Non-small Cell Lung Carcinoma Patients Research Articles

#2108 Secondary amyloidosis in a cancer patient on pembrolizumab—an unusual finding

Abstract Background and Aims With the widening horizon of ICPIs in the management of oncological disorders, we require to remain vigilant of the possible iRAEs. We present a case report of secondary amyloidosis in at metastatic non-small cell lung carcinoma (NSCLC) patient treated with Pembrolizumab. We aim to describe the clinic-biological & histopathological characteristics of ICPI-related kidney injury which may be beyond interstitial nephritis & its response to treatment & the role of kidney biopsy to define ICPI-related kidney injury. Treatment is challenging due to a paucity of relevant data, implicating further studies. Treatment with colchicine and steroids, tocilizumab in the setting of elevated interleukin-6 (IL6) levels have been reported in case series; unfortunately no appreciable renal benefit were noted. Method 77 year male, diabetic & hypertensive on regular medication for >15 yr, reformed smoker (≈50 pack-years of cigarette) diagnosed with NSCLC (EGFR–wild type, PDL1–70%), received Pembrolizumab (13 cycles) & Paclitaxel + Carboplatin & was in remission. Follow up PET showed partial response—new lesions in brain. Gemcitabine added to the treatment & had received 2 cycles, till hospitalization with febrile episode, decreased oral intake & progressive edema. Clinical evaluation was non-contributory. Hematology & biochemical evaluation (Table 1) showed raised serum creatinine 1.1 mg/dL (baseline 1 mg/dL), urinalysis—2+ protein, quantification showed 2.9295 g/24 h → 6.38 g/24 h (baseline uPCR-0.19 g/g). Abdominal ultrasound & ECHO finding were not conclusive. Fundoscopy showed no evidence of proliferative diabetic or hypertensive retinopathy. Results Kidney Biopsy (Figure) was done. LM showed, few of 8 gloms with mild segmental mesangial expansion due to amorphous extracellular deposits which was PAS & silver negative but showed congophilia (Fig. A,B,C,D). If negative for albumin, IgG, IgA, C3, C1q & had 1+ granularity in the mesangium on IgM staining & showed no light chain restriction in glomeruli & tubular cast for kappa & lambda. IHC (Fig. E) was positive for serum amyloid associated proteins. EM revealed minimal subendothelial & mesangial expansion due to extracellular material organized into randomly arranged fine fibrils, & no significant foot process effacement, electron dense deposits along the capillary basement membrane or within mesangium, glomerular basement membrane, thereby excluding possibility of light chain deposition disease. Conclusion Secondary amyloidosis with ICPI use has uncommonly & with Pembrolizumab rarely been reported. Treatment is challenging due to paucity of literature. Hassan Izzedine et al. in their case series, on Pembrolizumab treated cancer patient [N = 676], showed 12 patients (7 men) (Incidence 1.77%) developed AKI (n = 10) &/or Proteinuria (n = 2), median duration of use 9 months. All (n = 12) underwent renal biopsy, which showed AIN in 4, ATI in 5, MCD in 2. Recovery happened with withdrawal of drug coupled with corticosteroid. Reintroduction resulted in more severe recurrence of AIN in 1 patient only. Lapman et al. reported 1 case of secondary amyloidosis in cancer patients treated with Pembrolizumab. 42yr male Caucasian, had no reported chronic illness, except Asthma. Similarly developed significant proteinuria (Urine Pro 3+) & AKI (Sr. Creat 1.58 mg/dl; Baseline 1.0 mg/dl) after 90 days of Pembrolizumab therapy. Under went 2 Kidney Biopsy–1st Biopsy revealed AA amyloid. AA amyloidosis was attributed to Pembrolizumab as repeat Bx revealed progressive deposits despite remission of malignancy, but his kidney disease progressed, and had to be initiation on maintenance hemodialysis. Stopping Pembrolizumab & corticosteroids led to resolution of proteinuria in our patient too.

