Chemoradiation with Hypofractionated Proton Therapy in Stage II-III Non-Small Cell Lung Cancer: A YYY Phase 1/2 Trial

INTRODUCTION

Hypofractionated radiotherapy has been safely implemented into the treatment of early-stage non-small cell lung cancer (NSCLC), but not locally advanced (LA-) NSCLC due to prohibitive toxicities with photon therapy. Proton therapy, however, may allow for safe delivery of hypofractionated radiotherapy. We sought to determine whether hypofractionated proton therapy with concurrent chemotherapy improves overall survival.

METHODS & MATERIALS

The YYY conducted a phase 1/2 single-arm nonrandomized prospective multicenter trial from 2013 through 2018. Thirty-two patients were consented; 28 were eligible for on-study treatment. Patients had AJCCv7 stage II or III unresectable NSCLC and received hypofractionated proton therapy at 2.5-4 Gy per fraction to a total 60 Gy with concurrent platin-based doublet chemotherapy. The primary outcome was 1-year overall survival comparable to that reported for RTOG 9410 of 62%.

RESULTS

The trial closed early due to slow accrual, in part, from a competing trial, NRG 1308. Median patient age was 70 (range, 50-86) years. Patients were predominantly male (N=20), white (N=23), and prior smokers (N=27). Most had stage III NSCLC (N=22), 50% of whom had adenocarcinoma. After a median follow-up of 31 months, the 1- and 3-year overall survival rates were 89% and 49%, and progression-free survival rates were 58% and 32%, respectively. No acute grade 3 or higher esophagitis occurred. Only 14% developed a grade 3 or higher radiation-related pulmonary toxicity.

CONCLUSION

Hypofractionated proton therapy delivered at 2.5-3.53 Gy per fraction to a total 60 Gy with concurrent chemotherapy provides promising survival and additional examination through larger studies may be warranted.

Association of Systemic Steroid Treatment and Outcome in Patients Treated with Immune Checkpoint Inhibitors: A Real-World Analysis

Background: Immune-related adverse events (irAEs) are inflammatory side effects, which can occur during immune-checkpoint(s) inhibitors (ICIs) therapy. Steroids are the first-line agents to manage irAEs because of their immunosuppressive properties. However, it is still debated whether or when steroids can be administered without abrogating the therapeutic efforts of immunotherapy. Methods: We retrospectively evaluated 146 patients with metastatic non-small cell lung cancer (NSCLC), melanoma and renal cell carcinoma (RCC) treated with ICIs. We assessed the progression-free survival (PFS) of patients treated with steroids due to an irAE compared to a no-steroid group. Results: The early treatment with steroid (within the first 30 days from the beginning of immunotherapy) was not related to a shorter PFS (p = 0.077). Interestingly, patients who were treated with steroids after 30 days from the start of immunotherapy had significantly longer PFS (p = 0.017). In a multivariate analysis, treatment with steroids after 30 days was an independent prognostic factor for PFS (HR: 0.59 [95% CI 0.36–0.97], p = 0.037). Conclusions: This retrospective study points out that early systemic steroids administration to manage irAEs might not have a detrimental effect on patient clinical outcome in NSCLC, melanoma and RCC patients.

Effect of EG00229 on Radiation Resistance of Lung Adenocarcinoma Cells

Background: Neuropilin 1 (NRP1) is a pleiotropic receptor that interacts with multiple ligands and their receptors and plays a critical role in the process of tumor metastasis and radiation resistance in endothelial cells and tumor cells. In this study, we sought to investigate the mechanistic role of NRP1 in the radiation resistance of non-small cell lung cancer (NSCLC) cells and the role of EG00229 (an inhibitor of NRP1) on reversing radiation resistance.

Materials and Methods: A549 and H1299 NSCLC cells were used to construct radiation resistance models. Western blot, ELISA, and qRT-PCR were used to detect protein and mRNA levels of NRP1, epithelial-mesenchymal transition (EMT) markers, and molecules in signaling pathways. Immunofluorescence was used to measure changes in co-expression of NRP1 and VEGF-165 in radiation-resistant model cells. An immunoprecipitation assay was used to detect the binding capacity of NRP1 and VEGF-165.

Results: We successfully created two radiation resistant models (A549RR and H1299-RR). The expression levels of NRP1, EMT-related proteins, and proteins in metastasis-related pathways were increased in NSCLC cells with radiation resistance. After adding EG00229, the expression levels and binding capacity of NRP1 and VEGF-165 proteins were significantly reduced. The expression of EMT-related proteins and proteins in metastasis-related pathways were reduced in NSCLC cells with radiation resistance.

Conclusion: Our data provide an insight into the molecular mechanisms of radiation resistance and suggest that EG00229 may contribute to reversing the radiation resistance of NSCLC cells by inhibiting the binding of NRP1 and VEGF-165. Our findings could provide a novel theoretical and experimental foundation for improving the efficacy of lung cancer radiotherapy.

