Consequences of Losing Incidental Pulmonary Nodules to Follow-Up: Unmonitored Nodules Progressing to Stage IV Lung Cancer

INTRODUCTION

Lung cancer is the leading cause of cancer-related death globally. Incidental pulmonary nodules represent a golden opportunity for early diagnosis, which is critical for improving survival rates. This study explores the impact of missed pulmonary nodules on the progression of lung cancer.

METHODS

A total of 4,066 stage IV lung cancer cases from 2019 to 2021 in Danish hospitals were investigated to determine whether a chest computed tomography (CT) had been performed within 2 years before diagnosis. CT reports and images were reviewed to identify nodules that had been missed by radiologists or were not appropriately monitored, despite being mentioned by the radiologist, and to assess whether these nodules had progressed to stage IV lung cancer.

RESULTS

Among stage IV lung cancer patients, 13.6% had undergone a chest CT scan before their diagnosis; of these, 44.4% had nodules mentioned. Radiologists missed a nodule in 7.6% of cases. In total, 45.3% of nodules were not appropriately monitored. An estimated 2.5% of stage IV cases could have been detected earlier with proper surveillance.

CONCLUSION

This study underlines the significance of monitoring pulmonary nodules and proposes strategies for enhancing detection and surveillance. These strategies include centralized monitoring and the implementation of automated registries to prevent gaps in follow-up.

Digital Spatial Profiling to Predict Recurrence in Grade 3 Stage I Lung Adenocarcinoma

OBJECTIVE

Early-stage lung adenocarcinoma (LUAD) is treated with local therapy alone, though patients with grade 3 stage I LUAD a 50% 5-year recurrence rate. Our objective is to determine if analysis of the tumor microenvironment can create a predictive model for recurrence.

METHODS

Thirty-four grade 3 stage I LUAD patients underwent surgical resection. Digital spatial profiling was utilized to perform genomic (n=31) and proteomic (n=34) analysis of pancytokeratin positive (PanCK+) and negative (PanCK-) tumor cells. K-means clustering was performed on the top 50 differential genes and top 20 differential proteins, with Kaplan-Meier recurrence curves based on patient clustering. External validation of high expression genes was performed with Kaplan-Meier Plotter.

RESULTS

There were no significant clinicopathologic differences between patients who did (n=14) and did not (n=20) recur. Median time to recurrence was 806 days; median follow up with no recurrence was 2897 days. K-means clustering of PanCK+ genes resulted in a model with a Kaplan-Meier curve with C-index of 0.75. K-means clustering for PanCK- genes was less successful at differentiating recurrence (C-index 0.6). Genes upregulated or downregulated for recurrence were externally validated using available public databases. Proteomic data did not reach statistical significance but did internally validate the genomic data described above.

CONCLUSIONS

Genomic difference in LUAD may be able to predict risk of recurrence. After further validation, stratifying patients by this risk may help guide who will benefit from adjuvant therapy.

Upstaged from cT1a-c to pT2a lung cancer, related to visceral pleural invasion patients, after segmentectomy: is it an indication to complete resection to lobectomy?

OBJECTIVES

Segmentectomy may be indicated for T1a-cN0 non-small-cell lung cancer. However, several patients are upstaged pT2a at final pathological examination due to visceral pleural invasion (VPI). As resection is usually not completed to lobectomy, this may raise issue of potential worse prognosis. The aim of this study is to compare prognosis of VPI upstaged cT1N0 patients operated on by segmentectomy or lobectomy.

METHODS

Data of patients from 3 centres were analysed. This was a retrospective study, of patients operated on from April 2007 to December 2019. Survival and recurrence were assessed by Kaplan-Meier method and cox regression analysis.

RESULTS

Lobectomy and segmentectomy were performed in 191 (75.4%) and in 62 (24.5%) patients, respectively. No difference in 5-year disease-free survival rate between lobectomy (70%) and segmentectomy (64.7%) was observed. There was no difference in loco-regional recurrence, nor in ipsilateral pleural recurrence. The distant recurrence rate was higher (P = 0.027) in the segmentectomy group. Five-year overall survival rate was similar for both lobectomy (73%) and segmentectomy (75.8%) groups. After propensity score matching, there was no difference in 5-year disease-free survival rate (P = 0.27) between lobectomy (85%) and segmentectomy (66.9%), and in 5-year overall survival rate (P = 0.42) between the 2 groups (lobectomy 76.3% vs segmentectomy 80.1%). Segmentectomy was not impacting neither recurrence, nor survival.

CONCLUSIONS

Detection of VPI (pT2a upstage) in patients who underwent segmentectomy for cT1a-c non-small-cell lung cancer does not seem to be an indication to extend resection to lobectomy.

Epidemiological and therapeutic profiles of lung cancer patients in the Hokushin Region Japan: a retrospective hospital administrative database study

OBJECTIVE

This study was performed to validate the epidemiology, initial treatment, and clinical practice of lung cancer patients in the Hokushin region, Japan.

METHODS

We retrospectively surveyed data of 5503 newly diagnosed and registered lung cancer patients in 22 principal hospital-based cancer registries in Hokushin region linked with health insurance claims data for registered patients between 2016 and 2017.

RESULTS

The patients consisted of 3677 (66.8%) men and 1826 (33.2%) women with a mean (range) age of 72.2 (27-103) years). Diagnoses were small cell lung cancer (n = 512, 9.4%), squamous cell carcinoma (n = 1083, 19.7%), and non-squamous non-small cell lung cancer (NSCLC; n = 3906, 70.9%). The population with stage I disease in Toyama prefecture (41.1%) was smaller than in the other three prefectures associated with reduced selection of initial surgical therapy and increased frequencies of stage IV disease (33.2%) and best supportive care (18.6%). Initial chemotherapy for stage IV non-squamous NSCLC consisted of tyrosine kinase inhibitors in 39.3% of cases for EGFR and 4% of cases for ALK-positive non-squamous NSCLC, followed by platinum compounds (25.9%) non-platinum compounds (12.9%), and immune checkpoint inhibitors (10.2%). Carboplatin was the commonly prescribed first-line cytotoxic chemotherapeutic agent (65.4% of patients under 75 years and in 96.7% of patients over 75 years).

