Nrf2、Keap1蛋白在104例肺腺癌中的表达及其临床病理特征

背景与目的表皮生长因子受体酪氨酸激酶抑制剂（epidermal growth factor receptor tyrosine kinase inhibitors, EGFR-TKIs）是含有EGFR基因敏感突变肺腺癌患者一线治疗首选药物，但其疗效存在个体差异。已有研究表明核因子E2相关因子2（nuclear factor erythroid-2-related factor 2, Nrf2）在肺癌患者中存在个体表达差异，且其与化疗药物疗效相关。Nrf2激活可抑制EGFR-TKIs在EGFR基因突变细胞株中的敏感性。本研究旨在探讨Nrf2在含有EGFR基因突变肺腺癌患者中的表达及其与一线EGFR-TKIs疗效的相关性。方法应用免疫组化检测31例进展期含有EGFR基因突变的肺腺癌患者组织标本中Nrf2的表达。结果含有EGFR基因突变的进展期肺腺癌患者中Nrf2表达存在个体差异，Nrf2阳性率为77.4%，Nrf2核高表达率为38.7%；Nrf2在核内的表达水平与EGFR-TKIs缓解程度、无进展生存期（progression free survival, PFS）相关（P < 0.05），而与性别、年龄、吸烟、分化程度、EGFR基因突变状态和总生存期（Overall survival, OS）无关（P>0.05）。Nrf2阳性程度与PFS和OS显著相关（P < 0.05），Nrf2阳性组中位PFS、OS低于阴性组（P < 0.05）。多因素分析表明Nrf2在肿瘤细胞核内的表达水平是EGFR-TKIs PFS的独立预测因素，Nrf2在肿瘤细胞内的整体阳性程度是OS的独立预测因素（P < 0.05）。结论Nrf2在含有EGFR基因突变的肺腺癌患者中的表达水平与EGFR-TKIs疗效相关，Nrf2可能成为预测EGFR-TKIs疗效的一个理想指标。

For patients with advanced EGFR -mutant lung adenocarcinoma, progression-free survival (PFS) is significantly improved by epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI) medications. However, a subset of patients still experiences early disease progression. In this study, we aimed to identify potential risk factors associated with shorter PFS through next-generation sequencing (NGS) analysis. This retrospective study included patients with advanced EGFR -mutant lung adenocarcinoma who received first-line EGFR-TKI treatment with upfront NGS. The genetic alterations included two types, mutations and copy number variations. Alterations involving EGFR downstream signaling pathways were classified as ' PIK3CA-AKT/RAS-RAF alterations'. Clinical and histopathological data were also collected and analyzed. We studied a total of 82 advanced lung cancer patients with sensitive EGFR mutations. Multivariable analyses showed associations with a shorter PFS for the following factors: P IK3CA-AKT/RAS-RAF alterations [hazard ratio (HR) 3.197, P = 0.006], age ≤50 (HR 3.034, P = 0.010), and PD-L1 ≥50% (HR 2.256, P = 0.035). Based on the above risk factors, patients were classified into no-risk and ≥1 risk groups. In the no-risk group, third-generation EGFR-TKIs showed a numerically longer PFS compared to first/second-generation EGFR-TKIs (not reached vs. 20.0 months, P = 0.084). However, in patients with ≥1 risk factor, third-generation EGFR-TKIs showed no PFS advantages (6.6 vs. 6.2 months, P = 0.831). In conclusion, besides clinicopathological factors, NGS provides additional insights to predict shorter PFS after EGFR-TKI treatment. We identified three risk factors: (1) PIK3CA-AKT/RAS-RAF alterations, (2) age ≤50, and (3) PD-L1 ≥50%. Patients with these factors had poor PFS regardless of EGFR-TKI generation.

Estrogen receptor β (ERβ) can regulate cellular signaling through non-genomic mechanisms, potentially promoting resistance to epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs). However, the mechanisms underlying the ERβ-mediated resistance to EGFR TKIs remain poorly understood. In this study, we investigated the role of the interaction between ERβ1 and ERβ5 in non-genomic signaling in lung adenocarcinoma. We established PC9 cell lines stably overexpressing ERβ1 or ERβ1/ERβ5. Immunofluorescence revealed that ERβ5 overexpression partly retained ERβ1 in the cytoplasm. Immunoblotting analyses revealed that EGFR pathway activation levels were higher in PC9/ERβ1/5 cells than those in PC9/ERβ1 or control PC9 cells. In the presence of estradiol, PI3K/AKT/mTOR pathway activation levels were higher in ERβ1/5-expressing cells than those in ERβ1-expressing cells. Additionally, PC9/ERβ1/5 cells were less prone to the cytotoxic and pro-apoptotic effects of gefitinib compared with PC9/ERβ1 or control PC9 cells. Cytoplasmic ERβ1 was associated with poor progression-free survival in lung cancer patients treated with EGFR TKIs. These results suggest that cytoplasmic ERβ1 was responsible for EGFR TKI resistance slightly through non-genomic mechanism in EGFR mutant lung adenocarcinoma.

