ESMO expert consensus statements on the management of EGFR mutant non-small-cell lung cancer

The European Society for Medical Oncology (ESMO) held a virtual consensus-building process on epidermal growth factor receptor (EGFR)-mutant non-small-cell lung cancer in 2021. The consensus included a multidisciplinary panel of 34 leading experts in the management of lung cancer. The aim of the consensus was to develop recommendations on topics that are not covered in detail in the current ESMO Clinical Practice Guideline and where the available evidence is either limited or conflicting. The main topics identified for discussion were: (i) tissue and biomarkers analyses; (ii) early and locally advanced disease; (iii) metastatic disease and (iv) clinical trial design, patient's perspective and miscellaneous. The expert panel was divided into four working groups to address questions relating to one of the four topics outlined above. Relevant scientific literature was reviewed in advance. Recommendations were developed by the working groups and then presented to the entire panel for further discussion and amendment before voting. This manuscript presents the recommendations developed, including findings from the expert panel discussions, consensus recommendations and a summary of evidence supporting each recommendation.

Predicting immunotherapy outcomes under therapy in patients with advanced NSCLC using dNLR and its early dynamics

BACKGROUND

dNLR at the baseline (B), defined by neutrophils/[leucocytes-neutrophils], correlates with immune-checkpoint inhibitor (ICI) outcomes in advanced non-small-cell lung cancer (aNSCLC). However, dNLR is dynamic under therapy and its longitudinal assessment may provide data predicting efficacy. We sought to examine the impact of dNLR dynamics on ICI efficacy and understand its biological significance.

PATIENTS AND METHODS

aNSCLC patients receiving ICI at 17 EU/US centres were included [Feb/13-Jun/18]. As chemotherapy-only group was evaluated (NCT02105168). dNLR was determined at (B) and at cycle2 (C2) [dNLR≤3 = low]. B+C2 dNLR were combined in one score: good = low (B+C2), poor = high (B+C2), intermediate = other situations. In 57 patients, we prospectively explored the immunophenotype of circulating neutrophils, particularly the CD15+CD244-CD16^lowcells (immature) by flow cytometry.

RESULTS

About 1485 patients treatment with ICI were analysed. In ICI-treated patients, high dNLR (B) (~1/3rd) associated with worse progression-free (PFS)/overall survival (OS) (HR 1.56/HR 2.02, P < 0.0001) but not with chemotherapy alone (N = 173). High dNLR at C2 was associated with worse PFS/OS (HR 1.64/HR 2.15, P < 0.0001). When dNLR at both time points were considered together, those with persistently high dNLR (23%) had poor survival (mOS = 5 months (mo)), compared with high dNLR at one time point (22%; mOS = 9.2mo) and persistently low dNLR (55%; mOS = 18.6mo) (P < 0.0001). The dNLR impact remained significant after PD-L1 adjustment. By cytometry, high rate of immature neutrophils (B) (30/57) correlated with poor PFS/OS (P = 0.04; P = 0.0007), with a 12-week death rate of 49%.

CONCLUSION

The dNLR (B) and its dynamics (C2) under ICI associate with ICI outcomes in aNSCLC. Persistently high dNLR (B+C2) correlated with early ICI failure. Immature neutrophils may be a key subpopulation on ICI resistance.

Genomics of non-small cell lung cancer (NSCLC): Association between CT-based imaging features and EGFR and K-RAS mutations in 122 patients-An external validation

OBJECTIVE

To validate previously identified associations between radiological features and clinical features with Epidermal Growth Factor Receptor (EGFR)/ Kirsten RAt Sarcoma (KRAS) alterations in an independent group of patients with Non-Small Cell Lung Cancer (NSCLC).

MATERIAL AND METHODS

A total of 122 patients with NSCLC tested for EGFR/KRAS alterations were included. Clinical and radiological features were recorded. Univariate analysis were performed to look at the associations of the studied features with EGFR/KRAS alterations. Previously calculated composite model parameters for each gene alteration prediction were applied to this validation cohort. ROC (Receiver Operating Characteristic) curves were drawn using the previously validated composite models, and also for each significant individual characteristic of the previous training cohort model. The Area Under the ROC Curve (AUC) with 95% Confidence Intervals (CI) was calculated and compared between the full models.