CONCLUSION

This study revealed real-world data on epidemiological and treatment status in lung cancer in four prefectures in Hokushin region, Japan. Simultaneous analysis of nationwide registry and insurance data could provide valuable insights for the development of lung cancer screening and medical treatment strategies. In addition, the comparative data analysis with other lesions or countries will be useful for evaluating the differences in clinical practice of cancer managements.

Mortality after radiotherapy or surgery in the treatment of early-stage non-small-cell lung cancer: a population-based data analysis in the clinical cancer registry of Brandenburg-Berlin

PURPOSE

Stereotactic body radiotherapy (SBRT) is an established treatment method with favorable toxicity for inoperable early-stage non-small-cell lung cancer (NSCLC) patients. This paper aims to evaluate the importance of SBRT in the treatment of early-stage lung cancer patients compared to surgery as standard of care.

METHODS

The German clinical cancer register of Berlin-Brandenburg was assessed. Cases of lung cancer were considered if they had a TNM stage (clinical or pathological) of T1-T2a and N0/x and M0/x, corresponding to UICC stages I and II. In our analyses, cases diagnosed between 2000 and 2015 were included. We adjusted our models with propensity score matching. We compared patients treated with SBRT or surgery regarding age, Karnofsky performance status (KPS), sex, histological grade, and TNM classification. Further, we assessed the association of cancer-related parameters with mortality; hazard ratios (HR) from Cox proportional hazards models were computed.

RESULTS

A total of 558 patients with UICC stages I and II NSCLC were analyzed. In univariate survival models, we found similar survival rates in patients who underwent radiotherapy compared with surgery (HR 1.2, 95% confidence interval [CI] 0.92-1.56; p = 0.2). Our univariate subgroup analyses of patients > 75 years showed a statistically nonsignificant survival benefit for patients treated with SBRT (HR 0.86, 95% CI 0.54-1.35; p = 0.5). Likewise, in our T1 subanalysis, survival rates were similar between the two treatment groups regarding overall survival (HR 1.12, 95% CI 0.57-2.19; p = 0.7). The availability of histological data might be slightly beneficial in terms of survival (HR 0.89, 95% CI 0.68-1.15; p = 0.4). This effect was also not significant. Regarding the availability of histological status in our subgroup analyses of elderly patients, we could show similar survival rates as well (HR 0.70, 95% CI 0.44-1.23; p = 0.14). T1-staged patients also had a statistically nonsignificant survival benefit if histological grading was available (HR 0.75, 95% CI 0.39-1.44; p = 0.4). Concerning adjusted covariates, better KPS scores were associated with better survival in our matched univariate Cox regression models. Further, higher histological grades and TNM stages were related to a higher mortality risk.

CONCLUSION

Using population-based data, we observed an almost equal survival of patients treated with SBRT compared to surgery in stage I and II lung cancer. The availability of histological status might not be decisive in treatment planning. SBRT is comparable to surgery in terms of survival.

Comparison of long-term outcomes of stereotactic body radiotherapy (SBRT) via Helical tomotherapy for early-stage lung cancer with or without pathological proof

BACKGROUND

Stereotactic body radio therapy (SBRT) has emerged as a standard treatment option for nonsurgical candidates with early-stage non-small cell lung cancer (NSCLC). Pathological proof is sometimes difficult to obtain in patients with solitary pulmonary nodules (SPNs). We aimed to compare the clinical outcomes of stereotactic body radiotherapy via helical tomotherapy (HT-SBRT) for early-stage lung cancer patients with or without a pathological diagnosis.

METHODS

Between June 2011 and December 2016, we treated 119 lung cancer patients with HT-SBRT, including 55 with a clinical diagnosis and 64 with a pathological diagnosis. Survival outcomes, including local control (LC), progression-free survival (PFS), cancer-specific survival (CSS), and overall survival (OS), were compared between two cohorts with and without a pathological diagnosis.

RESULTS

The median follow-up for the whole group was 69 months. Patients with a clinical diagnosis were significantly older (p = 0.002). No significant differences were observed between the clinical and pathological diagnosis cohorts in terms of the long-term outcome, with 5-year LC, PFS, CSS, and OS of 87% versus 83% (p = 0.58), 48% versus 45% (p = 0.82), 87% versus 84% (p = 0.65), and 60% versus 63% (p = 0.79), respectively. Recurrence patterns and toxicity were also similar.

CONCLUSIONS

Empiric SBRT appears to be a safe and effective treatment option in a multidisciplinary setting when patients with SPNs highly suggestive of malignancy are unable/refuse to obtain a definitive pathological diagnosis.

Timely Curative Treatment and Overall Mortality Among Veterans With Stage I NSCLC

Introduction

Early stage lung cancer (LC) outcomes depend on the receipt of timely therapy. We aimed to determine the proportions of Veterans with stage I NSCLC in the age group eligible for LC screening (LCS) receiving timely curative treatment (≤12 wk after diagnosis), the factors associated with timely treatment and modality, and the factors associated with overall mortality.

Methods

Retrospective cohort study in Veterans aged 55 to 80 years when diagnosed with stage I NSCLC during 2011 to 2015. We used multivariate logistic regression models to determine factors associated with receiving timely therapy and receiving surgery versus stereotactic body radiation therapy (SBRT). We used multivariate Cox proportional hazards regression analysis to determine factors associated with overall mortality.

Results

We identified 4796 Veterans with stage I NSCLC; the cohort was predominantly older, White males, current or former smokers, and living in urban areas. Overall, 84% underwent surgery and 16% underwent SBRT. The median time to treatment was 63 days (61 d for surgery; 71 d for SBRT), with 30% treated more than 12 weeks. Unmarried Veterans with higher social deprivation index were less likely to receive timely therapy. Black race, female sex, and never smoking were associated with lower overall mortality. Older Veterans receiving treatment >12 wk, with higher comorbidity index, and squamous cell carcinoma had higher overall mortality.

