Small Cell Lung Cancer in Norway: Patterns of Care by Health Region and Survival Trends

INTRODUCTION/BACKGROUND

There has been a marked survival improvement for patients with non-small-cell lung cancer. We describe the national trends in characteristics and survival, and geographical differences in diagnostic workup, treatment, and survival for patients with small-cell lung cancer (SCLC).

MATERIALS AND METHODS

Patients registered with SCLC at the Cancer Registry of Norway in 2002 to 2022 were included. Trends in overall survival were estimated for all SCLC patients, patients with limited stage SCLC, patients undergoing surgery, and by health region. Adjusting for case-mix, a multivariable Cox regression was performed examining the association between health region and death.

RESULTS

The study included 8374 patients. The stage distribution remained unchanged during the study period. The 5-year overall survival increased from 7.7% to 22.8% for patients with limited stage. The use of multidisciplinary team meetings varied from 62.5% to 85.7%, and the use of positron emission tomography-computer tomography varied from 70.4% to 86.2% between the health regions. Treatment patterns differed markedly between the health regions, with the proportion dying without any registered treatment ranging from 1.2% to 10.9%. For limited stage patients in 2018 to 2022, the median overall survival ranged from 16.5 to 25.5 months across health regions, and the 5-year overall survival ranged from 18.7% to 28.7% (P = .019).

CONCLUSION

The survival for patients with SCLC remains poor. The use of diagnostic procedures, treatment modalities, and survival differed between regions, warranting investigations to further explore the reasons.

Distribution and characteristics of malignant tumours by lung lobe

BACKGROUND

The main focus on the characteristics of malignant lung tumours has been the size, position within the lobe, and infiltration into neighbouring structures. The aim of this study was to investigate the distribution and characteristics of malignant tumours between the lung lobes and whether the diagnosis, treatment, and outcome differed based on location.

METHODS

This study is based on 10,849 lung cancer patients diagnosed in 2018-2022 with complete data on the location and characteristics of the tumours. The proportions of tumours in each lobe divided by its volume were termed the relative proportion.

RESULTS

The right upper lobe comprised 31.2% of the tumours and 17.6% of the lung volume. The relative proportion of 1.77 was higher than in the other lobes (p < 0.001). The right middle lobe had a relative proportion of 0.64 but the highest proportion of neuroendocrine tumours (26.1% vs. 15.3 on average). Surgical resection was more often performed in patients with tumours in the lower lobes, and curative radiotherapy was more often performed in the upper lobes. After adjusting for age, sex, stage, and histology, the location of the tumour was found to be a significant independent predictor for resection but not for survival.

CONCLUSION

The main finding of the right upper lobe as a site of predilection for lung cancer is similar to tuberculosis and pneumoconiosis. This may be explained that most of the inhaled air, containing bacilli, inorganic particles or tobacco smoke goes to the upper and right parts of the lung.

Tracheal cancer: a rare and deadly but potentially curable disease that also affects younger people

OBJECTIVES

The incidence of tracheal cancer is low, few clinicians get much experience and the awareness may be low. Recent data on the treatment and outcome are limited. The aim of the present study was to present updated, national data on the incidence, characteristics, treatment and outcome for patients with tracheal cancer.

METHODS

All tracheal cancers registered at the Cancer Registry of Norway in 2000-2020 were extracted. The patient and tumour characteristics age, sex, stage, histology and treatment modality (surgery and radiotherapy) were examined. Overall, median and relative survival were estimated. Cox regression models were used to identify independent prognostic factors.

RESULTS

The 77 patients diagnosed with tracheal cancer equals a crude incidence rate and an age-standardized incidence rate of 0.075 and 0.046 per 100,000 per year respectively. The mean age was 63.8 years (range: 26-94). The numerical preponderance of men (n = 41) is not statistically significant. Eighteen patients (23.4%) were diagnosed in the localized stage. The 5-year overall survival was 31.7% [95% confidence interval (CI): 21.0-42.9], and in those treated with surgical resection or curative radiotherapy, it was 53.7% (95% CI: 26.1-75.0) and 37.8% (95% CI: 18.8-56.7), respectively. Age, histological type and treatment modality were identified as independent prognostic factors.

CONCLUSIONS

Despite improved survival, the prognosis for patients with tracheal cancer is still poor. Few are diagnosed in the early stage and thus most are not eligible for curative treatment, mainly surgery. An increased awareness and diagnosis in the earlier stage is crucial.

Whole genome copy number analyses reveal a highly aberrant genome in TP53 mutant lung adenocarcinoma tumors

BACKGROUND

Genetic alterations are common in non-small cell lung cancer (NSCLC), and DNA mutations and translocations are targets for therapy. Copy number aberrations occur frequently in NSCLC tumors and may influence gene expression and further alter signaling pathways. In this study we aimed to characterize the genomic architecture of NSCLC tumors and to identify genomic differences between tumors stratified by histology and mutation status. Furthermore, we sought to integrate DNA copy number data with mRNA expression to find genes with expression putatively regulated by copy number aberrations and the oncogenic pathways associated with these affected genes.

METHODS

Copy number data were obtained from 190 resected early-stage NSCLC tumors and gene expression data were available from 113 of the adenocarcinomas. Clinical and histopathological data were known, and EGFR-, KRAS- and TP53 mutation status was determined. Allele-specific copy number profiles were calculated using ASCAT, and regional copy number aberration were subsequently obtained and analyzed jointly with the gene expression data.