RESULTS

At univariate analysis, EGFR+ confirmed an association with an internal air bronchogram, pleural retraction, emphysema and lack of smoking; KRAS+ with round shape, emphysema and smoking. The AUC (95%CI) in the new cohort was confirmed to be high for EGFR+ prediction, with a value of: 0.82 (0.69-0.95) vs. 0.82 in the previous cohort, whereas it was smaller for KRAS+ prediction, with a value of 0.60 (0.48-0.72) vs. 0.67 in the previous cohort. Looking at single features in the new cohort, we found that the AUC for the models including only smoking was similar to that of the full model (including radiological and clinical features) for both gene alterations.

CONCLUSIONS

Although this study validated the significant association of clinical and radiological features with EGFR/KRAS alterations, models based on these composite features are not superior to smoking history alone to predict the mutations.

Validation of a polymerase chain reaction aided transcript titration assay (PATTY) for topoisomerase II in lung cancer samples

This report describes the validation of a polymerase chain reaction aided transcript titration assay (PATTY) for tumor samples. The results obtained with the PATTY were compared to those of RNase protection in a set of 7 human lung cancer cell lines and in 23 non-small cell lung cancer samples derived from resected patients. Whereas between PATTY and RNase protection assay a good correlation was observed in the cell lines (r = 0.74, p = 0.057), no correlation was observed within the tumor samples (r = 0.06, p = 0.78). This was also the case when only tumors with a high percentage of tumor cells (> 90%) were selected. Although PATTY is a valuable tool to measure mRNA expression in cell lines, our results caution the use of PATTY in human tumor samples without proper validation. The possible causes of these results are discussed.

Expression of DNA topoisomerase IIalpha and topoisomerase IIbeta genes predicts survival and response to chemotherapy in patients with small cell lung cancer

Drug resistance is a major problem in patients with small cell lung cancer; in fact, most die of resistant disease, despite an initial response. Several markers of drug resistance have been described in preclinical models, but the mechanism of drug resistance in lung cancer patients remains unknown. The objective of this study was to evaluate the role of the expression of a number of markers of drug resistance, proliferation, and apoptosis in relation to response to chemotherapy and survival in patients with small cell lung cancer. Tumor samples were derived from 93 previously untreated patients who were randomized in a Phase III study to receive cyclophosphamide, epirubicine, and etoposide or cyclophosphamide, epirubicine and vincristine alternating with carboplatin and etoposide. Paraffin-embedded samples, derived from the primary tumor site prior to chemotherapy, were analyzed by immunohistochemistry for expression of markers implicated in drug resistance [topoisomerase (topo) IIalpha, topo IIbeta, and multidrug resistance-associated protein], apoptosis (p53, p21, and bcl-2), or proliferation (Ki67). Response prediction was analyzed by chi2 test and logistic regression analysis; overall and disease-free survival curves were compared by log-rank test and Cox regression analysis. Shorter survival was observed in patients with extensive disease (P = 0.037) and poorer performance status (P = 0.028) and in patients whose tumors expressed high topo IIalpha levels (P = 0.01) and high Ki67 (P = 0.024). By multivariate analysis, the following factors were found to be predictive for worse survival: high expression levels of topo IIalpha, Ki67, and bcl-2; male sex; and extensive disease. High topo IIbeta expression was found to be predictive for lower overall and complete response rate. No relationship between apoptotic pathway markers or MRP and response to chemotherapy was observed. In conclusion, high expression of topo IIalpha was predictive of worse survival, and high expression of topo IIbeta was predictive of lower response rates. Furthermore, lower survival probability was observed in patients with bcl-2-positive tumors. Immunohistochemical assessment of these markers in diagnostic biopsies may give important prognostic information and may help selecting patients in the worse prognostic categories for new therapeutic strategies.