Conclusions

A total of 30% of the Veterans with stage I NSCLC in the age group eligible for LCS received curative treatment more than 12 weeks after diagnosis, which was associated with higher overall mortality. Delays in LC treatment could decrease the mortality benefits of LCS among the Veterans.

Lung Cancer Treatment Advances in 2022

The therapeutic landscape of lung cancer treatment is changing rapidly, and new data was presented at the recently concluded American Society of Clinical Oncology 2022 (ASCO22) meeting. We highlight studies of clinical relevance that represent significant updates in the current management of non-small cell lung cancer (SCLC) and small cell lung cancer (NSCLC). We summarize the updates in early-stage NSCLC, mutated and non-mutated advanced NSCLC as well as small cell lung cancer (SCLC), and discuss these advances in the context of the current clinical standard of care.

Detection of early-stage lung cancer in sputum using automated flow cytometry and machine learning

BACKGROUND

Low-dose spiral computed tomography (LDCT) may not lead to a clear treatment path when small to intermediate-sized lung nodules are identified. We have combined flow cytometry and machine learning to develop a sputum-based test (CyPath Lung) that can assist physicians in decision-making in such cases.

METHODS

Single cell suspensions prepared from induced sputum samples collected over three consecutive days were labeled with a viability dye to exclude dead cells, antibodies to distinguish cell types, and a porphyrin to label cancer-associated cells. The labeled cell suspension was run on a flow cytometer and the data collected. An analysis pipeline combining automated flow cytometry data processing with machine learning was developed to distinguish cancer from non-cancer samples from 150 patients at high risk of whom 28 had lung cancer. Flow data and patient features were evaluated to identify predictors of lung cancer. Random training and test sets were chosen to evaluate predictive variables iteratively until a robust model was identified. The final model was tested on a second, independent group of 32 samples, including six samples from patients diagnosed with lung cancer.

RESULTS

Automated analysis combined with machine learning resulted in a predictive model that achieved an area under the ROC curve (AUC) of 0.89 (95% CI 0.83-0.89). The sensitivity and specificity were 82% and 88%, respectively, and the negative and positive predictive values 96% and 61%, respectively. Importantly, the test was 92% sensitive and 87% specific in cases when nodules were < 20 mm (AUC of 0.94; 95% CI 0.89-0.99). Testing of the model on an independent second set of samples showed an AUC of 0.85 (95% CI 0.71-0.98) with an 83% sensitivity, 77% specificity, 95% negative predictive value and 45% positive predictive value. The model is robust to differences in sample processing and disease state.

CONCLUSION

CyPath Lung correctly classifies samples as cancer or non-cancer with high accuracy, including from participants at different disease stages and with nodules < 20 mm in diameter. This test is intended for use after lung cancer screening to improve early-stage lung cancer diagnosis. Trial registration ClinicalTrials.gov ID: NCT03457415; March 7, 2018.

Stereotactic Ablative Radiotherapy in the Treatment of Early-Stage Lung Cancer - A Done Deal?

Stereotactic ablative radiotherapy (SABR) is an important curative-intent treatment option for early-stage non-small cell lung cancer. It offers good cancer control without invasive surgery and has become the standard of care for medically inoperable patients. The literature on SABR for early-stage non-small cell lung cancer is substantial and continues to grow. However, there remain areas of controversy where data are limited - notably the use of SABR in medically operable patients. Other areas of some debate include the treatment of central/ultra-central and large (>5 cm) lesions, as well as treatment with co-existing interstitial lung disease. This review article provides an overview of the current literature together with a discussion of future directions.

Patient-clinician communication and patient-centered outcomes among patients with suspected stage I non-small cell lung cancer: a prospective cohort study

Among patients with suspected early-stage non-small cell lung cancer (NSCLC), we sought to evaluate the association of patient-clinician communication (PCC) with patient-centered outcomes (PCOs). We conducted a multicenter, prospective cohort study examining PCOs at five time points, up to 12-months post-treatment. We used generalized estimating equation (GEE) models adjusted for sociodemographic and clinical variables to examine the relationship between PCC (dichotomized as high- or low-quality) and decisional conflict, treatment self-efficacy, and anxiety. The cohort included 165 patients who were 62% male with a mean age of 70.7 ± SD 8.1 years. Adjusted GEE analysis including 810 observations revealed high-quality PCC was associated with no decisional conflict (adjusted odds ratio [aOR] = 0.14, 95% CI = 0.07 to 0.27) and higher self-efficacy (β = -0.26, 95% CI = -0.37 to -0.14). High-quality PCC was not associated with moderately severe anxiety (aOR = 0.68, 95% CI = 0.41 to 1.09), though was associated with decreased anxiety scores (β = -3.91, 95% CI = -6.48 to -1.35). Among individuals with suspected early-stage NSCLC, high-quality PCC is associated with less decisional conflict and higher self-efficacy; the relationship with anxiety is unclear. Clinicians should prioritize enhanced treatment-related communication at critical and vulnerable periods in the cancer care trajectory to improve PCOs.

High-dose stereotactic body radiotherapy using CyberKnife® for stage I peripheral lung cancer: a single-center retrospective study

Background

This retrospective study was performed to evaluate the efficacy and toxicity of high-dose stereotactic body radiotherapy (SBRT) using a CyberKnife® for patients with stage I peripheral non-small cell lung cancer (NSCLC).

Methods

Ninety-six patients with stage I peripheral NSCLC who were treated with SBRT using a CyberKnife® from August 2010 to June 2019 were identified and included in this study. Local control (LC), local progression-free survival (LPFS), progression-free survival (PFS), overall survival (OS), and late toxicity were evaluated. Potential risk factors associated with LC, LPFS, PFS, or OS were investigated by univariate analyses.

