 324 patients with AF and 2931 patients without AF. The primary outcome was MACE defined as a composite of CV death, nonfatal myocardial infarction, and nonfatal stroke. The secondary outcomes were all-cause death, CV death, stroke, heart failure (HF) hospitalization, and coronary/peripheral artery revascularization. The biomarkers were natural log-transformed for use as continuous variables.

Results

After adjustment for potential clinical confounders including anticoagulant drug use, sFlt-1 was significantly associated with MACE (hazard ratio for 1 standard deviation increase [HR], 1.55; 95% confidence interval [CI], 1.14–2.08), CV death (HR, 1.68; 95% CI, 1.10–2.48), and stroke (HR, 1.89; 95% CI, 1.16–3.10), but not with all-cause death (HR, 1.32; 95% CI, 0.99–1.73), HF hospitalization (HR, 0.97; 95% CI, 0.73–1.25), or revascularization (HR, 0.99; 95% CI, 0.74–1.28) in patients with AF, whereas sFlt-1 was significantly associated with MACE (HR, 1.19; 95% CI, 1.02–1.37), all-cause death (HR, 1.19; 95% CI, 1.05–1.34), CV death (HR, 1.26; 95% CI, 1.03–1.48), and HF hospitalization (HR, 1.26; 95% CI, 1.11–1.42), but not with stroke (HR, 1.06; 95% CI, 0.81–1.33) or revascularization (HR, 1.01; 95% CI, 0.95–1.07) in patients without AF. Among other biomarkers, only VEGF was significantly associated with MACE (HR, 1.55; 95% CI, 1.02–2.44), and no biomarkers were significantly associated with CV death or stroke in patients with AF. sFlt-1 added incremental prognostic information for MACE (P=0.005 for net reclassification improvement [NRI], P=0.026 for integrated discrimination improvement [IDI]) and stroke (P=0.034 for NRI, P=0.018 for IDI), but not for CV death (P=0.021 for NRI, P=0.134 for IDI), to the model with potential clinical confounders in patients with AF.

Conclusions

sFlt-1 independently predicted MACE and stroke in patients with AF and suspected or known CAD. sFlt-1 may serve as a novel prognostic biomarker to stratify the risk of MACE and stroke in patients with AF.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Health Labour Sciences Research Grant (2013-2014), AMED (2015-2017, Grant Number JP17ek0210008)

Serum amyloid A-low-density-lipoprotein complex and mortality in patients with suspected or known coronary artery disease: the ANOX study

Background

Serum amyloid A-low-density-lipoprotein (SAA-LDL) is a complex formed from the oxidative interaction between SAA and LDLs. A relatively small-scale study has shown that circulating SAA-LDL levels may serve as a prognostic marker in patients with stable coronary artery disease (CAD). However, the prognostic value of SAA-LDL should be confirmed in a larger-scale cohort study.

Methods

Using data from a multicenter, prospective cohort of 2416 patients with suspected or known CAD enrolled in the ANOX (Development of Novel Biomarkers Related to Angiogenesis or Oxidative Stress to Predict Cardiovascular Events) study, we assessed the prognostic value of serum levels of SAA-LDL. The primary outcome was all-cause death. The secondary outcomes were cardiovascular death and major adverse cardiovascular events (MACE) defined as a composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke. Patients were followed up over 3 years.

Results

Stepwise regression analysis including baseline data on potential clinical confounders (i.e., age, sex, body mass index, hypertension, dyslipidemia, diabetes, current smoking, estimated glomerular filtration rate, the Gensini score, previous myocardial infarction, previous stroke, previous heart failure hospitalization, atrial fibrillation, malignancies, anemia, antihypertensive drug use, statin use, and aspirin use) and established cardiovascular biomarkers (i.e., N-terminal pro-brain natriuretic peptide, high-sensitivity cardiac troponin I [hs-cTnI], and high-sensitivity C-reactive protein [hs-CRP]) revealed that independent determinants of SAA-LDL levels were female sex, dyslipidemia, the Gensini score, absence of statin use, hs-cTnI, and hs-CRP. After adjusting for potential clinical confounders and established cardiovascular biomarkers, the highest quartile of SAA-LDL levels (vs. the lowest quartile) was significantly associated with the incidence of all-cause death (hazard ratio [HR], 1.51; 95% confidence interval [CI], 1.02–2.26), but not with that of cardiovascular death (HR, 1.11; 95% CI, 0.59–2.10) or MACE (HR, 1.57; 95% CI, 0.97–2.57). Stratified analyses revealed that this association was pronounced in patients with low hs-cTnI (&lt;75th percentile) (HR, 1.85; 95% CI, 1.06–3.30) and in patients with low hs-CRP levels (≤1.0 mg/L) (HR, 2.30; 95% CI, 1.17–4.79).