RESULTS

The NSCLC tumors tissue displayed overall complex DNA copy number profiles with numerous recurrent aberrations. Despite histological differences, tissue samples from squamous cell carcinomas and adenocarcinomas had remarkably similar copy number patterns. The TP53-mutated lung adenocarcinomas displayed a highly aberrant genome, with significantly altered copy number profiles including gains, losses and focal complex events. The EGFR-mutant lung adenocarcinomas had specific arm-wise aberrations particularly at chromosome7p and 9q. A large number of genes displayed correlation between copy number and expression level, and the PI(3)K-mTOR pathway was highly enriched for such genes.

CONCLUSIONS

The genomic architecture in NSCLC tumors is complex, and particularly TP53-mutated lung adenocarcinomas displayed highly aberrant copy number profiles. We suggest to always include TP53-mutation status when studying copy number aberrations in NSCLC tumors. Copy number may further impact gene expression and alter cellular signaling pathways.

Protein Kinase C Isozymes Associated With Relapse Free Survival in Non-Small Cell Lung Cancer Patients

INTRODUCTION

Protein expression is deregulated in cancer, and the proteomic changes observed in lung cancer may be a consequence of mutations in essential genes. The purpose of this study was to identify protein expression associated with prognosis in lung cancers stratified by smoking status, molecular subtypes, and EGFR-, TP53-, and KRAS-mutations.

METHODS

We performed profiling of 295 cancer-relevant phosphorylated and non-phosphorylated proteins, using reverse phase protein arrays. Biopsies from 80 patients with operable lung adenocarcinomas were analyzed for protein expression and association with relapse free survival (RFS) were studied.

RESULTS

Spearman's rank correlation analysis identified 46 proteins with significant association to RFS (p<0.05). High expression of protein kinase C (PKC)-α and the phosporylated state of PKC-α, PKC-β, and PKC-δ, showed the strongest positive correlation to RFS, especially in the wild type samples. This was confirmed in gene expression data from 172 samples. Based on protein expression, unsupervised hierarchical clustering separated the samples into four subclusters enriched with the molecular subtypes terminal respiratory unit (TRU), proximal proliferative (PP), and proximal inflammatory (PI) (p=0.0001). Subcluster 2 contained a smaller cluster (2a) enriched with samples of the subtype PP, low expression of the PKC isozymes, and associated with poor RFS (p=0.003) compared to the other samples. Low expression of the PKC isozymes in the subtype PP and a reduced relapse free survival was confirmed with The Cancer Genome Atlas (TCGA) lung adenocarcinoma (LUAD) samples.

CONCLUSION

This study identified different proteins associated with RFS depending on molecular subtype, smoking- and mutational-status, with PKC-α, PKC-β, and PKC-δ showing the strongest correlation.

Identification of microRNAs involved in pathways which characterize the expression subtypes of NSCLC

Dysregulation of microRNAs is a common mechanism in the development of lung cancer, but the relationship between microRNAs and expression subtypes in non‐small‐cell lung cancer (NSCLC) is poorly explored. Here, we analyzed microRNA expression from 241 NSCLC samples and correlated this with the expression subtypes of adenocarcinomas (AD) and squamous cell carcinomas (SCC) to identify microRNAs specific for each subtype. Gene set variation analysis and the hallmark gene set were utilized to calculate gene set scores specific for each sample, and these were further correlated with the expression of the subtype‐specific microRNAs. In ADs, we identified nine aberrantly regulated microRNAs in the terminal respiratory unit (TRU), three in the proximal inflammatory (PI), and nine in the proximal proliferative subtype (PP). In SCCs, 1, 5, 5, and 9 microRNAs were significantly dysregulated in the basal, primitive, classical, and secretory subtypes, respectively. The subtype‐specific microRNAs were highly correlated to specific gene sets, and a distinct pattern of biological processes with high immune activity for the AD PI and SCC secretory subtypes, and upregulation of cell cycle‐related processes in AD PP, SCC primitive, and SCC classical subtypes were found. Several in silico predicted targets within the gene sets were identified for the subtype‐specific microRNAs, underpinning the findings. The results were significantly validated in the LUAD (n = 492) and LUSC (n = 380) TCGA dataset (False discovery rates‐corrected P‐value < 0.05). Our study provides novel insight into how expression subtypes determined with discrete biological processes may be regulated by subtype‐specific microRNAs. These results may have importance for the development of combinatory therapeutic strategies for lung cancer patients.

Increase in curative treatment and survival of lung cancer in Norway 2001-2016

We have studied the alterations in the use of curative treatment and the outcome for lung cancer patients in Norway 2001-2016. The Cancer Registry of Norway has a practically complete registration of all cancer diagnoses, treatments given and deaths. For the years 2001-2016, 43,137 patients were diagnosed with lung cancer. Stereotactic radiotherapy was established nationwide from 2008 and its use has increased, and in 2016, 8.8% were given this treatment. In addition 20.6% were operated and 8.5% were treated with conventional radiotherapy. Thus 37.9% of those diagnosed were treated with intention to cure, compared to 22.9% in 2001 (p < 0.0001). Further, the median survival for the whole group diagnosed with lung cancer increased from 6.0 (95% CI 5.6-6.7) months in 2001 to 11.8 (95% CI 10.9-12.7) in 2016. The 5 year survival increased from 9.4 (95% CI 8.1-10.8)% to 19.9 (95% CI 19.2-20.6)% in the same period. In 2016 the age adjusted incidence rate was 59.5 per 100,000 (Norwegian standard) and had increased significantly in both sexes. There had also been an increase in mean age at diagnosis and the proportion diagnosed in an early stage. The increase in curative treatment has been paralleled with a doubling in both the median and 5-year survival. The present results are used for surveillance and as a benchmark, and we are looking forward to reaching a proportion of 40% of patients given curative treatment.