Non-Small Cell Carcinoma-Not Otherwise Specified on Cytology Specimens in Patients with Solitary Pulmonary Lesion: Primary Lung Cancer or Metastatic Cancer?

Context:

Subtyping of solitary pulmonary lesion (SPL) in small amount of cytology specimen using a limited panel of immunohistochemistry (IHC) markers is very important to the correct choice of treatment. This study was performed to categorize non-small cell carcinoma-not otherwise specified (NSCC-NOS) on cytology in patients with SPL, especially with regard to the incidence of metastatic cancer.

Materials and Methods:

We reviewed 91 cases, in which a precise morphology-based, lineage-specific IHC-aided subtyping was not possible, that qualified as NSCC-NOS on cytology. A stepwise clinical approach and IHC of organ-specific markers was performed on each cell block (CB) to exclude metastasis from extrapulmonary malignancies.

Results:

Of the 91 evaluated cases, 65 (71.4%) were diagnosed as non-small cell lung carcinoma (NSCLC)-NOS, 24 (26.4%) were metastatic cancer, and the remaining 2 (2.2%) had undetermined diagnoses. The most frequent primary tumor site was the colorectum (41.7%), followed by breast (20.8%), kidney (8.3%), and then stomach, duodenum, liver, pancreas, gallbladder, prostate, and skin (4.2% each, 1 of 24). Moreover, we found that 7 of the 24 patients with metastatic cancer had a history of extrapulmonary malignancy that was unknown at the time of cytology-based diagnosis.

Conclusions:

These results underscored the need for accurate and stepwise clinical correlation to rule out the possibility of pulmonary metastasis from other sites and appropriate but judicious IHC (i.e., CDX2) on CB for SPL to increase refinement of the cytology diagnosis of NSCC-NOS.

Prognostic and Predictive Significance of PD-L1 Expression in Non-Small Cell Lung Cancer Patients: A Single-Center Experience

OBJECTIVE

To investigate the prognostic and predictive value of PD-L1 expression in operated non-small cell lung cancer (NSCLC) patients and to analyze its relationship with clinicopathological factors.

MATERIAL AND METHOD

A total of 90 patients with operable NSCLC were included in this retrospective single center study. Tumor blocks of patients were stained immunohistochemically with PD-L1 polyclonal antibody. When evaluated immunohistochemically and statistically, patients with tumor staining percentage of ≥5%, those with +2 and +3 membranous staining intensity, and those with ≥50% H-Score were considered positive. The relationship between PD-L1 expression status and clinicopathological features in addition to the prognostic effect of PD-L1 on survival were statistically analyzed.

RESULTS

The frequency of PD-L1 expression was 37%, 15% and 5% according to the staining percentage, staining intensity, and the H-Score, respectively. There was no significant relationship between PD-L1 expression and age, gender, smoking, tumor stage and histological subtype (p > 0.05). However, PD-L1 expression was relatively higher in patients < 65 years of age, men, smokers, patients with advanced tumor stage, and squamous cell subtype. Based on the analysis of the H-Score, no significant difference was noted regarding disease-free survival time between PD-L1 positive and PD-L1 negative patients (median 20 [95% CI 1.2-38.7] months vs. median 27 [95% CI 17.5-36] months, p=0.208). However, overall survival time was significantly shorter in PD-L1 positive compared to PD-L1 negative patients (median 24 months [95% CI 9.9-38] vs. median 48 months [95% CI 33.6-62.3], p=0.049).

CONCLUSION

In patients with high PD-L1 expression, the biological behavior of the cancer was more aggressive, and the life expectancy was shorter. PD-L1 expression seems to be a poor prognostic marker in NSCLC patients.

Comparative clinical study on microwave ablation combined with gemcitabine and cisplatin or combined with pemetrexed and cisplatin in treatment of advanced NSCLC

OBJECTIVE

Solving the limitations of single chemotherapy in the treatment of non-small cell lung cancer (NSCLC).

METHODS

About 100 patients with NSCLC treated in First Hospital of Jiaxing, Zhejiang from June 2016 to June 2018 were selected and randomly divided into MPC group and MGC group, with 50 cases in each group. The patients in MPC group were treated with microwave ablation (MWA) combined with PC while patients in MGC group were given MWA combined with gemcitabine plus cisplatin (GC). The therapeutic effects of the two groups as well as the complications and adverse reactions (ADRs) were observed and recorded.

RESULTS

There was no significant difference in disease response rate (MPC group 33.3% vs MGC group 32.0%), disease control rate (MPC group 86.4% vs MGC group 78.0%) and overall survival (1-, 2- and 3-year survival, MPC group 65%, 59%, 32.7% vs MGC group 58%, 46%, 30%) between the two groups. In addition, the ADR myelosuppression was slighter in MPC group. There were 12 cases (23%) developed myelosuppression in the MPC group and 20 cases (42%) in MGC group, with a significant difference between the two groups (P < 0.05). The treatment was interrupted for 0 case (0%) in MPC group because of myelosuppression while 4 cases (8.3%) in MGC group.