Background: Albeit epidermal growth factor receptor (EGFR) mutation status might be superior to other clinical and pathological factors for predicting response to epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs), the efficacy might differ a lot in patients with the same EGFR sensitive mutations. Thus, exploring factors associated with EGFR-TKIs efficacy other than EGFR mutation status is vital, especially in patients with EGFR-activating mutations. Methods: The present study retrospectively collected clinical and pathological data on a total of 128 patients with EGFR-activating lung adenocarcinoma who received first-generation EGFR-TKIs (including gefitinib, erlotinib or icotinib). Kaplan-Meier and Cox regression methods were applied to identify independent factors associated with progression-free survival (PFS) and to generate a prognostic index (PI) model. Results: The median PFS of the 128 patients was 14.9 months (95% CI, 13.2–16.5 months). A non-smoking history [hazard ratio (HR) =2.896; 95% CI, 1.501–5.558; P=0.002] and first-line EGFR-TKIs treatment (HR, 1.544; 95% CI, 0.999–2.386; P=0.05) were found to be independent predictive factors of a longer PFS with EGFR-TKIs therapy. Predictive model can be established as PI =1.063 × Smoking + 0.434 × Timing according to the results of Cox regression. Further analysis using the PI model indicated that there are differences of three groups in PFS: non-smoking and first-line therapy, non-smoking and non-first-line therapy, smoking regardless of treatment timing. Conclusions: The findings of the present study suggest that a non-smoking history and a first-line EGFR-TKIs treatment timing are independent predictors of a longer PFS in EGFR-mutant lung adenocarcinoma patients treated with first-generation EGFR-TKIs. PFS is longer for those who are never smokers and receive first-line EGFR-TKIs, compared with other groups.

Dual Inhibition of Met Kinase and Angiogenesis to Overcome HGF-Induced EGFR-TKI Resistance in EGFR Mutant Lung Cancer

This study compared the therapeutic effect of first-line epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI) with that of EGFR-TKI plus whole brain radiotherapy (WBRT) on patients with EGFR mutation-positive lung adenocarcinoma and brain metastases. A total of 139 patients with lung adenocarcinoma and brain metastases treated with first-line EGFRTKI therapy from September 2008 to December 2017 were enrolled in this study. The study endpoints were intracranial time to progression (TTP) and overall survival (OS). The effects of clinical pathological parameters and EGFR gene status on the study endpoints were compared. The results showed that the intracranial TTP was significantly longer in EGFR-TKI plus WBRT group than in EGFR-TKI group (median 30.0 vs.18.2 months, χ2=10.824, P=0.001), but no significant difference in the OS was noted between the two groups (median 48.0 vs. 41.1 months, χ2=0.012, P=0.912). Also, there was no statistically significant difference in the OS between patients treated with early and late radiotherapy (P=0.849) and between those with asymptomatic and those with symptomatic intracranial metastases (P=0.189). The OS and intracranial TTP of patients with intracranial oligometastases (≤3 metastatic sites) were not significantly different from those of patients with multiple intracranial metastases (P=0.104 and P=0.357, respectively), and exon 19 and exon 21 mutations didn't show significant effects on the OS and intracranial TTP of patients (P=0.418 and P=0.386, respectively). In conclusion, there was no statistically significant difference in the OS between the EGFR-TKI alone group and EGFR-TKI plus WBRT group. However, simultaneous use of WBRT was found to significantly prolong intracranial TTP and improve cerebral symptoms, and thus EGFR-TKI and WBRT combined may be clinically beneficial for patients with EGFR mutation-positive lung adenocarcinoma and brain metastases.