The immune microenvironment in non-small cell lung cancer is predictive of prognosis after surgery

The impact of the tumor immune microenvironment on overall survival in non‐small cell lung cancer (NSCLC) has been studied, but there is little information on its relevance for risk of relapse after surgery. Understanding more about the immune microenvironment in previously untreated NSCLC could help in identifying high‐risk patients and patients more likely to benefit from neoadjuvant/adjuvant immunotherapy. Here, we examined gene expression in 399 surgically derived NSCLC samples and 47 samples from normal lung, using Agilent microarray and RNA sequencing. In 335 of the tumor samples, programmed death‐ligand 1 (PD‐L1) expression was evaluated by immunohistochemistry. Gene expression was used to estimate content of immune cells and to calculate an immune score. Properties of the immune microenvironment, and its impact on prognosis, were compared in histological subgroups and gene expression subtypes. Tumors with an active immune microenvironment were found for both adenocarcinomas (AD) and squamous cell carcinomas (SCC). In AD, high immune score and high estimates of several immune cell types belonging to the adaptive immune system were associated with better progression‐free survival (PFS), while in SCC, no association between immune characteristics and PFS was found. The immune microenvironment, including PD‐L1 expression, and its impact on prognosis showed clear differences in AD and SCC gene expression subtypes. In conclusion, the NSCLC immune microenvironment is predictive of prognosis after surgery. Lung AD and SCC gene expression subtypes should be investigated as potential prognostic biomarkers in patients treated with immune checkpoint inhibitors.

Growth rates of pulmonary metastases after liver transplantation for unresectable colorectal liver metastases

Background

The previously reported SECA study demonstrated a dramatic 5-year survival improvement in patients with unresectable colorectal liver metastases (CLM) treated with liver transplantation (LT) compared with chemotherapy. The objective of this study was to assess whether immunosuppressive therapy accelerates the growth of pulmonary metastases in patients transplanted for unresectable CLM.

Methods

Chest CT scans from 11 patients in the SECA study resected for 18 pulmonary metastases were reviewed retrospectively. Tumour diameter, volume and CT characteristics were registered and tumour volume doubling time was calculated. Findings in the SECA group were compared with those of a control group consisting of 12 patients with non-transplanted rectal cancer resected for 26 pulmonary metastases. Disease-free survival (DFS) and overall survival (OS) after first pulmonary resection were determined.

Results

Median doubling time based on tumour diameter and volume in the SECA and control groups were 125 and 130 days (P = 0·658) and 110 and 129 days (P = 0·632) respectively. The metastases in both groups were distributed to all lung lobes and were mostly peripheral. Median DFS after LT in the SECA group and after primary pelvic surgery in the control group was 17 (range 6–42) and 18 (2–57) months respectively (P = 0·532). In the SECA group, estimated 5-year DFS and OS rates after first pulmonary resection were 39 and 51 per cent respectively.

Conclusion

Patients treated by LT for unresectable CLM have a good prognosis following resection of pulmonary metastases. Doubling time did not appear to be worse with the immunosuppression used after LT.

Abstract 3432: microRNA expression reflects site specificity of metastatic colorectal cancer

Colorectal Cancer (CRC) is one of the leading causes of cancer related deaths in the western world, and metastatic progression is the dominating cause of mortality. The primary site of CRC metastasis is the liver, followed by the lungs and peritoneal cavity, and prognosis for patients with metastatic CRC (mCRC) is poor, with only 10 % five-year survival. Although much is known about progression and metastasis of CRC; how primary CRC (pCRC) differs from mCRC on the molecular level and potential differences between metastases located in different organs are incompletely understood. This is important for our understanding of the disease, but also could have significant implications with respect to treatment. MicroRNAs have been shown to be key elements in cancer progression, but recent reports on CRC failed to consistently identify microRNA signatures of metastatic progression. We have addressed this using a smallRNA sequencing approach to analyze primary tumors and a set of liver, lung and peritoneal metastases, including corresponding adjacent tissue (colon, liver, lung, peritoneum). Further, we use the highly curated and updated microRNA reference MirGeneDB.org, the novel pipeline MirAthon - including a correction-algorithm of benign tissue microRNA signatures for tumor or metastatic samples, and we compare pCRC and site specific metastases separately. We are able to show that microRNA profiles of mCRC are distinct to pCRC in a site-specific manner. We identify a small panel of differentially expressed microRNAs including isoforms (isomiRs) hidden under a layer of benign signatures that we confirmed in other available datasets, too. Our findings will help better understand metastatic progression and site-specificity in CRC and could be potential biomarkers for mCRC.

Our work identifies microRNA signatures of mCRC and suggest that microRNA signatures reflect mCRC site specificity. Furthermore, the results underline the importance of using a curated reference for microRNA studies, and to differentiate metastases based on their localization ab initio.

Citation Format: Bastian Fromm, Eirik Høye, Diana Domanska, Christin Lund-Andersen, Annette Torgrund Kristensen, Vegar J. Dagenborg, Paul H. Boettger, Torveig W. Abrahamsen, Steinar Solberg, Stein G. Larsen, Bjørn Edwin, Eivind Hovig, Susanne Lorenz, Kjersti Flatmark. microRNA expression reflects site specificity of metastatic colorectal cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 3432. doi:10.1158/1538-7445.AM2017-3432

Gender-specific survival after surgical resection for early stage non-small cell lung cancer

BACKGROUND

Lung cancer is the leading cause of cancer death worldwide. The incidence and mortality rate of lung cancer in women has increased. Studies have indicated that females with non-small cell lung cancer (NSCLC) have better survival than males. We aimed to examine the impact of gender on 1-, 5- and 10-year survival after surgery for stage I and II NSCLC.