Conclusions

Elevated SAA-LDL levels were independently associated with the risk of all-cause death in patients with suspected or known CAD. The SAA-LDL level appears to serve as a prognostic biomarker for risk stratification in relatively low-risk patients with low hs-cTnI (&lt;75th percentile) or low hs-CRP (≤1.0 mg/L).

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): The ANOX study is supported by a Grant-in-Aid for Clinical Research from the National Hospital Organization.

Multiple systemic artery to pulmonary vessel fistulas (SAPVFs) completely resected by video-assisted thoracoscopic surgery: a case report

Background

Systemic artery to pulmonary vessel fistula (SAPVF) is an uncommon abnormal vascular communication between systemic arteries and the lung parenchyma. It has been reported that the appropriate treatment for SAPVF is embolization or surgical resection. However, in patients such as ours, who have many aberrant vessels or multiple lesions, surgery should be considered as the first-choice treatment.

Case presentation

This case report describes multiple SAPVFs and huge bullae at the apex of the left lung in a 43-year-old man that were resected completely with the video-assisted thoracoscopic surgery (VATS). The patient had an uneventful postoperative recovery without any complications and was discharged 9 days postoperatively. He had heavy smoking history, and the giant bullae and the diffuse emphysematous change were found in the lung. Therefore, the chronic inflammation may have been present in the thoracic cavity, which caused multiple SAPVFs.

Conclusions

We describe the clinical course and management of the patient with multiple SAPVFs who had no obvious history of surgery, trauma, or various inflammatory or infection diseases. VATS should be the first-choice treatment in patients with many abnormal vessels or multiple lesions.

Combination Antiemetic Therapy for Chemotherapy-Induced Nausea and Vomiting in Patients with NSCLC Receiving Carboplatin-Based Chemotherapy

Purpose

The incidence of delayed chemotherapy-induced nausea and vomiting (CINV) in patients with non-small cell lung cancer (NSCLC) receiving carboplatin (CBDCA)-based chemotherapy (CBDCA + pemetrexed or paclitaxel) has not been clearly described. Therefore, we attempted to evaluate whether delayed CINV could be controlled using a combination of three antiemetics and identify individual risk factors.

Methods

We pooled data from two prospective observational studies, namely a nationwide survey of CINV and a prospective, observational study in Japan, to assess whether delayed CINV could be controlled using a combination of three antiemetics and identified individual risk factors via inverse probability treatment-weighted analysis.

Results

In total, 240 patients were evaluable in this study (median age, 66 years; male, 173; female, 67). The three-antiemetic regimen controlled delayed nausea (31.6% vs 47.3%) and vomiting (5.1% vs 23.1%) better than two antiemetics. Younger age (<70 years; odds ratio [OR] = 2.233), motion sickness (OR = 3.472), drinking habits (OR = 1.972), receipt of the CBDCA + pemetrexed regimen (OR = 2.041), and the use of two antiemetics (OR = 1.926) were risk factors for delayed nausea. Female sex (OR = 3.372), drinking habits (OR = 2.272), receipt of the CBDCA+ pemetrexed regimen (OR = 2.314), and the use of two antiemetics (OR = 6.830) were risk factors for delayed vomiting.

Conclusion

Female sex, younger age, and receipt of the CBDCA + pemetrexed regimen increased the risk of CINV. Therefore, we recommend additional supportive antiemetics treatment for these patients.

Association between sex and outcomes in patients with non-small-cell lung cancer receiving combination chemoimmunotherapy as a first-line therapy: a systematic review and meta-analysis of randomized clinical trials

INTRODUCTION

Recently, several meta-analyses have investigated the association between sex and the efficacy of immune checkpoint inhibitors (ICIs) in non-small-cell lung cancer (NSCLC). However, this issue remains controversial, because the results have been inconsistent. Moreover, the effect of sex on outcomes in patients with NSCLC receiving combination chemoimmunotherapy as a first-line therapy is poorly understood. The aim of this study was to examine the association between sex and outcomes in patients with NSCLC receiving combination chemoimmunotherapy as a first-line therapy.