Clinical resistance to topoisomerase-targeted drugs

This review describes topoisomerase (topo)-mediated drug resistance and topo expression in human tissues and cancers. In some in vitro studies a relation has been observed between topo I, IIalpha or IIbeta expression and sensitivity to topo inhibitors. Drug resistance to topo inhibitors may, however, be multifactorial. Several topo inhibitors are substrates for drug membrane transporters. As most topo inhibitors are cell cycle specific, disturbances in cell cycle regulation can also confer resistance, and downstream events following DNA damage induced by topo inhibitors may be involved in regulating cell death or survival. Several studies in patient specimens have shown a relation between topo IIalpha expression and the proliferative state of the tumor, higher topo IIalpha levels being seen in more highly proliferating tumor types. In contrast, topo IIbeta appears to be expressed in both proliferating and quiescent cells. Furthermore, higher topo I levels were observed in some tumors when compared to their normal counterparts. In some studies a reduced topo IIalpha level was seen in samples taken after chemotherapy treatment, as compared with specimens prior to treatment. No unequivocal relation was observed, however, between expression or activity of the topo genes and response to chemotherapy; nonetheless only a few studies have properly addressed this question. This review summarizes the results of the clinical studies performed so far, and analyzes the critical issues in performing studies on patient material.

Determinants of CPT-11 and SN-38 activities in human lung cancer cells

Irinotecan (CPT-11) is a semisynthetic camptothecin derivative with a broad spectrum of anti-tumour activity. Carboxylesterase (CE) catalyses the conversion of CPT-11 to SN-38 (7-ethyl-10-hydroxycamptothecin), the active form of CPT-11. The antiproliferative effects of CPT-11 and SN-38, CE-activity and topoisomerase I protein expression were investigated in five human small-cell lung cancer (SCLC) cell lines and four human non-small-cell lung cancer (NSCLC) cell lines. Antiproliferative activity, expressed as IC50 values, was determined using the MTT assay. CPT-11 was significantly more active in SCLC than in NSCLC cell lines (P = 0.0036), whereas no significant difference between histological types was observed with SN-38. A significant correlation (r2 = 0.52, P = 0.028) was observed between CE activity and chemosensitivity to CPT-11 but not to SN-38, and significantly higher CE activity was observed in SCLC compared with NSCLC cell lines (P = 0.025). Western blotting experiments showed topoisomerase I protein expressions within a factor of 2, and a granular nuclear staining was detectable in all cell lines by immunocytochemistry of cytospins. No correlation was observed between protein expression and sensitivity to CPT-11 or SN-38. Cellular and medium concentrations of CPT-11 and SN-38 were measured by high-performance liquid chromatography (HPLC) in one SCLC cell line with high CE activity and high sensitivity to CPT-11, and one NSCLC cell line with low sensitivity to CPT-11 and CE activity. Intracellular concentrations of CPT-11 and SN-38 were higher in the SCLC cell line, and this was associated with an increase in cellular uptake of CPT-11 compared with the medium, and an increased intracellular formation of SN-38. In conclusion, CE activity appears to be associated with higher sensitivity to CPT-11 in human lung cancer cell lines and may partly explain the difference in the in vitro sensitivity to CPT-11 between SCLC and NSCLC cells. The assessment of CE activity in clinical material of lung cancer patients undergoing treatment with CPT-11 may be warranted. However, other mechanisms may influence sensitivity to CPT-11, possibly including drug transport.

Detection of cytokeratin-19 transcripts by reverse transcriptase-polymerase chain reaction in lung cancer cell lines and blood of lung cancer patients

Conflicting results have been reported on the use of cytokeratin-19 (CK-19) in the detection of tumor cells in the peripheral blood of patients with solid tumors. We investigated the expression of CK-19 in lung cancer cell lines and in human lung tumor samples using a nested reverse transcriptase (RT)-PCR to determine the sensitivity and specificity of this method. In addition, blood samples of lung cancer patients and healthy controls were analyzed for the presence of CK-19 transcripts. Amplification products were visualized by ethidium bromide staining and radioactive hybridization with a CK-19-specific probe. Application of a previously described nested RT-PCR for the detection of CK-19 resulted in amplification of the processed pseudogene. Therefore, a more stringent RT-PCR was developed by increasing the annealing temperature. RT-PCR amplification products for CK-19 were detected in 38 of 41 lung cancer cell lines. The three negative cell lines were all variant small-cell lung cancer cell lines. Concordant results were observed between CK-19 detection by immunohistochemistry and by RT-PCR. In serial RNA dilution experiments, CK-19 transcripts could be detected in 18 to 80 pg of total cellular RNA in three cell lines and in 60 ng total RNA in one cell line. The nested RT-PCR had the sensitivity of detecting 50 tumor cells in 10(6) peripheral blood mononuclear cells (PBMNC), and CK-19 transcripts were randomly detected in normal PBMNC. This study shows the necessity in processing parallel samples without reverse transcriptase enzyme to avoid amplification of pseudogenes. A serious problem in the detection of tissue-specific transcripts in PBMNC is the detection of illegitimate transcription levels. In conclusion, although CK-19 may be a useful marker for the detection of lung cancer cells, its application for the detection of circulating tumor cells is not recommended.