Results

Data of 96 patients were examined. The prescribed dose to the tumor was 54 Gy in 3 fractions in 91 patients and 60 Gy in 3 fractions in 5 patients. The median follow-up duration was 27 months. The 2-year LC, LPFS, PFS, and OS rates were 97%, 88%, 84%, and 90%, respectively. The T factor was significantly correlated with LC, LPFS, and PFS. The 2-year LC rate for patients with T1a/T1b and T1c/T2a disease was 100% and 90%, respectively (p < 0.05), and the 2-year PFS rate for the corresponding patients was 95% and 65%, respectively (p < 0.001). One patient (1%) developed grade 3 radiation pneumonitis.

Conclusions

High-dose SBRT using a CyberKnife® for stage I peripheral NSCLC produced favorable treatment outcomes with acceptable late toxicity. Further studies are needed to improve the treatment outcomes for patients with T1c/T2a disease.

Barriers to surveillance imaging adherence in early-staged lung cancer

Background

Frequency of post-treatment surveillance is highly variable following curative resection of non-small cell lung cancer (NSCLC). We sought to characterize surveillance practices after lobectomy for early-stage NSCLC and to identify the impact of various demographic factors on patterns of surveillance.

Methods

We included patients who underwent anatomic lobectomy for pathologic stage I NSCLC from 2007-2017. Demographic characteristics, post-operative imaging studies (internal and external), and travel distance were recorded. We defined the minimal standard of surveillance imaging studies (MSSIS) as ≥7 studies in the first 5 years (computed tomography/positron emission tomography). Patient sex, ethnicity, marital status, and distance traveled were evaluated as predictors of imaging receipt. Standard descriptive statistics, univariate, and multivariate analysis (MVR) were performed.

Results

A total of 1,288 patients were included. The mean age was 65.5±10.1 years, 589 (45.7%) were male, 1,081 (83.9%) were Caucasian, and 924 (71.7%) were married. Only 464 (36%) achieved MSSIS; being married [75.6% (351/464) vs. 68.8% (567/824), P=0.01] and having larger tumor size (2.63±0.04 vs. 2.49±0.05 cm, P=0.03) were both associated with MSSIS. Patients residing <100 miles from the hospital were more likely to have MSSIS, and more imaging at 24 months (4.1±2.2 vs. 3.7±2.0; P=0.006), 60 months (8.0±5.1 vs. 6.6±4.2, P=0.001) and overall (10±7.3 vs. 8.2±6.3; P=0.001). On MVR, tumor size and marital status were associated with MSSIS.

Conclusions

Two-thirds of patients at our institution did not undergo recommended surveillance imaging. Tumor size, being married, and living <100 miles from the medical center were associated with an increased number of imaging studies and greater adherence to guidelines.

Immune profiling after minimally invasive lobectomy

OBJECTIVES

Whether acute phase and immune responses are minimally affected following minimally invasive lung surgery needs further investigation. We performed a pilot study to evaluate the immune profile of patients who underwent video-assisted thoracoscopic surgery or robot-assisted thoracic surgery lobectomies for the treatment of suspicious or known stage I non-small-cell lung cancer.

METHODS

Blood samples were taken preoperatively and 3 and 24 h postoperatively were analysed for C-reactive protein, glucose, cortisol, tumour necrosis factor alpha (TNF-α), interleukin 8 (IL-8) and interleukin 10 (IL-10) levels. TNF-α, IL-8 and IL-10 were also measured in lung tissues. T (CD4, CD8), B (CD19) and natural killer (CD56, CD16) cell counts and natural killer cell functions were analysed using a flow cytometry-based assay before and after surgery.

RESULTS

Minimally invasive surgery (robot-assisted thoracic surgery + video-assisted thoracoscopic surgery) significantly decreased IL-10 (P = 0.016) levels after surgery. No significant differences were detected in TNF-α (P = 0.48) and IL-8 (P = 0.15) levels before and after surgery. C-reactive protein (P < 0.001), cortisol (P < 0.001) and glucose levels (P < 0.001) increased significantly after surgery. Lymphocyte, total T cell, CD3+CD4+ and CD3+CD8+ CD16+CD56+ cell counts were significantly lower on postoperative day 1.

CONCLUSION

There seems to be a dynamic balance between pro- and anti-inflammatory cytokines and immune cells following minimally invasive lobectomy.

Lobe-specific lymph node dissection in stage IA non-small-cell lung cancer: a retrospective cohort study

OBJECTIVES

To investigate lymph node (LN) metastasis according to tumour location and assess the impact of lobe-specific LN dissection on survival in stage IA non-small-cell lung cancer (NSCLC).

METHODS

We retrospectively analysed the data of patients with clinical stage IA NSCLC treated with lobectomy and systematic LN dissection at Asan Medical Center (Seoul, Korea) between June 2005 and April 2017. Patients who received neoadjuvant therapy had multiple primary tumours or missed the follow-up during the first postoperative year were excluded. The patients were divided into five groups according to involved lung lobes: right upper lobe (RUL), right middle lobe (RML), right lower lobe (RLL), left upper lobe (LUL) and left lower lobe (LLL), which were further divided into subgroups according to LN station metastasis. Overall survival (OS) and the incidence of metastasis were calculated for each subgroup. Efficacy indices (EIs) were calculated to determine the correlation between each lung lobe and LN station, and the impact of the dissection of these stations on survival.