Abstract 7499: Circulating tumor cell enumeration and protein expression by CapioCyte and Allegro Plus imaging

Abstract Radiation or chemoradiation followed by surgical resection is the current standard of therapy for many diseases. These treatments are increasingly supplemented with monoclonal antibodies, such as epidermal growth factor receptor (EGFR)-targeting and programmed death ligand 1 (PD-L1) checkpoint-blocking antibodies. The use of these therapies is typically dependent on solid tissue biopsy to confirm elevated expression of these markers in the solid tumor, which carries complications and may only be sampled at diagnosis. In contrast, a liquid biopsy may detect these markers with minimal invasiveness and at multiple points throughout treatment and recovery. Here, we describe the development of an automated and integrated workflow for circulating tumor cell (CTC) analysis. We previously demonstrated that the CapioCyte method is a highly sensitive approach for enrichment of CTCs using a combination of biomimetic rolling on recombinant E-selectin and antibody-mediated capture on a nanostructured polymer surface within a flow chamber for capture. Here we report a fully automated CapioCyte instrument for CTC purification and immunofluorescence staining using epithelial, white blood cell and nuclear makers to identify and distinguish CTCs from WBCs while also quantifying EGFR or PD-L1 presence on respective CTCs. The immunostaining conditions were developed and validated for high analytical sensitivity and specificity using cell lines and health donor white blood cells with known biomarker status. The final assay conditions were transferred to the CapioCyte for automated immunostaining. CapioCyte enriched and stained CTC samples are paired with the BioView Allegro Plus platform, an imaging and analysis solution using machine learning and customized algorithms for automated imaging and CTC candidate identification based on high-resolution Z-stack images. The reported comprehensive and automated workflow was used to enumerate CTCs in patients with non-small cell lung carcinoma (NSCLC) in a feasibility cohort. Median CTC counts from NSCLC patients was 7.5 CTC/ml (n=26, mean 51.7, range 0.3 - 406.2). Studies are on-going to expand the cohort including testing blood from head and neck cancer patients and respective EGFR and PD-L1 status. The combined and automated CapioCyte-Allegro Plus workflow shows great potential for routine quantification of CTCs and EGFR and PD-L1 status. Citation Format: Ju-heon Lim, Chassidy Johnson, Tal Kaplan, Michael J. Poellmann, Yuval Harari, Elad Kfir, Andrew Z. Wang, Seungpyo Hong. Circulating tumor cell enumeration and protein expression by CapioCyte and Allegro Plus imaging [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 7499.

Abstract 2397: Double lung transplantation (DLT) in patients with stage IVA lung-limited non-small cell lung carcinoma (NSCLC): A case series

Abstract Introduction: Despite technological advances and expanded indications in lung transplantation, lung cancer constituted less than 0.1% of the lung transplantation over the past two decades. DLT may offer curative treatment for stage IVA NSCLC patients without extrapulmonary disease. We present a case series of consecutive NSCLC patients who underwent DLT. Methods: Patients treated with DLT were identified between 09/2021 and 09/2023 at Canning Thoracic Institute of Northwestern University. All patients had enrolled in the DLT registry aimed for lung-limited malignancies (DREAM) study (NCT05671887). Exclusion criteria include: presence of extrapulmonary disease and medical ineligibility for lung transplantation. All patients were followed up with computed tomography and tumor-informed ctDNA assay every 12 weeks. Results: Five patients with stage IVA NSCLC who underwent DLT were included. Three (60%) patients had invasive mucinous, and two (40%) had invasive non-mucinous adenocarcinoma histology. One of the two invasive non-mucinous patients had acinar, and the other had mixed lepidic, papillary, and acinar histology. Patients were aged 56-70; one (20%) was Asian, four (80%) were White, three (60%) were male, and two (40%) had a history of smoking. No patient had a past medical history of interstitial lung disease (ILD) or chronic obstructive pulmonary disease (COPD). All patients had high oxygen requirements before DLT due to cancer progression. Pre-transplant endobronchial ultrasound and evaluation of bilateral pneumonectomy lungs found no lymph node involvement (pN0). One patient had an epidermal growth factor receptor (EGFR) mutated cancer and but had failed relevant targeted therapy prior to transplant. All patients had disease progression on standard of care treatments with/without clinical trials. The indication for DLT was respiratory failure or refractory cancer for all patients. After DLT, one patient had a recurrence of the disease at 18 months with a 1cm solid nodule and was treated with stereotactic body radiotherapy (SBRT). Both original and recurrent tumors had invasive mucinous adenocarcinoma histology, negative PD-L1 expression, and the same JAK3 c.2174C>T, P725L mutated clone. It suggests that the recurrence likely arose from the original cancer. Transplant rejection did not occur in any of the cases. Following the transplant, there was no requirement for oxygen therapy for any patient. All patients are alive with 25, 15, 6, 3, and 1-month posttransplant follow-up. Conclusion: Five patients underwent DLT successfully without significant complications. Notably, one patient (25 months post-transplant) experienced cancer recurrence 18 months post-transplant and was effectively treated with SBRT. Ongoing DREAM study will continue to investigate the role of DLT in stage IVA NSCLC patients (especially in pN0). Citation Format: Young Kwang Chae, Tarik Demir, Liam Il-Young Chung, Carolyn Moloney, Rade Tomic, Ankit Bharat. Double lung transplantation (DLT) in patients with stage IVA lung-limited non-small cell lung carcinoma (NSCLC): A case series [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 2397.