BackgroundIncreased focus surrounds identifying patients with advanced non-small cell lung cancer (NSCLC) who will benefit from treatment with epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKI). EGFR mutation, gene copy number, coexpression of ErbB proteins and ligands, and epithelial to mesenchymal transition markers all correlate with EGFR TKI sensitivity, and while prediction of sensitivity using any one of the markers does identify responders, individual markers do not encompass all potential responders due to high levels of inter-patient and inter-tumor variability. We hypothesized that a multivariate predictor of EGFR TKI sensitivity based on gene expression data would offer a clinically useful method of accounting for the increased variability inherent in predicting response to EGFR TKI and for elucidation of mechanisms of aberrant EGFR signalling. Furthermore, we anticipated that this methodology would result in improved predictions compared to single parameters alone both in vitro and in vivo.ResultsGene expression data derived from cell lines that demonstrate differential sensitivity to EGFR TKI, such as erlotinib, were used to generate models for a priori prediction of response. The gene expression signature of EGFR TKI sensitivity displays significant biological relevance in lung cancer biology in that pertinent signalling molecules and downstream effector molecules are present in the signature. Diagonal linear discriminant analysis using this gene signature was highly effective in classifying out-of-sample cancer cell lines by sensitivity to EGFR inhibition, and was more accurate than classifying by mutational status alone. Using the same predictor, we classified human lung adenocarcinomas and captured the majority of tumors with high levels of EGFR activation as well as those harbouring activating mutations in the kinase domain. We have demonstrated that predictive models of EGFR TKI sensitivity can classify both out-of-sample cell lines and lung adenocarcinomas.ConclusionThese data suggest that multivariate predictors of response to EGFR TKI have potential for clinical use and likely provide a robust and accurate predictor of EGFR TKI sensitivity that is not achieved with single biomarkers or clinical characteristics in non-small cell lung cancers.

The aim of this study was to analyse the long-term survival outcomes and prognostic factors of patients receiving epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) as first-line treatment for postoperative recurrent EGFR-mutated lung adenocarcinoma. Using a multi-institutional database, we performed a retrospective chart review to identify all patients who had undergone complete resection of stage I-III EGFR-mutated lung adenocarcinoma at 11 acute care hospitals between 2009 and 2016 and had received first-line EGFR-TKI treatment for postoperative recurrence. Adverse events, progression-free survival (PFS) and overall survival (OS) were investigated. Survival outcomes were assessed using Kaplan-Meier analysis. Cox proportional hazards models were used to calculate the hazard ratios (HRs) and 95% confidence intervals (CIs) for PFS and OS. The study sample comprised 154 patients with a median age of 69. The total numbers of events were 101 for PFS and 60 for OS. The median PFS and OS were 26.1 and 55.4 months, respectively. In the multivariable analysis, EGFR ex 21 L858R mutation (HR: 1.71, 95% CI: 1.15-2.55) and shorter disease-free intervals (HR: 0.98, 95% CI: 0.96-0.99) were significantly associated with shorter PFS. Age (HR: 1.03, 95% CI: 1.00-1.07), smoking history (HR: 2.31, 95% CI: 1.35-3.94) and pathological N2 disease at the initial surgery (HR: 2.30, 95% CI: 1.32-4.00) were significantly associated with shorter OS. First-line EGFR-TKI treatment was generally associated with favourable survival outcomes in patients with postoperative recurrent EGFR-mutated lung adenocarcinoma. EGFR ex 21 L858R mutation may be an important prognostic factor for shorter PFS.

Role of Oral Tetracyclines in Preventing Acneiform Rash in Patients With Non-small Cell Lung Cancer Treated With Epidermal Growth Factor Receptor Tyrosine Kinase Inhibitors: A Systematic Review.

BackgroundEpidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) are increasingly used for advanced non-small cell lung cancer (NSCLC) as first-line therapy. The bioavailability and efficacy of oral EGFR-TKIs could be affected by acid suppression (AS) therapy such as PPIs and H2RAs which are reported to be over-prescribed. Hence, there is a need to investigate the effect of AS on the overall survival (OS), progression-free survival (PFS) and adverse effect profile in patients treated with EGFR TKIs.MethodsAn electronic database search of Medline and Embase was performed following PRISMA guidelines on 17 January 2021. Studies analyzing interactions between EGFR TKIs and PPIs/H2RAs in NSCLC patients were included. s, non-English or non-Japanese studies or studies using non-EGFR TKIs were excluded. Hazard ratios (HRs) were pooled using generic inverse variance random effects model. Effect sizes for dichotomous variables were pooled using Mantel-Haenszel random effects model. Significance was considered at P≤0.05. Heterogeneity was assessed with Cochran Q-test and I2 test. Publication bias was assessed with funnel plots. The assessment of quality and risk of bias of randomized and non-randomized studies were undertaken with RoB 2 and the ROBINS-I tool respectively.ResultsOut of 1,173 potentially relevant articles, 14 articles were included in the final analysis. The pooled prevalence of AS in patients taking EGFR TKI was 30.71% in 4,010 individuals. Patients who were treated only with EGFR TKI had significantly better OS (HR =1.46, 95% CI: 1.27–1.72; P<0.00001) and PFS (HR =1.63, 95% CI: 1.35–1.98; P<0.00001). The OS for EGFR mutation positive patients only was as similarly significant as the OS in all patients taking EGFR TKI, while the PFS in mutation positive patients was significantly worsened with AS. PPIs resulted in a significantly worsened OS and PFS but H2RAs did not produce significantly different OS and PFS between AS and non-AS users. There were no significant differences in the incidence of rash (OR =0.81, 95% CI: 0.50–1.32; P=0.40), diarrhoea (OR =1.03, 95% CI: 0.63–1.67; P=0.91) or other adverse effects.ConclusionsCo-administration of AS medications with first-generation EGFR-TKIs in NSCLC worsens survival outcomes. Physicians should only prescribe AS medications when absolutely clinically indicated.

Background: Epidermal Growth Factor Receptor (EGFR) Tyrosine Kinase inhibitor (TKI) can improve progression free survival in patients with treatment naive EGFR mutant metastatic non-small cell lung cancer (NSCLC) compared with platinum-based chemotherapy, but no statistically significant difference is observed in overall survival. The survival time of EGFR mutant NSCLC patients treated with at least two systemic chemotherapy regimens and one EGFR TKI was 34.8 months in a previous study. Objective: The present study was to determine the median survival time of advanced NSCLC patients who received EGFR-TKIs in Chulabhorn Hospital. Materials and Methods: We retrospectively reviewed the medical records of advanced NSCLC cases treated with EGFR TKIs in Chulabhorn Hospital during 2009 to 2011. Results: Among 243 advanced NSCLC cases, 72 patients received EGFR TKIs. EGFR mutation status was positive in 14 (19.17%) patients. The median overall survival time was 30.04 months (95% CI: 18.71 to 49.48 months) in all patients, compared with 49.49 months (95% CI: 15.93 to NR) in EGFR mutation-positive patients (n=14). No statistically significant difference of overall survival was noted between EGFR mutation status groups (p=0.51). Conclusion: The median survival time for Thai patients treated with EGFR TKIs was comparable to historical data and irrespective of EGFR mutation status. Keywords: Metastatic non-small cell lung cancer, EGFR TKIs, Survival

1323 - Study of the Safety and Efficacy of Epidermal Growth Factor Receptor Tyrosine Kinase Inhibitors in 97 Patients with Epidermal Growth Factor Receptor Mutation-Positive Non-Small Cell Lung Cancer

To determine the efficacy of first-generation epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) in molecularly selected patients with advanced non-small cell lung cancer (NSCLC), we performed this pooled analysis. Randomized trials of EGFR-TKIs as treatment for advanced NSCLC were included for this meta-analysis. We used published hazard ratios (HRs), if available, or derived treatment estimates from other survival data. Pooled estimates of treatment efficacy of EGFR-TKIs in the selected patients by EGFR-mutation status were calculated. Out of 2134 retrieved articles, 30 randomized controlled trials (RCTs) enrolling more than 4053 patients with wild-type EGFR tumors and 1592 patients with mutant EGFR tumors were identified. For EGFR mutant patients, EGFR-TKIs treatment improved progression-free survival (PFS) compared with chemotherapy: the summary HRs were 0.41 (p < 0.00001) for the first-line setting and 0.46 (p = 0.02) for second/third-line setting, respectively. Also, the same superior trend was found with TKIs maintenance over placebo (HR = 0.14, p < 0.00001) and with TKIs combined with chemotherapy over chemotherapy (HR = 0.49, p = .002) in both the first-line and maintenance therapy settings. For EGFR wild-type patients, EGFR-TKIs have fared worse than chemotherapy in the first-line setting (HR = 1.65, p = .03) and in the second/third-line setting (HR = 1.27, p = .005). However, EGFR-TKIs maintenance still produced a reduction of 19 % in the risk of progression over placebo (HR = 0.81, p = .02). Furthermore, EGFR-TKIs added to chemotherapy as first-line treatment resulted in an improvement of PFS over chemotherapy alone in such wild-type EGFR patients (HR = 0.82, p = .03). In overall survival (OS) analysis, only EGFR-TKIs single agent was inferior to chemotherapy in EGFR wild-type patients (HR = 1.13, p = .02). No statistically significant difference in terms of OS was observed in any other subgroup analysis. For EGFR mutant patients, EGFR-TKIs therapy produced a prominent PFS benefit in all settings. Among EGFR wild-type patients, EGFR-TKIs were inferior to chemotherapy both for first-line treatment and for second/third-line treatment. However, EGFR-TKIs maintenance and addition of EGFR-TKIs to chemotherapy could provide additive benefit over chemotherapy alone in such EGFR wild-type patients.

Epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) significantly improve outcomes of patients with EGFR-mutated non-small-cell lung cancer (NSCLC). However, acquired resistance inevitably emerges and remains a major challenge. The present study aimed to evaluate the efficacy of EGFR-TKIs plus bevacizumab in advanced non-squamous NSCLC patients with gradual progression on EGFR-TKIs.Advanced non-squamous EGFR-mutated NSCLC patients with gradual progression on EGFR-TKIs were administered bevacizumab while EGFR-TKIs were continued until disease progression occurred. Tumor lesions were assessed, and blood samples were collected at the start of the combination treatment and every 6 weeks until disease progression.Among the 15 included patients, there were no grade 3 or higher adverse events (AEs). Partial response (PR) and stable disease (SD) were achieved in 1 and 13 patients, respectively, with an objective response rate (ORR) of 6.7% and a disease control rate (DCR) of 93.3%. The median progression-free survival 2 (PFS2), defined as the time from the initiation of combination treatment to disease progression, was 5.0 (95% confidence interval [CI]: 4.0–6.0) months. Additionally, Spearman correlation analysis revealed that PFS2 was positively correlated with the serum vascular endothelial growth factor (VEGF) level at baseline (r = 0.7212, P = .0234). Patients with high baseline serum VEGF levels showed a better median PFS2 than those with low baseline serum VEGF levels (5.5 months vs 3.6 months, P = .0333).EGFR-TKIs plus bevacizumab led to a durable prolongation of PFS in non-squamous NSCLC patients with gradual progression on EGFR-TKIs. This therapeutic regimen was well tolerated and could be a promising strategy for these patients. Serum VEGF could be a potential biomarker to predict a subset of patients who are likely to benefit from EGFR-TKIs combined with bevacizumab.

Some but not all patients with non-small-cell lung cancer (NSCLC) respond to treatment with epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs). We developed and tested the ability of a predictive algorithm based on matrix-assisted laser desorption ionization (MALDI) mass spectrometry (MS) analysis of pretreatment serum to identify patients who are likely to benefit from treatment with EGFR TKIs. Serum collected from NSCLC patients before treatment with gefitinib or erlotinib were analyzed by MALDI MS. Spectra were acquired independently at two institutions. An algorithm to predict outcomes after treatment with EGFR TKIs was developed from a training set of 139 patients from three cohorts. The algorithm was then tested in two independent validation cohorts of 67 and 96 patients who were treated with gefitinib and erlotinib, respectively, and in three control cohorts of patients who were not treated with EGFR TKIs. The clinical outcomes of survival and time to progression were analyzed. An algorithm based on eight distinct m/z features was developed based on outcomes after EGFR TKI therapy in training set patients. Classifications based on spectra acquired at the two institutions had a concordance of 97.1%. For both validation cohorts, the classifier identified patients who showed improved outcomes after EGFR TKI treatment. In one cohort, median survival of patients in the predicted "good" and "poor" groups was 207 and 92 days, respectively (hazard ratio [HR] of death in the good versus poor groups = 0.50, 95% confidence interval [CI] = 0.24 to 0.78). In the other cohort, median survivals were 306 versus 107 days (HR = 0.41, 95% CI = 0.17 to 0.63). The classifier did not predict outcomes in patients who did not receive EGFR TKI treatment. This MALDI MS algorithm was not merely prognostic but could classify NSCLC patients for good or poor outcomes after treatment with EGFR TKIs. This algorithm may thus assist in the pretreatment selection of appropriate subgroups of NSCLC patients for treatment with EGFR TKIs.