RESULTS

A total of 1202 patients were analysed. The 5-year OS in the RUL, RML, RLL, LUL and LLL groups was 74%, 88%, 78%, 80% and 75%, respectively. The incidence of single LN station metastasis was 11%, 10%, 10%, 16% and 14%, respectively. The lobe-specific LNs for RUL, RML, RLL, LUL and LLL were stations 2/3/4, 4/7, 2/4/7, 4/5/6 and 6/7/9, respectively. Moreover, the LN stations with high EIs for RUL, RML, RLL, LUL and LLL were 4, 7, 7, 5 and 7, respectively. In the RUL group, the incidence of metastasis to stations 2, 3 and 4 was 2.3%, 0.5% and 7.6%, and the EI was 0.8, 0.3 and 4.3, respectively. In RML, the incidence of metastasis to stations 4 and 7 was 4% and 6%, and the EI was 1.3 and 2.4, respectively. In RLL, the incidence of metastasis to stations 2, 4 and 7 was 4.4%, 5.6% and 8.3%, and the EI was 1.3, 1.4 and 3.3, respectively. In LUL, the incidence of metastasis to stations 4, 5 and 6 was 1.4%, 11.8% and 2.5%, and the EI was 0.4, 7.1 and 0.5, respectively. In LLL, the incidence of metastasis to stations 6, 7 and 9 was 1.1%, 5.7% and 1.7%, and the EI was 0.6, 2.3 and 0.5, respectively. Furthermore, the OS of patients with lobe-specific LN metastasis was statistically significantly different from that of the non-lobe-specific LN metastasis group with P-values of <0.001 for RUL, 0.002 for RML, 0.002 for RLL, 0.001 for LUL and 0.003 for LLL.

CONCLUSIONS

Our findings support the use of lobe-specific LN dissection in stage IA NSCLC. When LN stations with high EI were negative, LN metastasis in other stations was unlikely. The incidence of LN metastasis beyond lobe-specific LN stations was ∼1% in all subgroups. Dissection of non-lobe-specific LNs may not improve the OS; however, prospective randomized controlled trials are needed to modify the standard approach.

Computerized tomography-Guided Microwave Ablation of Patients with Stage I Non-small Cell Lung Cancers: A Single-Institution Retrospective Study

Objectives:

The objective of the study was to retrospectively investigate the safety and efficacy of computerized tomography-guided microwave ablation (MWA) in the treatment of Stage I non-small cell lung cancers (NSCLCs).

Material and Methods:

This retrospective, single-center study evaluated 21 patients (10 males and 11 females; mean age 73.8 ± 8.2 years) with Stage I peripheral NSCLCs treated with MWA between 2010 and 2020. All patients were surveyed for metastatic disease. Clinical success was defined as absence of FDG avidity on follow-up imaging. Tumor growth within 5 mm of the original ablated territory was defined as local recurrence. Welch t-test and Fisher’s exact test were used for univariate analysis. Hazard ratio (HR) and odds ratio (OR) were determined using Cox regression and Firth logistic regression. Significance was P < 0.05. Data are expressed as mean ± standard deviation.

Results:

Ablated tumors had longest dimension 17.4 ± 5.4 mm and depth 19.7 ± 15.1 mm from the pleural surface. Median follow-up was 20 months (range, 0.6–56 months). Mean overall survival (OS) following lung cancer diagnosis or MWA was 26.2 ± 15.4 months (range, 5–56 months) and 23.7 ± 15.1 months (range, 3–55 months). OS at 1, 2, and 5 years was 67.6%, 61.8%, and 45.7%, respectively. Progression-free survival (PFS) was 19.1 ± 16.2 months (range, 1–55 months). PFS at 1, 2, and 5 years was 44.5%, 32.9%, and 32.9%, respectively. Technical success was 100%, while clinical success was observed in 95.2% (20/21) of patients. One patient had local residual disease following MWA and was treated with chemotherapy. Local control was 90% with recurrence in two patients following ablation. Six patients (28.6%) experienced post-ablation complications, with pneumothorax being the most common event (23.8% of patients). Female gender was associated with 90% reduction in risk of death (HR 0.1, P = 0.014). Tumor longest dimension was associated with a 10% increase in risk of death (P = 0.197). Several comorbidities were associated with increased hazard. Univariate analysis revealed pre-ablation forced vital capacity trended higher among survivors (84.7 ± 15.2% vs. 73 ± 21.6%, P = 0.093). Adjusted for age and sex, adenocarcinoma, and neuroendocrine histology trended toward improved OS (OR: 0.13, 0.13) and PFS (OR: 0.88, 0.37) compared to squamous cell carcinoma.

Conclusion:

MWA provides a safe and effective alternative to stereotactic brachytherapy resulting in promising OS and PFS in patients with Stage I peripheral NSCLC. Larger sample sizes are needed to further define the effects of underlying comorbidities and tumor biology.

A prognosis-related molecular subtype for early-stage non-small lung cell carcinoma by multi-omics integration analysis

Background

Early-stage non-small cell lung carcinoma (NSCLC) accounts for more than 80% of lung cancer, which is a kind of cancer with high heterogeneity, so the genetic heterogeneity and molecular subtype should be explored.

Methods

Partitioning Around Medoid algorithm was used to acquire the molecular subtype for early-stage NSCLC based on prognosis-related mRNAs and methylation sites. Random forest (RF) and support vector machine (SVM) were used to build prediction models for subtypes.

Results

Six prognosis-related subtypes for early-stage NSCLC, including 4 subtypes for lung squamous cell carcinoma (LUSC) and 2 subtypes for lung adenocarcinoma (LUAD), were identified. There were highly expressed and hypermethylated gene regions for LUSC-C1 and LUAD-C2, highly expressed region for LUAD-C1, and hypermethylated regions for LUSC-C3 and LUSC-C4. Molecular subtypes for LUSC were mainly determined by DNA methylation (14 mRNAs and 362 methylation sites). Molecular subtypes for LUAD were determined by both mRNA and DNA methylation information (143 mRNAs and 458 methylation sites). Ten methylation sites were selected as biomarkers for prediction of LUSC-C1 and LUSC-C3, respectively. Nine genes and 1 methylation site were selected as biomarkers for LUAD subtype prediction. These subtypes can be predicted by the selected biomarkers with RF and SVM models.

Conclusions

In conclusion, we proposed a prognosis-related molecular subtype for early-stage NSCLC, which can provide important information for personalized therapy of patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-07846-0.