Prognostic value of the expression of p53, bcl-2, and bax oncoproteins, and neovascularization in patients with radically resected non-small-cell lung cancer

PURPOSE

To assess the prognostic value of p53, bcl-2, bax, and neovascularization in radically resected non-small-cell lung cancer (NSCLC) patients.

PATIENTS AND METHODS

Tumors from 116 patients were assessed by immunohistochemistry for expression of p53 (DO7 and PAb1081), bcl-2, and the quantification of microvessel density (CD-31). In addition, the expression of bax was assessed in 61 stage I tumors. The median levels of expression of each marker were used as cutoff points.

RESULTS

p53 was not correlated to any patient or tumor characteristic, whereas bcl-2 showed higher expression in squamous cell carcinomas (P < .001). bax expression was significantly related with male sex (P = .006) and adenocarcinoma type (P = .0013). p53 status, assessed with one monoclonal antibody (MoAb), was not predictive for survival; however, the combination of staining results obtained with two MoAbs identified the DO7-/PAb1801+ tumors as those with the worst prognosis. bcl-2 expression was associated with longer survival in stage I patients (P = .0169). The combined group expressing p53+(PAb1801)/bcl-2- had the worst survival in stage I patients (P = .034) and in the whole series in comparison with the other combinations of the two oncoproteins. bax expression alone had no influence on survival of stage I patients, but patients with bax+/bcl-2- tumors had the worst prognosis (P = .02 in comparison with bax+/bcl-2+). Tumor neovascularization was not related with other factors, and patients with CD-31+ tumors had a shorter survival duration than those with CD-31- tumors only in stage II (P = .0283). By multivariate analysis including all patients, the presence of p53+/ bcl-2- tumor expression and large tumor diameter (> or = 4cm) were independent prognostic factors for shorter survival duration. For stage I, only the presence of bax+/ bcl-2- tumor expression had a significant negative influence on survival.

CONCLUSION

The interaction and the regulation of new biologic markers, such as those involved in the apoptotic pathway, are complex. Combinations of the expression of several of them may give more valuable information than the study of just one. Prognostic influence of p53 staining varied depending on the choice of antibody and the combination of bcl-2- together with p53+ (PAb1801) or with bax+ had the worst influence on survival for patients with stage I NSCLC.

Expression of the human major vault protein LRP in human lung cancer samples and normal lung tissues

BACKGROUND

The recently discovered LRP protein has been shown to be involved in drug resistance and possibly in detoxification processes.

MATERIALS AND METHODS

To study the relation between LRP expression and exposure to cigarette smoke, LRP immunoreactivity was evaluated in 39 paraffin embedded normal lung tissues derived from patients operated on for pneumothorax, and related to amount of pack years smoked. We also studied the LRP protein expression in 36 non-small-cell lung cancer (NSCLC) samples and related the expression to patient characteristics and survival. Furthermore 17 lung tumor samples (10 NSCLC and 7 SCLC) derived from patients treated with chemotherapy were analysed in order to investigate the relation between LRP or MRP expression and the patient's response to chemotherapy.

RESULTS

In the normal lung tissues, LRP intensity levels were not correlated to the amount of pack years smoked, although a trend was seen for higher LRP intensity levels in patients who smoked more than 10 pack years. LRP expression was significantly higher in NSCLC samples than in SCLC samples, and all SCLC samples displayed very low LRP expression. Within NSCLC, squamous cell and adenocarcinomas had higher LRP expression than large cell undifferentiated and mixed tumors. In NSCLC patients LRP expression was not a prognostic factor for survival. At initial analysis LRP expression levels did not predict for the response to chemotherapy. Only 3 out of 17 patients expressed MRP, and all SCLC samples were MRP negative.

CONCLUSIONS

Striking different expression levels were seen between NSCLC and SCLC for both LRP and MRP. In a preliminary analysis LRP expression was not predictive for response to chemotherapy in lung cancer patients. In pneumothorax patients LRP levels were not correlated with the amount of pack years smoked.