METHODS

We searched PubMed and Scopus from database inception to Feb 18, 2022 and performed a systematic review and meta-analysis of randomized and controlled clinical trials investigating ICI+non-ICI vs non-ICI as a first-line therapy in NSCLC. The pooled hazard ratios (HRs) and 95% confidence intervals (CIs) for overall survival (OS) and progression-free survival (PFS) in male and female patients were calculated using common and random-effects models.

RESULTS

We analyzed 5,830 patients, comprising 4,137 (71.0%) males and 1,693 (29.0%) females, from nine randomized clinical trials. The pooled HR (95%CI) for OS comparing ICI+non-ICI vs non-ICI was 0.80 (0.72-0.87) for males and 0.69 (0.54-0.89) for females. The pooled HR (95%CI) for PFS comparing ICI+non-ICI vs non-ICI was 0.60 (0.55-0.66) for males and 0.56 (0.44-0.70) for females.

CONCLUSIONS

In patients with NSCLC receiving combination chemoimmunotherapy as a first-line therapy, a greater improvement in OS and PFS was observed in female patients than in male patients.

Clinical significance of the combination of preoperative SUVmax and CEA in patients with clinical stage IA lung adenocarcinoma

BACKGROUND

Preoperative maximum standardized uptake value (SUVmax) of 2-[18F]-fluoro-2-deoxy-D-glucose positron emission tomography and serum carcinoembryonic antigen (CEA) have been reported as prognostic factors for lung adenocarcinoma. However, the significance of combined SUVmax and CEA in early-stage lung adenocarcinoma is not well known.

METHODS

We retrospectively evaluated the relationship between the combination of SUVmax and CEA and the prognosis of 410 patients with clinical stage IA lung adenocarcinoma who underwent resection. The cutoff values for SUVmax and CEA were determined by receiver operating characteristic curve analysis, and patients were categorized into high SC (SUVmax and CEA) group (SUVmax ≥2.96 and CEA ≥5.3), moderate SC group (either SUVmax <2.96 and CEA ≥5.3 or SUVmax ≥2.96 and CEA <5.3) and low SC group (SUVmax <2.96 and CEA <5.3).

RESULTS

Kaplan-Meier curve analysis showed that patients with clinical stage IA lung adenocarcinoma in the high SC group had significantly shorter overall survival (OS) and recurrence-free survival (RFS) than the other groups (p = 0.011 and p < 0.0001, respectively). Multivariate analysis showed that high SC was an independent prognostic factor of OS (p = 0.029) and RFS (p < 0.0001).

CONCLUSIONS

High values of SUVmax and CEA were associated with poor OS and RFS in patients with stage IA lung adenocarcinoma. Simultaneous evaluation of SUVmax and CEA may be an effective prognostic marker to determine the optimal treatment strategy of early-stage lung adenocarcinoma.

Relationship between consolidation tumor ratio and tumor-infiltrating lymphocytes in small-sized lung adenocarcinoma

Background

Consolidation tumor ratio (CTR) is associated with cancer progression and histological invasiveness in lung adenocarcinoma (LAD). However, little is known about the association between CTR and immune‐related factors, including tumor‐infiltrating lymphocytes (TILs) density or tumor expression of programmed death ligand 1 (PD‐L1) and indoleamine 2,3‐dioxygenase 1 (IDO1) in small‐sized LAD.

Methods

This study included 258 patients with LAD (<3 cm) who underwent surgery. Patients were assigned to four groups: CTR = 0; 0 < CTR <0.5; 0.5 ≤ CTR <1 (ground‐glass opacity [GGO] group); and CTR = 1 (pure‐solid group). CD4⁺, CD8⁺, and FoxP3⁺ TIL density and PD‐L1 and IDO1 tumor expression were assessed by immunohistochemistry.

Results

Among the GGO group, CD8⁺ and FoxP3⁺ TIL density increased significantly with increasing CTR (p < 0.001 and p < 0.001, respectively). Moreover, PD‐L1 and IDO1 expression was significantly higher in the pure‐solid group than in the GGO group (p < 0.001 and p < 0.001, respectively).