Prognostic factors and clinical outcomes after stereotactic radiotherapy for primary lung tumors

Aim

To characterize the population treated with SBRT for early-stage primary lung tumors in our institution, determine their outcomes, and identify potential prognosis factors.

Background

Stereotactic radiotherapy (SBRT) is an alternative treatment for inoperable patients with early-stage lung cancer. It confers a local control rate around 90% at 3 years, and 2-3 year overall survival rates of 43-60% in this population.

Materials and methods

We retrospectively analyzed all patients treated in our department between 2012 and 2017 and evaluated local progression-free survival (L-PFS), nodal or distant progression-free survival (ND-PFS), global progression-free survival (G-PFS), overall survival (OS), and disease specific survival (DSS). Univariate (UVA) and multivariate (MVA) models were built to assess the influence of each variable.

Results

We identified 218 patients with 233 tumors. Most were male (78.9%) with a median age of 73 years. Median follow-up was 22 months. At 18 months, L-PFS was 93.7%, ND-PFS was 82.2%, G-PFS was 76.0%, DSS was 90.5%, and OS was 78.0% in ≤ T2 tumors. On UVA, T2 tumors were associated with lower L-PFS, G-PFS and DSS than T1, with no significant impact on ND-PFS or OS, an effect that persisted on MVA. On UVA, L-PFS and G-PFS were negatively influenced by female gender and a 5-fraction schedule was associated with worse G-PFS, which was not confirmed on MVA.

Conclusion

Our local and distant control rates and survival were similar to those previously reported. On MVA, T2 tumors displayed lower L-PFS, G-PFS and DSS, with no difference in OS.

Long-term results of robotic anatomical segmentectomy for early-stage non-small-cell lung cancer

OBJECTIVES

Anatomical segmentectomy is advocated for curative resection in select patients. We investigated the long-term results of robotic anatomical segmentectomy with mediastinal nodal dissection in patients with early-stage lung cancer.

METHODS

We retrospectively reviewed patients who underwent robotic anatomical segmentectomy for early-stage non-small-cell lung cancer (NSCLC). The follow-up data were obtained to determine survival and statistically significant risk factors in both univariable and multivariable models.

RESULTS

Seventy-one patients had clinical stage I NSCLC (36 men, 35 women, mean age 70 ± 12 years). All patients underwent R0 resection. The mean operating time was 134 min. Ten of 71 (14%) patients were upstaged. Eight of 71 (11%) patients were upstaged due to the size of tumour in the pathological specimen, and 2 of 71 (3%) patients were upstaged due to microscopic N2 nodal metastasis. Median hospitalization was 4 days (2-31 days). Complication rate was 29%. There were no complications attributable to the surgical robot. No patient died within 90 days. Mean follow-up was 54 months (range 2 months to 9 years). The overall 5-year survival was 43%, whereas lung cancer-specific 5-year survival was 55%. The 5-year lung cancer-specific survival for pathological stage I disease was 73%. Local or mediastinal recurrence occurred in 4 of 71(5%) patients. Pathological upstaging or recurrence resulted in 0% 5-year survival. The univariable and multivariable analyses showed that advanced age and pathological upstaging were statistically significant risk factors for lung cancer-specific death.

CONCLUSIONS

Robotic anatomical segmentectomy with mediastinal nodal dissection is a safe and feasible procedure. Accurate preoperative clinical staging is of critical importance for long-term survival.

Biologically Effective Dose in Stereotactic Body Radiotherapy and Survival for Patients With Early-Stage NSCLC

INTRODUCTION

Stereotactic body radiotherapy (SBRT) results in excellent local control of stage I NSCLC. Radiobiology models predict greater tumor response when higher biologically effective doses (BED₁₀) are given. Prior studies support a BED₁₀ greater than or equal to 100 Gy with SBRT; however, data are limited comparing outcomes after various SBRT regimens. We therefore sought to evaluate national trends and the effect of using "low" versus "high" BED₁₀ SBRT courses on overall survival (OS).

METHODS

This retrospective study used the National Cancer Data Base to identify patients diagnosed with clinical stage I (cT1-2aN0M0) NSCLC from 2004 to 2014 treated with SBRT. Patients were categorized into LowBED (100-129 Gy) or HighBED (≥130 Gy) groups. A 1:1 matched analysis based on patient and tumor characteristics was used to compare OS by BED₁₀ group. Tumor centrality was not assessed.

RESULTS

O 25,039 patients treated with LowBED (n = 14,756; 59%) or HighBED (n = 10,283; 41%) SBRT, 20,542 were matched. Shifts in HighBED to LowBED SBRT regimen use correlated with key publications in the literature. In the matched cohort, 5-year OS rates were 26% for LowBED and 34% for HighBED groups (p = 0.039). On multivariate analysis, receipt of LowBED was associated with significantly worse survival (hazard ratio = 1.046, 95% confidence interval: 1.004-1.090, p = 0.032).

CONCLUSIONS

LowBED SBRT for treating stage I NSCLC is becoming more common. However, our findings suggest SBRT regimens with BED₁₀ greater than or equal to 130 Gy may confer an additional survival benefit. Additional studies are required to evaluate the dose-response relationship and toxicities associated with modern HighBED SBRT.

Preoperative biopsy and tumor recurrence of stage I adenocarcinoma of the lung

PURPOSE

To evaluate whether preoperative biopsy affects the outcomes of patients undergoing at least lobectomy for stage I lung adenocarcinoma.

METHODS

We reviewed the medical records of patients who underwent surgery for stage I lung adenocarcinoma between 2006 and 2013. Tumor recurrence and survival were compared between patients who underwent preoperative biopsy, including computed tomographic-guided needle biopsy and transbronchial biopsy, and those who underwent intraoperative frozen section.