CONCLUSION

The two therapeutic regimens have similar efficacy in treatment of advanced NSCLC, but MPC causes slighter myelosuppression and can be the first-line therapy for advanced NSCLC.

Feasibility Study of Adjuvant Chemotherapy with Carboplatin and Nab-Paclitaxel for Completely Resected NSCLC

Purpose

Adjuvant chemotherapy with cisplatin (CDDP) plus vinorelbine is the standard regimen for the treatment of non-small cell lung cancer (NSCLC). However, CDDP elicits severe toxic effects, including emesis, neurotoxicity, and renal damage; carboplatin (CBDCA) may be a feasible alternative for CDDP-unfit patients. CBDCA plus paclitaxel (PTX) adjuvant chemotherapy showed a survival benefit for patients with stage IB tumors >4 cm in size, while CBDCA plus nanoparticle albumin-bound (nab)-PTX showed greater efficacy and lower neurotoxicity than CBDCA plus PTX in advanced NSCLC. Here, we investigated the feasibility of using CBDCA plus nab-PTX as adjuvant chemotherapy for NSCLC.

Patients and Methods

Patients with completely resected stage II or III NSCLC, with an Eastern Cooperative Oncology Group performance status of 0–1 and adequate kidney function, received four cycles of postoperative adjuvant chemotherapy with CBDCA (AUC=5 mg/mL/min, on day 1) and nab-PTX (100 mg/m², on days 1, 8, and 15) administered every 4 weeks within 8 weeks after surgery. The study was designed as a prospective, single-center, Phase II study. The primary endpoint was the completion rate of chemotherapy; secondary endpoints were two-year relapse-free survival (RFS) and safety. The expected completion rate was 80%, with a 50% lower limit.

Results

Of 21 enrolled patients, 18 (85.7%) were CDDP-unfit owing to age (≥75 years old [n=11, 52.4%]) or mild renal impairment (n=7, 33.3%). Nineteen of the 21 enrolled patients were assigned to the intervention. The most common grade 3 or 4 adverse events were neutropenia (n=15, 78.9%) and anemia (n=3, 15.8%). The completion rate for the four cycles was 63.2% (95% CI, 38.4–83.7). Two-year RFS was 56.8% (95% CI, 29.7–76.9).

Conclusion

The completion rate for CBDCA plus nab-PTX as adjuvant chemotherapy for CDDP-unfit NSCLC patients did not reach treatment feasibility. Further dose modifications may be required in future studies.

The Prognostic Role of MET Protein Expression Among Surgically Resected Non-small Cell Lung Cancer Patients: A Meta-Analysis

Objectives: MET protein expression has been reported to be in relevance with the survival of NSCLC patients in various studies, yet the results were inconsistent. The purpose of our study set out to determine the prognostic role of both c-MET and p-MET expression among NSCLC that underwent surgical resection.

Methods: Data were obtained from retrospective cohort studies by searching on PubMed, Cochrane Library, EMBASE and Web of Science, and a meta-analysis was performed to assess the prognostic role of MET expression among NSCLC.

Results: Totally 18 literatures including 5,572 surgically resected NSCLC cases staged I-IV were included for data synthesis. The positive rate of c-MET and p-MET was 1,753/4,315 and 135/1,257. The pooled hazard ratios (HRs) regarding c-MET and p-MET expression for overall survival (OS) was 1.623 (95% CI: 1.176–2.240, p = 0.003) and 1.710 (95% CI: 0.823–3.533, p = 0.15), respectively. Subgroup analysis results on Asian (HR = 2.115, p < 0.001), adenocarcinoma (HR = 2.220, p < 0.001) and rabbit polyclonal antibodies (HR = 2.107, p < 0.001) etc. were also indicative.

Conclusion: C-MET over-expression among NSCLC patients that underwent surgical resection is a prognostic factor that indicated adverse survival on OS. Whereas, p-met didn't appear to have an impact on the prognosis of NSCLC. The studies are need and the topic could be re-valued by then.

Gender Differences in the Recurrence Timing of Patients Undergoing Resection for Non-Small Cell Lung Cancer

Objective:

This study was designed to visually represent postoperative recurrence patterns using event dynamics and to assess sex-based differences in the timing of recurrence for non-small cell lung cancer.

Methods:

We studied 829 patients (538 men, 291 women) with NSCLC who underwent complete pulmonary resection in 9 hospitals. Event dynamics with the use of life-table methods were evaluated, and only first events (distant metastases or local recurrence) were considered. The effects of sex, histological type, pathological stage, and smoking history were studied.

Result:

The resulting smoothed hazard rate curves indicated that the recurrence risk pattern definitely correlated with sex, with a sharp peak in the first year in men and a broad peak during the first 2 to 3 years in women. These findings were also confirmed by analyses according to pathological stage, histological type, and smoking history.

Conclusion:

The peak times of recurrence differed considerably between men and women. The delayed time of peak recurrence in women, associated with a longer disease-free interval within subsets of patients with similar disease stage, histological type, and smoking status, might account for the better survival in women.