Conclusions

CTR was correlated with the abundance of CD8⁺ and FoxP3⁺ TILs in the GGO group. PD‐L1 and IDO1 positivity rates were significantly higher in the pure‐solid group than in the GGO group. Increased CTR may be correlated with immunosuppressive condition.

Antibiotic-dependent effect of probiotics in patients with non-small cell lung cancer treated with PD-1 checkpoint blockade

BACKGROUND

We previously validated in European patients with NSCLC treated with programmed death-1 (PD-1) checkpoint inhibitors the cumulative detrimental effect of concomitant medications.

MATERIALS AND METHODS

We evaluated the prognostic ability of a "drug score" computed on the basis of baseline corticosteroids, proton pump inhibitors, and antibiotics, in an independent cohort of Japanese patients with advanced NSCLC treated with PD-1 monotherapy. Subsequently, we assessed the impact of baseline probiotics on the score's diagnostic ability and their interaction with antibiotics in influencing survival.

RESULTS

Among the 293 eligible patients, good (19.5 months), intermediate (13.4 months), and poor (3.7 months) risk groups displayed a significantly different overall survival (OS) (log-rank test for trend: p = 0.016), but with a limited diagnostic ability (C-index: 0.57, 95%CI: 0.53-0.61), while no significant impact on progression-free survival (PFS) was reported (log-rank test for trend: p = 0.080; C-index: 0.55, 95%CI: 0.52-0.58). Considering the impact of the probiotics∗antibiotics interaction (p-value 0.0510) on OS, we implemented the drug score by assigning 0 points to concomitant antibiotics and probiotics. With the adapted drug score good, intermediate, and poor risk patients achieved a median OS of 19.6 months, 13.1 months, and 3.7 months, respectively, with a similar diagnostic ability (log-rank test for trend: p = 0.006; C-index: 0.58, 95%CI: 0.54-0.61). However, the diagnostic ability for PFS of the adapted score was improved (log-rank test for trend: p = 0.034; C-index: 0.62, 95%CI: 0.54-0.69).

CONCLUSIONS

Although we failed to validate the drug score in this independent Japanese cohort, we showed that probiotics may have an antibiotic-dependent impact on its prognostic value. Further investigation looking at the effect of concomitant medications and probiotics across cohorts of different ethnicities is warranted.

Predictive model of the prognosis in non-small cell lung cancer treated with first-line immunotherapy based on machine learning

e21125

Background: In recent years, there have been expectations for the application of artificial intelligence (AI) in the clinical practice of lung cancer. In the first-line setting, immune checkpoint inhibitors (ICIs) in combination with cytotoxic agents (CTx) have become a standard-of-care for patients with non-small cell lung cancer (NSCLC); however, no absolute biomarkers have been established for the prediction of the response to such therapy. In this study, we aimed to construct a new prognostic model by using AI in NSCLC patients treated with first-line ICI plus CTx. Methods: We retrospectively identified 218 NSCLC patients with advanced or postoperatively recurrent disease. They received first-line treatment with ICI alone or in combination with cytotoxic agents between January 2016 and October 2020. AI model using Gradient Boosting Decision Tree (GBDT) was used to identify predictors (explanatory variables) of the survivals (objective variables). A total of 53 factors were selected for the explanatory variables including clinical, hematological and pathological information. The objective variables were overall survival (OS) and progression-free survival (PFS). GBDT constructed the optimal predicting model, and calculated the contribution of each explanatory variable to the objective variables. Additionally, the importance of each feature was interpreted by SHapley Additive exPlanation (SHAP). Results: The median follow-up period was 14.4 months (range: 0.5-52.0) after the initiation of the therapy. The characteristics were shown below; the median age was 69 years old (range: 36-85); males and females were 165 (75.7%) and 53 (24.3%); patients with ICI alone or combination with cytotoxic anticancer agents were 91 (41.7%) or 127 (58.3%); the distributions of performance status (PS) were 107 (49.1%), 94 (43.1%), 13 (6.0%) with PS 0, 1 and 2; the Sq, non-Sq and others were found in 51 (23.4%), 165 (75.7%) and 2 (0.9%); 170 patients (78.0%) showed a PD-L1 expression of > 1% and 36 (16.5%) patients had no PD-L1 expression. The median PFS and OS were 10.2 and 21.8 months, respectively. The predicting optimal model for OS and PFS were constructed by GBDT, and the respective area under the curves (AUC) were 0.724 and 0.656. The explanatory variables indicating high contribution to OS were serum C-reactive protein (CRP), cytokeratin subunit 19 fragment (CYFRA), alkaline phosphatase (ALP), peripheral lymphocyte count and chloride ion level. As for PFS, the highest five contributions were CYFRA, CRP, immune-related adverse events, ALP and peripheral platelet count. Furthermore, all of these factors were explained their importance by SHAP. Neither PD-L1 expression nor PS were predictors of the survivals. Conclusions: Machine learning identified several novel factors possibly contributing to the prognoses in NSCLCs patients treated with the first-line immunotherapy.