MRP is frequently expressed in human lung-cancer cell lines, in non-small-cell lung cancer and in normal lungs

The multidrug resistance-associated protein (MRP), a new membrane transporter related to non-Pgp multidrug resistance, is overexpressed in some drug-selected cancer-cell lines. The role of MRP in unselected cell lines and in human cancer is unknown. MRP gene expression, determined by RNase protection assay and chemosensitivity to doxorubicin, etoposide and cisplatin, determined by MTT assay, were assessed in 18 non-drug-selected lung-cancer cell lines (10 small-cell lung cancer, 6 non-small-cell lung cancer, and 1 carcinoid). MRP gene expression was also investigated in normal lung tissue and primary non-small-cell lung cancer. All cell lines except one and all normal lung tissues and primary non-small-cell lung cancers expressed detectable levels of MRP. Expression was significantly lower in cell lines than in normal and neoplastic lung. MRP protein expression was also assessed by immunohistochemistry using the monoclonal antibody MRPr1; comparable levels of expression were observed between mRNA and protein in cell lines; however, in tumor samples intense staining was observed in tumor cells as well as in infiltrating normal cells in tumors, making the results less comparable to those obtained by RNase expression. MRP expression did not directly correlate with function in a calcein accumulation assay in 2 unselected cell lines. No gene amplification was observed by Southern-blot analysis, in the unselected cell lines or in tumor samples. In general, in cell lines, MRP gene expression was correlated with lower chemosensitivity to doxorubicin and etoposide, but not to cisplatin. However, MRP expression did not directly correlate with MRP function as assessed by a calcein accumulation assay in one of 2 unselected cell lines examined. Our results suggest that MRP may be implicated in drug resistance in unselected lung-cancer cell lines and its role in normal lung and primary lung cancer warrants further investigation in patients undergoing chemotherapy.

Prevalence and characteristics of nutritional depletion in patients with stable COPD eligible for pulmonary rehabilitation

Prevalence and characteristics of nutritional depletion were established by body composition measurements in 255 COPD patients in stable clinical condition admitted to a pulmonary rehabilitation center. Depletion of body weight, fat-free mass (using bioelectrical resistance measurements), and muscle mass [from creatinine height index (CHI) and midarm muscle circumference] was most pronounced (40 to 50%) in patients suffering from chronic hypoxemia and in normoxemic patients with severe airflow obstruction (FEV1 < 35%) but also occurred in +/- 25% of patients with moderate airflow obstruction. Classification of the patients in four groups by body weight and fat-free mass revealed that depletion of fat-free mass may occur in normal-weight COPD patients (Group 3). These patients also exhibit a decreased CHI (61 +/- 21%, mean +/- SD) and suffer from physical impairment (12-min walking distance, WD, 532 +/- 152 m) to an even greater degree than underweight patients with relative preservation of fat-free mass (Group 2) (CHI = 73 +/- 16%; WD = 744 +/- 233 m). No systematic differences were established between the four groups in serum protein concentrations or medication use. We conclude that fat-free mass is a better indicator of body mass depletion than body weight. Classification of COPD patients by body weight and fat-free mass may have consequences for planning and interpretation of intervention strategies, particularly in Group 2 and 3 patients.

Within-day variation of bioelectrical resistance measurements in patients with chronic obstructive pulmonary disease

The relative contribution of a meal, exercise and diuretic therapy to within day variation of resistance values from bioelectrical impedance measurements was studied in several groups of patients with severe Chronic Obstructive Pulmonary Disease (COPD). All patients were in a stable clinical condition. Fasting resistance (RES) in the early morning was significantly higher than RES values during the day ((mean +/- SD): 26 +/- 21 Ohms, p < 0.001). Relative to a non-fasting pre-meal value no significant decrease in RES was measured within 4h after ingestion of the meal. RES did not change significantly after a submaximal exercise challenge on the bicycle ergometer. No consistent effect of oral diuretics (40 mg furosemide), was established within 5h after administration. Measurements on two consecutive days at the same time in the nourished state, were highly reproducible: mean change 4 +/- 20 Ohms, NS). We conclude that in patients with stable COPD, within day variation has only a slight impact on the estimation of fat free mass for between-patient comparison, but it is important to take this into account during follow up studies.