MATERIALS AND METHODS

During the period 2003-2013, 692 patients operated for stage I and II NSCLC were prospectively registered. Patients were stratified into four groups according to gender and age over or less than 66 years. The relationship between gender and age on overall survival was investigated. Adjustment for multiple confounders was performed using the Cox proportional hazard regression model.

RESULTS

Surgical resection was performed in 368 (53.2%) males and 324 (46.8%) females. During the study period, mortality was 35.2% in younger females, 34.9% in younger males, 42.8% in older females and 51.2% in older males. Stratified by age, there were no significant gender differences with regard to survival [hazard ratio (HR) 1.16, 95% confidence interval (CI) 0.91-1.46, p = .23]. Comparing the younger and the older patients adjusted for confounders, the mortality risk was significantly increased in elderly patients [females, adjusted HR 1.60, 95% CI 1.12-2.28]. Compared with population data, standardized mortality ratio was increased to 4.1 (95% CI 3.5-4.7) in males and to 6.5 (95% CI 5.4-7.6) in females.

CONCLUSION

Overall survival did not differ significantly between males and females. Adjusted for confounding factors, we found a significantly increased mortality risk in elder patients compared to their younger counterparts. However, five-year overall survival of more than 50% for older patients with NSCLC should encourage surgical treatment also in elderly lung cancer patients.

Effects on the ATP Content of Cultured Cells after Radiographic Contrast Media Exposure

The ATP content of cultured cells after exposure to meglumine-calcium metrizoate, sodium metrizoate, iohexol, iopamidol and saline was studied. Initially, the ATP content diminished rapidly for a short period and thereafter slowly during the incubation. After incubation with contrast media or saline, the ATP content slowly increased to normal when the cells were reincubated with fresh nutrient medium. Different contrast media and saline with the same final osmolality produced a similar effect on the ATP content of the cultured cells. Cellular association of meglumine-sodium diatrizoate, sodium metrizoate, sodium-iothalamate, iohexol and iopamidol was also examined. The established cell line NHIK 3025 as well as primary cultures of human umbilical endothelium were found to accumulate contrast media in a time-and concentration-dependent manner. When the incubation was carried out at 4°C, the cellular accumulation of contrast medium was less than 35 per cent of that seen at 37°C. It therefore seems that energy-dependent processes are involved to some degree.

Detection of disseminated tumor cells in lymph nodes from patients with early stage non-small cell lung cancer

BACKGROUND

The regional lymph node involvement is a major prognostic factor in patients with non-small cell lung cancer (NSCLC) undergoing surgical resection. Disease relapse is common, suggesting that early disseminated disease is already present in the regional lymph nodes at the time of surgery, and that the current nodal staging classification might be suboptimal. Early detection of disseminated tumor cells (DTCs) in lymph nodes could potentially enable identification of subcategories of patients with high risk of disease relapse.

METHOD

Lymph node samples were collected from 128 NSCLC patients at the time of surgery and the presence of DTCs determined by immunomagnetic selection (IMS) using the MOC31 antibody recognizing EpCAM. Results obtained with IMS were compared to the pathological staging obtained by histopathology. Associations between the presence of DTCs and clinicopathological variables and patient outcome were investigated.

RESULTS

DTCs were detected in 40 % of the lymph node samples by IMS. Their presence was significantly associated with pN status as assessed by histopathology, and samples from 83 % of the patients with lymph node metastases (pN1-2) had detectable DTCs. In the group of patients who were negative for lymph node metastases by standard histopathology (pN0) DTCs were detected in 32 %. The presence of DTCs was not associated with any other clinicopathological variables. Patients with IMS-positive samples showed decreased relapse free survival compared to patients with IMS-negative samples, but the difference was not statistically significant. The pN status was significantly associated with both relapse free and overall survival, but the presence of DTCs had no prognostic impact in the subcategory of patients with pN0 status.

CONCLUSION

Our findings do not support further development of lymph node DTC detection for clinical use in early stage NSCLC.

Survival After Surgical Resection for Lung Cancer in Patients With Chronic Obstructive Pulmonary Disease

BACKGROUND

The best curable therapy for lung cancer is surgical resection. Chronic obstructive pulmonary disease (COPD) may influence survival, and lung function is crucial in the preoperative assessment. We hypothesized that COPD would influence survival after lung cancer resection.

METHODS

During the period 2003 to 2013, 688 patients were operated on for stage I and II non-small cell lung cancer and prospectively registered. Spirometry was performed, and COPD categorized according to the definition by the Global Initiative for Chronic Obstructive Lung Disease. An explanatory strategy was used to investigate the relationship between severe COPD and survival.

RESULTS

COPD was present in 455 patients (66.1%) and was severe in 51 (7.4%) and mild to moderate in 404 (58.7%), whereas 233 patients (33.9%) had normal lung function. Cumulative survival was similar in patients with normal lung function and patients with mild to moderate COPD. Patients with severe COPD had significantly reduced cumulative survival after 2 and 5 years of 63.5% (95% confidence interval [CI], 48.4% to 75.2%) and 41.8% (95% CI, 26.5% to 56.3%), respectively, compared with nonsevere COPD at 81.7% (95% CI, 77.4% to 85.2%) and 61.3% (95% CI, 55.3% to 66.6%), respectively. Severe COPD was associated with a 69% increased risk of mortality (adjusted hazard ratio, 1.69; 95% CI, 1.12 to 2.55).