Survival after recurrence following surgical resected non-small cell lung cancer: A multicenter, prospective cohort study

Objectives

The optimal treatment for recurrent non–small cell lung cancer (NSCLC) has not been standardized. In this prospective cohort study, we evaluated post-recurrence survival (PRS) after treatment of recurrent NSCLC and identified prognostic factors after recurrence.

Methods

This multicenter prospective cohort study was conducted in 14 hospitals. The inclusion criteria for this study were patients with recurrence after radical resection for NSCLC. Information about the patient characteristics at recurrence, tumor-related variables, primary surgery, and treatment for recurrence was collected. After registration, follow-up data, such as treatment and survival outcomes, were obtained every 3 months.

Results

From 2010 to 2015, 505 cases were enrolled, and 495 cases were analyzed. As initial treatment for recurrence, 263 patients (53%) received chemotherapy, 46 (9%) received chemoradiotherapy, 98 (20%) had definitive radiotherapy, 14 (3%) received palliative radiotherapy, and 31 (6%) underwent surgical resection. The remaining 43 patients (9%) received supportive care. The median PRS and 5-year survival rates for all cases were 30 months and 31.9%, respectively. The median PRS according to the initial treatment was as follows: supportive care, 8 months; palliative radiotherapy, 16 months; definitive radiotherapy, 30 months; chemotherapy, 31 months; chemoradiotherapy, 35 months; and surgery, not reached. A multivariate analysis showed that the age, gender, performance status, histology presence of symptoms, duration from primary surgery to recurrence, and number of recurrent foci were independent prognostic factors for PRS.

Conclusions

The PRS of patients with recurrent NSCLC was different depending on the patient's background characteristics and initial treatment for recurrence.

Long-term complete response to gefitinib after treatment termination in a patient with recurrent post-operative EGFR-mutated lung adenocarcinoma: case report and literature review

Non-small-cell lung cancer (NSCLC) with epidermal growth factor receptor (EGFR) mutations is highly sensitive to EGFR-tyrosine kinase inhibitor (EGFR-TKI). However, few cases of advanced NSCLC completely cured by EGFR-TKIs have been reported. We present an extremely rare case of lung adenocarcinoma that was completely cured by gefitinib administration. A 36-year-old Japanese woman was diagnosed with clinical Stage IIIB (T2N3M0) lung adenocarcinoma originating from the left upper lobe in April 2006. After the two cycles of chemotherapy, it was down-staged to ycStage IA (T1N0M0). She underwent a thoracotomy with left upper lobectomy, pulmonary angioplasty, and mediastinal nodal dissection in July 2006 [ypStage IIIA (T3N1M0)]. Eighteen months later, she was found to have lymphadenopathy of the right supraclavicular nodes. Fine needle aspiration cytology of the lymph node indicated adenocarcinoma. She started gefitinib therapy for recurrent lung cancer with EGFR mutation (exon 19 deletion) in January 2008. Four months afterward, computed tomography (CT) showed her right supraclavicular nodes had shrunk dramatically. Treatment with gefitinib was continued. Thereafter, no disease progression was observed throughout her approximately 8-year gefitinib treatment, and gefitinib was terminated in November 2016. Although the patient received no other treatment, she has suffered no recurrence in the 4 years since. A review of the literature, including our case, is also presented.

Distinct association of VEGF-C and VEGF-D with prognosis in patients with chronic heart failure: the PREHOSP-CHF study

Background

The lymphatic system has been suggested to play an important role in cardiovascular (CV) diseases including heart failure (HF). Vascular endothelial growth factor C (VEGF-C) and VEGF-D are key regulators of lymphoangiogenesis.

Purpose

To investigate the association of VEGF-C and VEGF-D with prognosis in patients with chronic HF (CHF).