RESULTS

Among 509 patients, 229 patients (44.9%) underwent preoperative biopsy and 280 patients had lung adenocarcinoma diagnosed by intraoperative frozen section (reference group). Recurrence developed in 65 (12.8%) patients within a median follow-up period of 54.4 months. Multivariate analysis demonstrated that preoperative biopsy (OR 1.97, p = 0.045), radiological solid appearance (OR 5.43, p < 0.001), and angiolymphatic invasion (OR 2.48, p = 0.010) were independent predictors of recurrence. In the overall cohort, preoperative biopsy appeared to worsen 5-year disease-free and overall survival significantly (76.6% vs. 93.0%, p < 0.001; and 83.8% vs. 94.5%, p = 0.002, respectively) compared with the reference group. After propensity matching, multivariable logistic regression still identified preoperative biopsy as an independent predictor of overall recurrence (OR 2.21, p = 0.048) after adjusting for tumor characteristics.

CONCLUSION

Preoperative biopsy might be considered a prognosticator of recurrence of stage I adenocarcinoma of the lungs in patients who undergo at least anatomic lobectomy without postoperative adjuvant chemotherapy.

Effect of Radiation Doses to the Heart on Survival for Stereotactic Ablative Radiotherapy for Early-stage Non-Small-cell Lung Cancer: An Artificial Neural Network Approach

INTRODUCTION

The cardiac radiation dose is an important predictor of cardiac toxicity and overall survival (OS) for patients with locally advanced non-small-cell lung cancer (NSCLC). However, radiation-induced cardiac toxicity among patients with early-stage NSCLC who have undergone stereotactic ablative radiotherapy (SABR) has been less well-characterized. Our objective was to assess the associations between cardiac radiation dosimetry and OS in patients with early-stage NSCLC undergoing SABR.

MATERIALS AND METHODS

From 2009 to 2014, 153 patients with early-stage NSCLC had undergone SABR at a single institution. The maximum dose, mean dose, V_10Gy, V_25Gy, and V_50Gy to 15 cardiac substructures and the whole heart were analyzed for their association with OS using the Kaplan-Meier method. An artificial neural network (ANN) analysis was performed to modulate confounding behaviors of dosimetric variables to predict for OS.

RESULTS

A total of 112 patients were included in the present analysis. The right ventricle (RV) V_10Gy most negatively predicted for OS, such that patients who had received a RV V_10Gy dose < 4% had significantly longer OS than patients who had received a RV V_10Gy does > 4% (5.3 years vs. 2.4 years). On ANN analysis, 74 input features, including cardiac dosimetry parameters, predicted for survival with a test accuracy of 64.7%. A repeat ANN analysis using dosimetry to dose neutral structure confirmed the predictive power of cardiac dosimetry.

CONCLUSION

Cardiac dosimetry to subvolumes of the heart was associated with decreased OS in patients with early-stage NSCLC undergoing SABR. These data support the importance of minimizing the radiation dose to cardiac substructures. Further prioritizing the heart as an organ at risk might be warranted. Additionally, cardiac follow-up should be considered.

A Brief Report on Survival After Robotic Lobectomy for Early-Stage Lung Cancer

INTRODUCTION

Robotic-assisted surgery has become the first choice for several conditions since its introduction in clinical practice in 2000. However, the U.S. Food and Drug Administration has recently raised a warning against the use of robotic surgical approaches for the cure and prevention of cancer following the publication of two studies focused on endometrial cancer. We conducted an internal audit to retrospectively analyze our experience to assess the safety and feasibility of robotic-assisted surgery compared to open surgery.

METHODS

We selected a 5-year period to guarantee at least 2 years of follow-up (2011-2016) and identified 1139 patients who underwent lobectomy for NSCLC in our division. The primary data set analyzed included 544 early-stage clinical N0 patients (348 open and 196 robotic surgeries). We compared 131 patients of each group individually matched, with demographic and clinical characteristics almost identical.

RESULTS

No difference was observed between the cohorts, either in terms of recurrence-free survival (hazard ratio: 1.09; p = 0.55) or overall survival (hazard ratio: 0.86; p = 0.36). The 5-year recurrence of disease risk and overall survival were 24.9% and 83.2%, respectively, in the open group and 24.6% and 86.1%, respectively, in the robotic group.

CONCLUSIONS

These data underline that robotic-assisted lobectomy for early NSCLC is a safe and feasible technique with adequate long-term and progression-free survival compared to open surgery.

Postoperative Recurrence and Survival After Segmentectomy for Clinical Stage 0 or IA Lung Cancer

BACKGROUND

Although radical segmentectomy is an accepted treatment option for small-sized lung cancer, the outcomes remain unclear. The present study aimed to elucidate recurrence patterns and to identify predictors of time to recurrence after intentional segmentectomy for early lung cancer.

PATIENTS AND METHODS

Prospectively collected data of 166 patients who could tolerate lobectomy and underwent intentional segmentectomy for clinical stage 0 or IA non-small-cell lung cancer between 2007 and 2016 were retrospectively analyzed. Surgical indication for intentional segmentectomy was clinical stage 0 or IA ground glass opacity-dominant tumor ≤ 3 cm or solid-dominant tumor ≤ 2 cm on high-resolution computed tomography.

RESULTS

The median follow-up duration was 48.8 months, during which 6 (3.6%) patients developed recurrences. The 5-year recurrence-free survival and 5-year overall survival rates were 93.1% (95% confidence interval [CI], 87.9%-96.1%) and 93.5% (95% CI, 87.7%-96.4%), respectively. Two (1.2%) patients who developed local-only recurrences subsequently underwent completion lobectomy; no cancer-related deaths were seen for these patients. In multivariable analysis, consolidation to maximum tumor diameter (C/T) ratio (hazard ratio, 1.07; 95% CI, 1.01-1.22; P = .02) was an independent predictive factor for time to recurrence. All 6 patients with recurrence had a tumor with a C/T ratio of 86% or higher.

CONCLUSIONS

Based on these findings, favorable survival is expected after intentional segmentectomy for selected patients with clinical stage 0 or IA non-small-cell lung cancer. Patients with a higher C/T ratio tumor appear to be at higher risk of recurrence after intentional segmentectomy.