CONCLUSIONS

With careful preoperative selection, surgical resection may safely be offered to lung cancer patients with severe COPD. However, these patients have decreased long-term overall survival. Similar survival between patients with normal lung function and mild to moderate COPD suggests that similar indications for lung cancer operations may be applied.

The MYCN-HMGA2-CDKN2A pathway in non-small cell lung carcinoma--differences in histological subtypes

Background

Extensive research has increased our understanding of the molecular alterations needed for non-small cell lung cancer (NSCLC) development. Deregulation of a pathway including MYCN, HMGA2 and CDKN2A, with the participation of DICER1, is of importance in several solid tumours, and may also be of significance in the pathogenesis of NSCLC.

Methods

Gene expression of MYCN, HMGA2, CDKN2A and DICER1 were investigated with RT-qPCR in surgically resected NSCLC tumour tissue from 175 patients. Expression of the let-7 microRNA family was performed in 78 adenocarcinomas and 16 matching normal lung tissue samples using microarrays. The protein levels of HMGA2 were determined by immunohistochemistry in 156 tumour samples and the protein expression was correlated with gene expression. Associations between clinical data, including time to recurrence, and expression of mRNA, protein and microRNAs were analysed.

Results

Compared to adenocarcinomas, squamous cell carcinomas had a median 5-fold increase in mRNA expression of HMGA2 (p = 0.003). A positive correlation (r = 0.513, p < 0.010) between HMGA2 mRNA expression and HMGA2 protein expression was seen. At the protein level, 90 % of the squamous cell carcinomas expressed high levels of the HMGA2 protein compared to 47 % of the adenocarcinomas (p < 0.0001). MYCN was positively correlated with HMGA2 (p < 0.010) and DICER1 mRNA expression (p < 0.010), and the expression of the let-7 microRNAs seemed to be correlated with the genes studied. MYCN expression was associated with time to recurrence in multivariate survival analyses (p = 0.020).

Conclusions

A significant difference in HMGA2 mRNA expression between the histological subtypes of NSCLC was seen with a higher expression in the squamous cell carcinomas. This was also found at the protein level, and we found a good correlation between the mRNA and the protein expression of HMGA2. Moreover, the expression of MYCN, HMGA2, and DICER1 seems to be correlated to each other and the expression of the let7-genes impacted by their expression. MYCN gene expression seems to be of importance in time to recurrence in this patient cohort with resected NSCLC.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-016-2104-9) contains supplementary material, which is available to authorized users.

Genome-wide DNA methylation analyses in lung adenocarcinomas: Association with EGFR, KRAS and TP53 mutation status, gene expression and prognosis

BACKGROUND

DNA methylation alterations are early events in tumorigenesis and important in the regulation of gene expression in cancer cells. Lung cancer patients have in general a poor prognosis, and a deeper insight into the epigenetic landscape in lung adenocarcinoma tumors and its prognostic implications is needed.

RESULTS

We determined whole-genome DNA methylation profiles of 164 fresh frozen lung adenocarcinoma samples and 19 samples of matched normal lung tissue using the Illumina Infinium 450K array. A large number of differentially methylated CpGs in lung adenocarcinoma tissue were identified, and specific methylation profiles were observed in tumors with mutations in the EGFR-, KRAS- or TP53 genes and according to the patients' smoking status. The methylation levels were correlated with gene expression and both positive and negative correlations were seen. Methylation profiles of the tumor samples identified subtypes of tumors with distinct prognosis, including one subtype enriched for TP53 mutant tumors. A prognostic index based on the methylation levels of 33 CpGs was established, and was significantly associated with prognosis in the univariate analysis using an independent cohort of lung adenocarcinoma patients from The Cancer Genome Atlas project. CpGs in the HOX B and HOX C gene clusters were represented in the prognostic signature.

CONCLUSIONS

Methylation differences mirror biologically important features in the etiology of lung adenocarcinomas and influence prognosis.

Strategies for clinical implementation of TNM-Immunoscore in resected nonsmall-cell lung cancer

Immunoscore is a prognostic tool defined to quantify in situ immune cell infiltrates and appears highly promising as a supplement to the tumor-node-metastasis (TNM) classification of various tumors. In colorectal cancer, an international task force has initiated prospective multicenter studies aiming to implement TNM-Immunoscore (TNM-I) in a routine clinical setting. In breast cancer, recommendations for the evaluation of tumor-infiltrating lymphocytes (TILs) have been proposed by an international working group. Regardless of promising results, there are potential obstacles related to implementing TNM-I into the clinic. Diverse methods may be needed for different malignancies and even within each cancer entity. Nevertheless, a uniform approach across malignancies would be advantageous. In nonsmall-cell lung cancer (NSCLC), there are several previous reports indicating an apparent prognostic importance of TILs, but studies on TILs in a TNM-I setting are sparse and no general recommendations are made. However, recently published data is promising, evoking a realistic hope of a clinical useful NSCLC TNM-I. This review will focus on the TNM-I potential in NSCLC and propose strategies for clinical implementation of a TNM-I in resected NSCLC.