Abstract 4252: Evaluation of NXI-101 in non-small cell lung cancer (NSCLC) using patient-derived organotypic tumor spheroids (PDOTS): Targeting a novel tumorigenic pathway

Abstract ONCOKINE-1 (OK-1), a soluble protein that is released by tumor cells, is implicated in the resistance of immunotherapy. Here we evaluated the efficacy of NXI-101, a monoclonal antibody that binds and neutralizes OK-1, in a model of patient-derived organotypic tumor spheroids (PDOTS) derived from non-small cell lung carcinoma (NSCLC) patients. NSCLC PDOTS were treated with NXI-101 and the effects of the drug were evaluated on day 3 post-treatment. Cytotoxicity was measured by Hoechst/Propidium Iodide staining and quantified by measuring the area-weighted percentage of cell death. Significant cytotoxicity was observed in 2 out of 10 patient tumors (20%) as a monotherapy and 4 out of 10 (40%) when used in combination with atezolizumab. The therapeutic response for both treatments was positively correlated (p<0.05) with the level of OK-1 expression, determined by immunohistochemistry using tissue sections taken on the day of tumor specimen collection. NXI-101 alone and in combination with atezolizumab had immunomodulatory effects that were associated with cytotoxic response. For example, transcriptomic analysis, Nanostring IO 360 Panel, indicated that the drug treatments resulted in the inhibition of TGF-β pathways and stimulated a number of immune pathways in 3 of the 4 responsive PDOTS. These pathways include interferon-α, JAK-STAT, and dendritic cell activation markers. We also observed evidence of activation of these same pathways in 2 of the 6 non-responsive PDOTS. These data support the prospects of NXI-101 as a first-in-class therapeutic for the treatment of NSCLC when used alone or in combination with an immune checkpoint inhibitor. Moreover, the findings highlight the PDOTS platform's substantial value in capturing patient-specific tumor response variability and providing robust support for the mechanistic evaluation of cancer therapeutics. Citation Format: Julia Vail, Hyung Gun Maeng, Je Woong Jang, Kyungjin Boo, Je-In Youn, Alyssa Martin, Aaron Goldman, Kyoung Wan Yoon, Michael A. Perricone. Evaluation of NXI-101 in non-small cell lung cancer (NSCLC) using patient-derived organotypic tumor spheroids (PDOTS): Targeting a novel tumorigenic pathway [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 4252.

Biomarker Turnaround Times and Impact on Treatment Decisions in Patients with Advanced Non-Small Cell Lung Carcinoma at a Large Canadian Community Hospital with an Affiliated Regional Cancer Centre.

Background: Timely reporting of molecular biomarkers is critical in guiding optimal treatment decisions in patients with advanced non-small cell lung carcinoma (NSCLC). Any delays along the tissue or treatment pathway may be associated with suboptimal treatment/outcomes and a reduced quality of life. For many centres, biomarkers are tested off-site. Methods: A retrospective chart review of 123 patients with advanced NSCLC seen between 1 June 2021 and 30 June 2022 was conducted. With a focus on core biomarkers (PD L1, EGFR, and ALK), the outcome variables were as follows: total turnaround time (total TAT), divided into pre-laboratory, laboratory, and post-laboratory time intervals, as well as time to treatment decision (TOTD) and time to optimal systemic therapy decision (TOTSD). Results: At first consult, only 20.3% of patients had all core biomarker results available. The median total TAT was significantly longer for non-squamous (non-SCC) than squamous cell carcinoma (SCC) specimens (36.5 versus 22 days, p < 0.001). The median pre-laboratory time for the entire cohort was 5 calendar days. The median laboratory testing time was greater for non-SCC compared to the SCC specimens (23 versus 12 days, p < 0.001). The median time from consult to TOTD was 19 calendar days for the entire cohort. Conclusions: This study emphasizes the need for the expansion of regional resources to meet the clinical needs of advanced NSCLC patients treated at a regional cancer centre which uses an off-site molecular laboratory.