Methods

The PREHOSP-CHF study is a multicenter prospective cohort study to determine the predictive value of angiogenesis-related biomarkers in CHF. A total of 1,024 patients (mean age, 75.5±12.6 years; male, 58.7%) admitted to acute decompensated HF were included in the analyses. The primary outcome was MACE defined as a composite of CV death or HF hospitalization. The secondary outcomes were all-cause death, CV death, and HF hospitalizations. Serum levels of VEGF-C and VEGF-D, as well as N-terminal pro B-type natriuretic peptide (NT-proBNP), high sensitivity cardiac troponin-I (hs-cTnI), high sensitive C reactive protein (hs-CRP), VEGF, and soluble VEGF receptor-2 (sVEGFR-2) were measured at the time of discharge. Patients were followed-up over two years.

Results

Median [interquartile range] of VEGF-C and VEGF-D levels were 4821 [3633–6131] pg/ml and 404 [296–559] pg/ml, respectively. In multivariate stepwise regression analysis, independent determinants of VEGF-C levels were younger age, female gender, absence of prior HF hospitalization, chronic kidney disease, and anemia, lower ejection fraction, lower NT-proBNP levels, higher VEGF levels, and higher sVEGFR-2 levels, while those of VEGF-D levels were lower body mass index, presence of diabetes and atrial fibrillation, and higher NT-proBNP levels. During the follow-up, a total of 209 (20.4%) all-cause deaths, 112 (10.9%) CV deaths, and 309 (30.2%) HF hospitalizations occurred. After adjusting for established risk factors and CV biomarkers, VEGF-C levels were significantly and inversely associated with the incidence of MACE and non-CV death (Fig.1, model 4). On the other hand, VEGF-D levels were significantly and positively associated with the incidence of HF hospitalization (Fig. 1, model 4). When we divided the patients into 4 groups based on the median of VEGF-C and VEGF-D levels, patients with low VEGF-C and high VEGF-D showed significantly higher incidence of MACE, all-cause death, CV death, and HF hospitalization compared to those with high VEGF-C and low VEGF-D (Fig. 2).

Conclusions

Among patients with CHF, VEGF-C and VEGF-D had different characteristic and association with the incidence of adverse events. VEGF-C levels were inversely associated with the incidence of MACE and non-CV death, and VEGF-D levels were positively associated with the incidence of HF hospitalization. These results suggests different effects of VEGF-C and VEGF-D in CHF. Combination of VEGF-C and VEGF-D enables us to make good risk stratification in patients with CHF.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Grant-in-Aid for Clinical Research from the National Hospital Organization Figure 1Figure 2

Impact of atrial fibrillation on soluble fms-like tyrosine kinase-1 and cardiovascular events in patients with suspected or known coronary artery disease: the EXCEED-J study

Background

Soluble fms-like tyrosine kinase-1 (sFlt-1), a vascular endothelial growth factor (VEGF) antagonist, has been suggested as a marker of endothelial dysfunction. Circulating sFlt-1 levels are associated with adverse outcomes in patients with preeclampsia, chronic kidney disease, and heart failure. Atrial fibrillation (AF) and coronary artery disease (CAD) are both associated with endothelial dysfunction. However, whether sFlt-1 can predict cardiovascular (CV) events and whether AF modifies the relationship between sFlt-1 and CV events in patients with suspected or known CAD are unknown.

Methods

We performed a nationwide, multicenter, prospective cohort study to determine the prognostic value of sFlt-1 and other biomarkers in patients with suspected or known CAD undergoing elective angiography. Heparin-free fasting serum was collected from the peripheral vein to determine levels of sFlt-1, VEGF, placental growth factor, cystatin C, neutrophil gelatinase-associated lipocalin, N-terminal pro-brain natriuretic peptide (NT-proBNP), high-sensitivity cardiac troponin-I (hs-cTnI), and high-sensitivity C-reactive protein (hs-CRP). The primary outcome was 3-point major adverse CV events (3P-MACE) defined as a composite of CV death, nonfatal myocardial infarction, and nonfatal stroke. The secondary outcomes were all-cause death, CV death, and 5P-MACE defined as a composite of 3P-MACE, heart failure hospitalization, and coronary/peripheral artery revascularization.