Modelling atmospheric oxidation of 2-aminoethanol (MEA) emitted from post-combustion capture using WRF-Chem

Carbon capture and storage (CCS) is a technological solution that can reduce the amount of carbon dioxide (CO2) emissions from the use of fossil fuel in power plants and other industries. A leading method today is amine based post-combustion capture, in which 2-aminoethanol (MEA) is one of the most studied absorption solvents. In this process, amines are released to the atmosphere through evaporation and entrainment from the CO2 absorber column. Modelling is a key instrument for simulating the atmospheric dispersion and chemical transformation of MEA, and for projections of ground-level air concentrations and deposition rates. In this study, the Weather Research and Forecasting model inline coupled with chemistry, WRF-Chem, was applied to quantify the impact of using a comprehensive MEA photo-oxidation sequence compared to using a simplified MEA scheme. Main discrepancies were found for iminoethanol (roughly doubled in the detailed scheme) and 2-nitro aminoethanol, short MEA-nitramine (reduced by factor of two in the detailed scheme). The study indicates that MEA emissions from a full-scale capture plant can modify regional background levels of isocyanic acid. Predicted atmospheric concentrations of isocyanic acid were however below the limit value of 1 ppbv for ambient exposure. The dependence of the formation of hazardous compounds in the OH-initiated oxidation of MEA on ambient level of nitrogen oxides (NOx) was studied in a scenario without NOx emissions from a refinery area in the vicinity of the capture plant. Hourly MEA-nitramine peak concentrations higher than 40 pg m(-3) did only occur when NOx mixing ratios were above 2 ppbv. Therefore, the spatial variability and temporal variability of levels of OH and NOx need to be taken into account in the health risk assessment. The health risk due to direct emissions of nitrosamines and nitramines from full-scale CO2 capture should be investigated in future studies.

Trajectories of Symptom Occurrence and Severity From Before Through Five Months After Lung Cancer Surgery

CONTEXT

Limited information is available about lung cancer patients' symptoms in the pre- and postoperative periods.

OBJECTIVES

Study purposes were to evaluate for changes in symptom occurrence and severity from the preoperative period to five months after surgery and to evaluate for predictors of the occurrence and trajectories of these symptoms.

METHODS

Patients completed the Memorial Symptom Assessment Scale before and at one and five months after surgery. Changes in the six most common physical symptoms and the most common psychological symptom were evaluated using multilevel growth mixture modeling. Age, gender, comorbidity, and receipt of adjuvant chemotherapy were included as covariates in the conditional models for symptom occurrence and severity.

RESULTS

The total number of symptoms increased significantly from the preoperative to the one month assessment. At five months, the number of symptoms was lower than at one month but significantly higher than at the preoperative assessment. The occurrence of five of the symptoms (i.e., pain, lack of energy, shortness of breath, feeling drowsy, and worrying) increased significantly from before through the first month after surgery and then decreased over time. Cough and difficulty sleeping persisted over the five months of the study. In general, the effect of the four covariates was to increase patients' overall symptom burden.

CONCLUSION

Changes in the occurrence and severity of these seven symptoms were variable. All seven symptoms occurred at relatively high rates and were of moderate severity. Findings can be used to identify patients who are at higher risk for more severe symptoms.

Identification of novel fusion genes in lung cancer using breakpoint assembly of transcriptome sequencing data

Genomic translocation events frequently underlie cancer development through generation of gene fusions with oncogenic properties. Identification of such fusion transcripts by transcriptome sequencing might help to discover new potential therapeutic targets. We developed TRUP (Tumor-specimen suited RNA-seq Unified Pipeline) (https://github.com/ruping/TRUP), a computational approach that combines split-read and read-pair analysis with de novo assembly for the identification of chimeric transcripts in cancer specimens. We apply TRUP to RNA-seq data of different tumor types, and find it to be more sensitive than alternative tools in detecting chimeric transcripts, such as secondary rearrangements in EML4-ALK-positive lung tumors, or recurrent inactivating rearrangements affecting RASSF8.

Frequent mutations in chromatin-remodelling genes in pulmonary carcinoids

Pulmonary carcinoids are rare neuroendocrine tumours of the lung. The molecular alterations underlying the pathogenesis of these tumours have not been systematically studied so far. Here we perform gene copy number analysis (n=54), genome/exome (n=44) and transcriptome (n=69) sequencing of pulmonary carcinoids and observe frequent mutations in chromatin-remodelling genes. Covalent histone modifiers and subunits of the SWI/SNF complex are mutated in 40 and 22.2% of the cases, respectively, with MEN1, PSIP1 and ARID1A being recurrently affected. In contrast to small-cell lung cancer and large-cell neuroendocrine lung tumours, TP53 and RB1 mutations are rare events, suggesting that pulmonary carcinoids are not early progenitor lesions of the highly aggressive lung neuroendocrine tumours but arise through independent cellular mechanisms. These data also suggest that inactivation of chromatin-remodelling genes is sufficient to drive transformation in pulmonary carcinoids.

Unique microRNA-profiles in EGFR-mutated lung adenocarcinomas

The findings of mutations and the development of targeted therapies have improved lung cancer management. Still, the prognosis remains poor, and we need to know more about the genetic and epigenetic alterations in lung cancer. MicroRNAs are involved in crucial biological processes like carcinogenesis by regulating gene expression at the post-transcriptional level. In this project, we have studied the microRNA expression of lung adenocarcinomas and corresponding normal lung tissue and correlated the expression with clinical data and EGFR- and KRAS-mutational status. Agilent microarrays have been used, examining microRNA expression in 154 surgically resected lung adenocarcinomas and 20 corresponding normal lung tissue samples. Findings were confirmed by RT-qPCR in the same cohort and in an independent cohort of 103 lung cancer patients. EGFR and KRAS mutation analyses were also performed. 129 microRNAs were significantly differentially expressed in lung adenocarcinomas compared with normal lung tissue, and 17 microRNAs were differentially expressed between EGFR-mutated and EGFR wildtype tumors. We identified microRNAs associated with time to progression. We have identified several aberrantly expressed microRNAs that discriminate lung adenocarcinomas from normal lung tissue, and hence may be potential biomarkers for early detection. We have found microRNAs that are differentially expressed between EGFR-mutated and EGFR wildtype lung adenocarcinomas, suggesting that microRNAs can be used as molecular biomarkers in classification. We hypothesize that microRNA expression can be used as biomarkers for clinical course.