Non-invasive diagnosis of early-stage lung cancer using high-throughput targeted DNA methylation sequencing of circulating tumor DNA (ctDNA)

Rational: LDCT screening can identify early-stage lung cancers yet introduces excessive false positives and it remains a great challenge to differentiate malignant tumors from benign solitary pulmonary nodules, which calls for better non-invasive diagnostic tools.

Methods: We performed DNA methylation profiling by high throughput DNA bisulfite sequencing in tissue samples (nodule size < 3 cm in diameter) to learn methylation patterns that differentiate cancerous tumors from benign lesions. Then we filtered out methylation patterns exhibiting high background in circulating tumor DNA (ctDNA) and built an assay for plasma sample classification.

Results: We first performed methylation profiling of 230 tissue samples to learn cancer-specific methylation patterns which achieved a sensitivity of 92.7% (88.3% - 97.1%) and a specificity of 92.8% (89.3% - 96.3%). These tissue-derived DNA methylation markers were further filtered using a training set of 66 plasma samples and 9 markers were selected to build a diagnostic prediction model. From an independent validation set of additional 66 plasma samples, this model obtained a sensitivity of 79.5% (63.5% - 90.7%) and a specificity of 85.2% (66.3% - 95.8%) for differentiating patients with malignant tumor (n = 39) from patients with benign lesions (n = 27). Additionally, when tested on gender and age matched asymptomatic normal individuals (n = 118), our model achieved a specificity of 93.2% (89.0% - 98.3%). Specifically, our assay is highly sensitive towards early‐stage lung cancer, with a sensitivity of 75.0% (55.0%-90.0%) in 20 stage Ia lung cancer patients and 85.7% (57.1%-100.0%) in 7 stage Ib lung cancer patients.

Conclusions: We have developed a novel sensitive blood based non‐invasive diagnostic assay for detecting early stage lung cancer as well as differentiating lung cancers from benign pulmonary nodules.

A treatment planning comparison between modulated tri-cobalt-60 teletherapy and linear accelerator-based stereotactic body radiotherapy for central early-stage non-small cell lung cancer

We evaluated the feasibility of planning stereotactic body radiotherapy (SBRT) for large central early-stage non-small cell lung cancer with a tri-cobalt-60 (tri-(60)Co) system equipped with real-time magnetic resonance imaging (MRI) guidance, as compared to linear accelerator (LINAC)-based SBRT. In all, 20 patients with large central early-stage non-small cell lung cancer who were treated between 2010 and 2015 with LINAC-based SBRT were replanned using a tri-(60)Co system for a prescription dose of 50Gy in 4 fractions. Doses to organs at risk were evaluated based on established MD Anderson constraints for central lung SBRT. R100 values were calculated as the total tissue volume receiving 100% of the dose (V100) divided by the planning target volume and compared to assess dose conformity. Dosimetric comparisons between LINAC-based and tri-(60)Co SBRT plans were performed using Student׳s t-test and Wilcoxon Ranks test. Blinded reviews by radiation oncologists were performed to assess the suitability of both plans for clinical delivery. The mean planning target volume was 48.3cc (range: 12.1 to 139.4cc). Of the tri-(60)Co SBRT plans, a mean 97.4% of dosimetric parameters per patient met MD Anderson dose constraints, whereas a mean 98.8% of dosimetric parameters per patient were met with LINAC-based SBRT planning (p = 0.056). R100 values were similar between both plans (1.20 vs 1.21, p = 0.79). Upon blinded review by 4 radiation oncologists, an average of 90% of the tri-(60)Co SBRT plans were considered acceptable for clinical delivery compared with 100% of the corresponding LINAC-based SBRT plans (p = 0.17). SBRT planning using the tri-(60)Co system with built-in MRI is feasible and achieves clinically acceptable plans for most central lung patients, with similar target dose conformity and organ at risk dosimetry. The added benefit of real-time MRI-guided therapy may further optimize tumor targeting while improving normal tissue sparing, which warrants further investigation in a prospective feasibility clinical trial.

Lung cancer screening: the European perspective

European studies have contributed significantly to the understanding of lung cancer screening. Smoking within screening, quality of life, nodule management, minimally invasive treatments, cancer prevention programs, and risk models have been extensively investigated by European groups. Mortality data from European screening studies have not been encouraging so far, but long-term results of the NELSON study are eagerly awaited. Investigations on molecular markers of lung cancer are ongoing in Europe; preliminary results suggest they may become an important screening tool in the future.

Extraction bag lavage cytology during video-assisted thoracoscopic surgery for primary lung cancer

OBJECTIVES

Sample extraction from the thoracic cavity through an intercostal space during video-assisted thoracoscopic surgery can result in cancer cell contamination by tumour crushing and tumour cell extravasation, and may have adverse effects on the surgical outcome. Lavage cytology of the sample extraction bag was investigated to clarify the risk of cancer cell spillage and identify the clinicopathological features associated with susceptibility to cancer cell spillage during extraction.

METHODS

Lavage cytology of the sample extraction bag was investigated in 464 patients with negative pleural lavage cytology who underwent lung resection for primary lung cancer via video-assisted thoracoscopic surgery between January 2010 and December 2012. The surgical procedures, pathological findings and clinical course were evaluated by hospital record review.

RESULTS

The incidence of positive bag lavage cytology (BLC) was 13.6%. Statistically significant factors associated with susceptibility to BLC positivity were tumour size, standardized uptake value of positron emission tomography, pathological features such as pathological N score, pleural invasion, vascular invasion and papillary-predominant adenocarcinoma. Among patients with Stage I lung cancer, the survival rate was significantly lower in the BLC-positive group than in the BLC-negative group.

CONCLUSIONS

BLC positivity can be related to oncological characteristics such as tumour invasiveness and adhesiveness as opposed to tumour size and surgical margin, and may help to determine the prognosis of Stage I lung cancer. The sample extraction bag must be carefully manoeuvred through the intercostal space to prevent cancer cell dissemination to the chest wall or thoracic cavity.