Results

3311 patients were consecutively enrolled between Nov 2013 and May 2017. After excluding 56 ineligible patients, 3255 patients (324 AF and 2931 non-AF) were followed up over 3 years (follow-up rate, 99%). During the follow-up, 156 patients developed 3P-MACE, 215 died from any cause, 82 died from cardiovascular disease, and 1361 developed 5P-MACE. The sFlt-1 level was significantly higher in AF compared to non-AF patients (p&lt;0.001). Stepwise regression analysis revealed that the sFlt-1 level was independently associated with AF. After adjusting for potential clinical confounders, serum levels of sFlt-1, NT-proBNP, hs-cTnI and cystatin C, but not other biomarkers, were significantly associated with 3P-MACE in the entire cohort. These associations were still significant in non-AF patients, whereas only the sFlt-1 level was significantly associated with 3P-MACE in AF patients. Serum levels of sFlt-1, but not other biomarkers, were also significantly associated with CV death in AF patients. Among the biomarkers, only the hs-CRP level was significantly associated with all-cause death, and no biomarker was significantly associated with 5P-MACE in AF patients. Furthermore, sFlt-1 provided an incremental prognostic information for 3P-MACE to the model with potential clinical confounders in AF, but not in non-AF patients.

Conclusions

Serum levels of sFlt-1 were significantly associated with 3P-MACE in patients with suspected or known CAD. This association was pronounced in AF patients.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The EXCEED-J study is supported by Health Labour Sciences Research Grant (2013-2014), AMED (2015-2017, Grant Number JP17ek0210008) and Grant-in-Aid for Clinical Research from the National Hospital Organization (2018-2020).

Preoperative prognostic nutritional index level is associated with tumour-infiltrating lymphocyte status in patients with surgically resected lung squamous cell carcinoma

OBJECTIVES

The prognostic nutritional index (PNI) is an indicator of systemic immune-nutritional condition and is a well-known prognostic biomarker in lung cancer patients. Tumour-infiltrating lymphocytes (TILs) is a specific histological feature of cancers, influencing an individual's immunological tumour responses. However, whether PNI can reflect lung cancer patients' prognosis through local immunity such as TIL is unclear.

METHODS

We selected 64 lung squamous cell carcinoma patients who underwent curative operations. We investigated the significance of preoperative PNI level and evaluated the relationship between PNI and immune cells surrounding the lung cancer tissue using immunohistochemical analysis of a cluster of differentiation (CD)3, CD4, CD8 and CD68.

RESULTS

A low-PNI level was significantly associated with a worse postoperative prognosis (P = 0.042). The PNI (hazard ratio 2.768, 95% confidence interval 1.320-5.957; P = 0.007) was an independent prognostic factor. The low-PNI group had a significantly shorter recurrence-free survival and overall survival (P = 0.013 and P = 0.002, log-rank test) compared with the high-PNI group. A significant positive correlation between PNI components including preoperative peripheral blood lymphocyte count and serum albumin concentration, and TILs, was observed. Absolute numbers of TILs in the preoperative high-PNI group were significantly increased compared with those in the preoperative low-PNI group (CD3+ cells; P = 0.002, CD4+ cells; P = 0.049 and CD8+ cells; P = 0.024).

CONCLUSIONS

The preoperative PNI level was strongly associated with the postoperative outcome in lung cancer patients. Considering the positive relationship between preoperative PNI level and TIL status, preoperative immune-nutritional condition may influence lung cancer patients' postoperative prognosis through local immunity as well as systemic immune response.

Prognostic value of postoperative decrease in serum albumin on surgically resected early-stage non-small cell lung carcinoma: A multicenter retrospective study

Background

Preoperative nutritional status is an important host-related prognostic factor for non-small cell lung carcinoma (NSCLC); however, the significance of postoperative changes in nutritional status remains unclear. This study aimed to elucidate the significance of postoperative decreases in serum albumin (ΔAlb) on the outcomes of early-stage NSCLC.

Methods

We analyzed 443 training cohort (TC) and 642 validation cohort (VC) patients with pStage IA NSCLC who underwent surgery and did not recur within 1 year. We measured preoperative serum albumin levels (preAlb) and postoperative levels 1 year after surgery (postAlb), and calculated ΔAlb as (preAlb − postAlb)/preAlb × 100%. A cutoff value of 11% for ΔAlb was defined on the basis of the receiver operating characteristic curve for the TC.