Role of EBUS-TBNA in Mediastinal Staging of NSCLC Patients

Abstract Purpose Mediastinal staging in non-small-cell lung carcinoma (NSCLC) is essential for appropriate treatment. Invasive mediastinal staging is necessary and mediastinoscopy has been the gold standard, but it is associated with morbidity. The aim of this study is to evaluate the efficacy of endobronchial ultrasonography transbronchial needle aspiration (EBUS-TBNA), compare it with mediastinoscopy, and assess the endosonographic features of lymph nodes for prediction of metastasis. Methods This is a retrospective study of 200 patients with NSCLC who underwent EBUS-TBNA from January 2017 to December 2019. The patients with potentially resectable NSCLC who underwent EBUS-TBNA were included. Standard definitions of sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and diagnostic accuracy were used to determine the diagnostic performance of EBUS-TBNA. Results A total of 200 patients and 616 nodes were studied, out of which 515 were benign and 101 were malignant. Out of 200 cases, 129 (64.5%) had &lt;N2 disease, 59 (29.5%) had N2 disease, and 12 (6%) had N3 disease. EBUS-TBNA had a sensitivity of 78.87%, specificity of 96.12%, NPV of 89.2%, PPV of 91.8%, and accuracy of 90%. Ultrasonography (USG) features of 297 nodes were available and statistical significance was seen in rounded shape, size greater than 10 mm, ill-defined nodal margins, absence of hilum, and hypoechoic echotexture (p &lt; 0.05). Conclusion EBUS-TBNA is a safe and efficacious procedure for mediastinal sampling of NSCLC patients. Familiarity with endosonographic features of lymph nodes, which can predict malignancy in nodes, may further improve the yield of EBUS-TBNA and reduce under-staging.

The Role of miR-29a and miR-143 on the Anti-apoptotic MCL-1/cIAP-2 Genes Expression in EGFR Mutated Non-small Cell Lung Carcinoma Patients.

The survival rate of lung cancer is low due to the high frequency of drug resistance in patients with mutations in the driver genes. Overexpression of anti-apoptotic genes is one of the most prominent features of tumor drug resistance. EGFR signaling induces the expression of anti-apoptotic genes. Also, microRNAs (miRNAs) have a critical role in regulating biological functions such as apoptosis; a process mostly eluded in cancer progression. The mutation screening was performed on one thousand non-small cell lung carcinoma patients to enroll clinical samples in this study. Bioinformatics analysis predicted that miRNAs (miR-29a, miR-143) might regulate MCL-1 and cIAP-2 expression. We investigated the expression of MCL-1, cIAP-2, miR-29a, and miR-143 encoding genes in adenocarcinoma patients with or without EGFR mutations before treatment. The potential role of miR-29a and miR-143 on gene expression was evaluated by overexpression and luciferase assays in HEK-293T cells. EGFR mutations were found in 262 patients (26.2%) with a greater incidence in females (36.23% vs. 20.37%, P = 0.001). The expression levels of MCL-1 and cIAP-2 genes in patients with mutated EGFR were higher than those of wild-type EGFR. In contrast, compared to those of patients with wild-type EGFR, the expression levels of miR-29a and miR-143 were lower in the patients carrying EGFR mutations. In cell culture, overexpression of miR-29a and miR-143 significantly downregulated the expression of MCL-1 and cIAP-2. Dual-luciferase reporter experiments confirmed that miR-29a and miR-143 target MCL-1 and cIAP-2 mRNAs, respectively. Our results suggest that upregulation of EGFR signaling in lung cancer cells may increase anti-apoptotic MCL-1 and cIAP-2 gene expression, possibly through downregulation of miR-29a-3p and miR-143-3p.

Variant Allele Frequency Analysis of Circulating Tumor DNA as a Promising Tool in Assessing the Effectiveness of Treatment in Non-Small Cell Lung Carcinoma Patients.