Abstract 1962: Differentially expressed microRNAs in adenocarcinomas of the lung and tumor-adjacent normal lung tissue

Introduction: Lung cancer is the most common cause of cancer deaths worldwide. The findings of new mutations and the development of targeted therapies have improved lung cancer management. Still, the prognosis remains poor and we need to know more about the genetic and epigenetic alterations in the tumors to better understand the biology of lung cancer.

MicroRNAs are small non-coding RNAs that are involved in crucial biological processes in carcinogenesis by regulating gene expression at the post transcriptional level. In this project we have studied the microRNA expression patterns of lung adenocarcinomas and correspondent tumor-adjacent normal lung tissue and correlated the expression patterns with clinical data and mutational status.

Methods: We have examined microRNA expression pattern in tumor tissues from 154 surgically resected lung adenocarcinomas and from 20 tumor-adjacent normal lung tissue samples. The expression of 1205 human microRNAs was conducted using the 60K microRNA microarray from Agilent technology. EGFR and KRAS mutation analyses were also performed.

The analysis of differentially expressed microRNAs between groups of samples was done using significance analyses of microarrays (SAM) in the J-express software. We also performed survival analysis using univariate- and multivariate Cox regression analysis. The results are about to be validated by qRT-PCR.

Results: Preliminary results show 129 differentially expressed microRNAs in tumor compared to the tumor-adjacent normal lung tissue. EGFR and KRAS mutations were found in 22/152 (14.5%) and 47/137 (34.3%) samples respectively. We have detected 17 microRNAs that are differentially expressed in EGFR mutated tumors compared to EGFR wildtype tumors. Two microRNAs were identified to have a strong association with time to progression in both univariate- and multivariate Cox regression analysis.

Discussion: The microRNAs are thought to play an essential role in the development and progression of human malignancies, including lung cancer. We have identified several aberrantly expressed microRNAs that can discriminate lung adenocarcinoma tumor tissue from tumor-adjacent normal lung tissue samples. This can lead to the identification of biomarkers for early detection. 17 microRNAs were differentially expressed between EGFR mutated- and EGFR wt lung adenocarcinomas suggesting that microRNAs can be used as molecular biomarkers for lung cancer classification. We have also identified microRNAs that can be used as prognostic biomarkers. We are now confirming our results with qRT-PCR. We hypothesize that microRNA can be used as biomarkers for classification and clinical course.

Citation Format: Maria Bjaanæs, Rita Halvorsen, Steinar Solberg, Lars Jørgensen, Odd-Terje Brustugun, Åslaug Helland. Differentially expressed microRNAs in adenocarcinomas of the lung and tumor-adjacent normal lung tissue. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 1962. doi:10.1158/1538-7445.AM2013-1962

Identification and characterization of cells with cancer stem cell properties in human primary lung cancer cell lines

Lung cancer (LC) with its different subtypes is generally known as a therapy resistant cancer with the highest morbidity rate worldwide. Therapy resistance of a tumor is thought to be related to cancer stem cells (CSCs) within the tumors. There have been indications that the lung cancer is propagated and maintained by a small population of CSCs. To study this question we established a panel of 15 primary lung cancer cell lines (PLCCLs) from 20 fresh primary tumors using a robust serum-free culture system. We subsequently focused on identification of lung CSCs by studying these cell lines derived from 4 representative lung cancer subtypes such as small cell lung cancer (SCLC), large cell carcinoma (LCC), squamous cell carcinoma (SCC) and adenocarcinoma (AC). We identified a small population of cells strongly positive for CD44 (CD44^high) and a main population which was either weakly positive or negative for CD44 (CD44^low/−). Co-expression of CD90 further narrowed down the putative stem cell population in PLCCLs from SCLC and LCC as spheroid-forming cells were mainly found within the CD44^highCD90⁺ sub-population. Moreover, these CD44^highCD90⁺ cells revealed mesenchymal morphology, increased expression of mesenchymal markers N-Cadherin and Vimentin, increased mRNA levels of the embryonic stem cell related genes Nanog and Oct4 and increased resistance to irradiation compared to other sub-populations studied, suggesting the CD44^highCD90⁺ population a good candidate for the lung CSCs. Both CD44^highCD90⁺ and CD44^highCD90⁻ cells in the PLCCL derived from SCC formed spheroids, whereas the CD44^low/− cells were lacking this potential. These results indicate that CD44^highCD90⁺ sub-population may represent CSCs in SCLC and LCC, whereas in SCC lung cancer subtype, CSC potentials were found within the CD44^high sub-population.

An unusual case of the syndrome of cervical rib with subclavian artery thrombosis and cerebellar and cerebral infarctions

Background

Cerebellar and cerebral infarctions caused by the syndrome of cervical rib with thrombosis of subclavian artery are very unusual.