Results

Patients were divided into ΔAlb-Decreased and ΔAlb-Stable groups, including 100 (22.6%) and 343 (77.4%) in the TC, and 58 (9.0%) and 584 (90.1%) in the VC. ΔAlb-Decreased was associated with male sex (p = 0.0490), smoking (p = 0.0156), and non-adenocarcinoma (p<0.0001) in the TC, and pT1b (p = 0.0169) and non-adenocarcinoma (p = 0.0251) in the VC. Multivariable analysis identified ΔAlb as an independent prognostic factor for disease-free survival (DFS) and overall survival (OS) in both cohorts (VC: DFS, HR = 1.9, 95%CI: 1.10–3.15, p = 0.0197; OS, HR = 2.0, 95%CI: 1.13–3.45, p = 0.0173). Moreover, subgroup analysis demonstrated that the prognostic value of ΔAlb was consistent for age, sex, smoking history, surgical procedure, and histological type.

Conclusion

We demonstrated a negative impact of postoperative decrease of the serum albumin on the prognosis of patients with early-stage NSCLC. Postoperative changes in nutritional status might be important in NSCLC outcomes.

Spontaneous hemopneumothorax with a ruptured aneurysm in the second intercostal artery: report of a case

Ruptured intercostal aneurysm is a rare cause of spontaneous hemopneumothorax (SHP). A 29-year-old woman presented to our hospital with left neck pain and, in the emergency room, suddenly lost consciousness. Chest radiography showed massive pleural effusion and the moderate collapse of the left lung. A chest drain was placed and 800 mL of bloody pleural effusion was collected. Contrast-enhanced computed tomography showed a ruptured aneurysm near the left pulmonary apex. Emergency angiography further revealed the ruptured aneurysm in the second intercostal artery. Transcatheter angiographic embolization (TAE) was performed, which resulted in hemostasis. On hospitalization day 2, the hematoma was removed via video-assisted thoracic surgery. A bulla was also identified in the lower lobe and removed. She was discharged from the hospital on a postoperative day 6 without complications. Thus, TAE might be effective to control bleeding during the initial treatment of SHP due to a ruptured aneurysm.

Prognostic Impact of Albumin-bilirubin (ALBI) Grade on Non-small Lung Cell Carcinoma: A Propensity-score Matched Analysis

BACKGROUND/AIM

Albumin-bilirubin (ALBI) grade is an indicator of liver dysfunction and is useful for predicting postoperative prognosis of hepatocellular carcinomas. However, the significance of ALBI grade in non-small cell lung carcinoma (NSCLC) has not been elucidated.

PATIENTS AND METHODS

We analyzed 947 patients with pStage IA-IIIA NSCLC. We divided patients into ALBI grade 1 and grade 2/3 groups. We then analyzed the association of ABLI grade with clinicopathological characteristics and prognosis in NSCLC by using propensity-score matching.

RESULTS

ALBI grade 2/3 was significantly associated with older age, male sex, advanced pT status, and histological type. Even after propensity-score matching, ALBI grade 2/3 patients had significantly worse cancer-specific survival (CSS) than ALBI grade 1 patients (5-year CSS: 87.3% versus 92.8%; p=0.0247). In multivariate analysis, ALBI grade 2/3 was an independent predictor of CSS (HR=1.9; 95%CI=1.11-3.11; p=0.0177).

CONCLUSION

ALBI grade was an independent prognostic factor in surgically resected NSCLC.

Strongly correlated superconductivity in a copper-based metal-organic framework with a perfect kagome lattice

Metal-organic frameworks (MOFs), which are self-assemblies of metal ions and organic ligands, provide a tunable platform to search a new state of matter. A two-dimensional (2D) perfect kagome lattice, whose geometrical frustration is a key to realizing quantum spin liquids, has been formed in the π - d conjugated 2D MOF [Cu₃(C₆S₆)] _n (Cu-BHT). The recent discovery of its superconductivity with a critical temperature T _c of 0.25 kelvin raises fundamental questions about the nature of electron pairing. Here, we show that Cu-BHT is a strongly correlated unconventional superconductor with extremely low superfluid density. A nonexponential temperature dependence of superfluid density is observed, indicating the possible presence of superconducting gap nodes. The magnitude of superfluid density is much smaller than those in conventional superconductors and follows the Uemura's relation of strongly correlated superconductors. These results imply that the unconventional superconductivity in Cu-BHT originates from electron correlations related to spin fluctuations of kagome lattice.