Case presentation

We report the case of a 49-year-old male patient with a right cervical rib compression leading to subclavian arterial thrombosis and both cerebellar and cerebral infarctions secondary to retrograde thromboembolisation. Follow-up imaging revealed partial resolution of the thrombosis after combined anti-coagulant and anti-platelet therapy. The cervical rib and first costa were surgically removed to prevent additional events.

Conclusion

Cervical rib vascular compression should be promptly diagnosed and treated in order to avoid further complications, including cerebrovascular ischemic events.

Diagnostic accuracy of computed tomography and histopathology in the diagnosis of usual interstitial pneumonia

BACKGROUND

The relative clinical benefit of histopathology and computed tomography (CT) in patients with idiopathic interstitial pneumonia (IIP) is under debate.

PURPOSE

To analyze thin-section CT features and histopathologic findings in patients with usual interstitial pneumonia (UIP) in the clinical context of idiopathic pulmonary fibrosis (IPF), and to evaluate and compare diagnostic accuracy of the two methods among patients with an appropriate spectrum of IIP.

MATERIAL AND METHODS

The study included 91 patients (49 men; mean age 53.2 years; median follow-up 7.2 years) with clinically suspected interstitial lung disease. All underwent surgical lung biopsy and thin-section CT. Two independent readers retrospectively assessed the CT images for the extent and pattern of abnormality and made a first-choice diagnosis. Two pathologists retrospectively assessed the histopathologic slides. In 64 patients with IIP, a retrospective composite reference standard identified 41 patients with UIP. CT characteristics of UIP and IIPs other than UIP were compared with univariate and multivariate analyses.

RESULTS

There was good agreement between the readers for the correct first-choice CT diagnosis of UIP (κ = 0.79). The sensitivity, specificity, and positive predictive value of the CT diagnosis of UIP were 63%, 96%, and 96%, respectively. The sensitivity, specificity, and positive predictive value of the histological diagnosis of UIP were 73%, 74%, and 83%, respectively. The CT feature that best differentiated UIP from IIPs other than UIP was the extent of reticular pattern (odds ratio, 5.1).

CONCLUSION

Surgical lung biopsy may not be warranted in patients with thin-section CT diagnosis of UIP.

Abdominal aortic aneurysms, or a relatively large diameter of non-aneurysmal aortas, increase total and cardiovascular mortality: the Tromsø study

BACKGROUND

In a population-based study in Tromsø, Norway, the authors assessed whether an abdominal aortic aneurysm (AAA) or the maximal infrarenal aortic diameter in a non-aneurismal aorta influence total and cardiovascular disease (CVD) mortality.

METHODS

A total of 6640 men and women, aged 25-84 years, were included in a 10-year mortality follow-up: 345 subjects with a diagnosed AAA and 6295 subjects with a non-aneurismal aorta. Non-aneurismal aortic diameter and prevalent AAAs were categorized into seven groups.

RESULTS

In subjects without an AAA, an aortic diameter > or =30 mm increased age- and sex-adjusted total mortality [mortality rate ratio (MRR) = 3.73, 95% confidence interval (CI) 1.77-7.89] and CVD mortality (MRR = 9.24, 95% CI 4.07-20.97) compared with subjects with aortic diameter of 21-23 mm. An AAA at screening was strongly associated with deaths from aortic aneurysm and was associated with total (MRR = 1.60, 95% CI 1.31-1.96) and CVD mortality (MRR = 2.41, 95% CI 1.81-3.21). This was not explained by deaths due to an AAA. Adjustments for CVD risk factors could fully explain the increased total, but not CVD mortality in subjects with an AAA.

CONCLUSIONS

An AAA increases total and CVD mortality. In the large majority of subjects with a non-aneurysmal aorta, the diameter does not influence total or CVD mortality. However, in individuals with a maximal diameter >26 mm (2% of the population), a positive relationship is found.

Risk factors for abdominal aortic aneurysms: a 7-year prospective study: the Tromsø Study, 1994-2001

BACKGROUND

Abdominal aortic aneurysm is an asymptomatic condition with a high mortality rate related to rupture.

METHODS AND RESULTS

In a cohort of 2035 men and 2310 women in Tromsø, Norway, who were 25 to 82 years old in 1994, the authors identified risk factors for incident abdominal aortic aneurysm over the next 7 years. The impact of smoking was studied in particular. Ultrasound examination was performed initially in 1994/1995 and repeated in 2001. There were 119 incident cases of abdominal aortic aneurysms (an incidence of 0.4% per year). Male sex and increasing age were strong risk factors. In addition, the following variables were significantly associated with increased abdominal aortic aneurysm incidence: Smoking (OR=13.72, 95% CI 6.12 to 30.78, comparing current smokers of > or =20 cigarettes/d with never-smokers), hypertension (OR=1.54, 95% CI 1.03 to 2.30), hypercholesterolemia (OR=2.11, 95% CI 1.23 to 3.64, comparing subjects with serum total cholesterol > or =7.55 mmol/L with those with total cholesterol <5.85 mmol/L), and low high-density lipoprotein cholesterol (OR=3.25, 95% CI 1.68 to 6.27, comparing subjects with high-density lipoprotein cholesterol <1.25 mmol/L with those with high-density lipoprotein > or =1.83 mmol/L). In addition, use of statins was associated with increased risk of abdominal aortic aneurysm (OR=3.77, 95% CI 1.45 to 9.81), but this was probably a marker of high risk of cardiovascular diseases.

CONCLUSIONS

The results demonstrate strong associations between traditional atherosclerosis risk factors and the risk of incident abdominal aortic aneurysms.