Despite the different possible paths of treatment, lung cancer remains one of the leading causes of death in oncological patients. New tools guiding the therapeutic process are under scientific investigation, and one of the promising indicators of the effectiveness of therapy in patients with NSCLC is variant allele frequency (VAF) analysis. VAF is a metric characterized as the measurement of the specific variant allele proportion within a genomic locus, and it can be determined using methods based on NGS or PCR. It can be assessed using not only tissue samples but also ctDNA (circulating tumor DNA) isolated from liquid biopsy. The non-invasive characteristic of liquid biopsy enables a more frequent collection of material and increases the potential of VAF analysis in monitoring therapy. Several studies have been performed on patients with NSCLC to evaluate the possibility of VAF usage. The research carried out so far demonstrates that the evaluation of VAF dynamics may be useful in monitoring tumor progression, remission, and recurrence during or after treatment. Moreover, the use of VAF analysis appears to be beneficial in making treatment decisions. However, several issues require better understanding and standardization before VAF testing can be implemented in clinical practice. In this review, we discuss the difficulties in the application of ctDNA VAF analysis in clinical routine, discussing the diagnostic and methodological challenges in VAF measurement in liquid biopsy. We highlight the possible applications of VAF-based measurements that are under consideration in clinical trials in the monitoring of personalized treatments for patients with NSCLC.

Unveiling diagnostic potential of extracellular DNA and lung tissue-specific X gene expression in non-small cell lung carcinoma patients

BackgroundLiquid biopsy (circulating cells and biomolecules) has revolutionized a non-invasive, efficient, and accurate alternative to tissue biopsy. AimTo investigate the diagnostic utility of circulating cell-free (cf) DNA levels and lung tissue-specific X(LunX) gene expression and its association with micrometastasis in non-small cell lung carcinoma (NSCLC) patients. MethodsBlood (serum) samples of 81 NSCLC patients and matched 76 controls were collected, along with clinicopathological details. The cf-DNA was quantitated by amplifying β-globin and compared with the standard curve plotted by TaqMan control human genome DNA. LunX gene expression was measured by reverse transcription and SYBR Green chemistry-based real-time PCR. The relative fold was calculated by using the 2-ΔΔCT method. ResultsThe mean cf. DNA levels in NSCLC, lung squamous cell carcinoma (LUSC) and lung adenocarcinoma (LUAD) were significantly higher compared to controls (p < 0.0001). LunX gene expression was significantly higher in NSCLC (2.04-fold, p < 0.0001) and LUSC (1.90-fold, p < 0.0001); however, it slightly decreased in LUAD (1.31-fold, p < 0.0001) patients. With increased tumor size (T3 and T4), cf. DNA levels significantly increased (p < 0.0001). However, TNM was not associated with cf. DNA levels (p < 0.05). In contrast, LunX gene expression showed a higher fold with involvement of lymph nodes (N2; p = 0.015, N3; p = 0.009) and LunX 2-fold higher expression of LunX in metastasis (p = 0.0001). Smoking pack-year significantly influenced the levels of cf. DNA and LunX gene expression (p < 0.0001). There was no correlation between cfDNA levels and LunX gene expression (r = 0.06, p = 0.63). LunX demonstrated superior performance (AUC;0.886) with high sensitivity (100%) and specificity (62.96%). The cfDNA also showed good accuracy (AUC;0.729) but had a relatively low PPV. ConclusionLunX and cfDNA hold promise as potential non-invasive diagnostic biomarkers for NSCLC; however, LunX exhibited superior diagnostic performance in this study.

The Predictive Value of 8-Hydroxy-Deoxyguanosine (8-OHdG) Serum Concentrations in Irradiated Non-Small Cell Lung Carcinoma (NSCLC) Patients.

Ionizing radiation is strongly linked to direct or indirect DNA damage, as with the production of reactive oxygen species (ROS), which in turn produce DNA damage products, such as 8-hydroxy-2-deoxyguanosine (8-OHdG). In this study, we aimed to investigate the formation of 8-OHdG after irradiation in patients with non-small cell cancer (NSCLC) and its use as a biomarker. Sixteen patients with squamous and thirty-six patients with non-squamous pathology were included. An enzyme-linked-immunosorbent assay (ELISA) was performed before and after radiation. A dose-dependent relationship was confirmed: 8-OHdG plasma concentrations, increased in the total of NSCLC patients and specifically with a linear correlation in non-squamous pathology; in squamous histology, after an initial increase, a significant decrease followed after 20 Gy dose of irradiation. The pretreatment total irradiated tumor volume (cm3) was positively correlated with 8-OHdG levels in patients with squamous histology. When plotting the 8-OHdG plasma concentration at a 10 Gy irradiation dose to the baseline, the AUC was 0.873 (95% CI 0.614-0.984), p < 0.0001, with an associated criterion value of >1378 as a cutoff (sensitivity 72.7%, specificity 100%). When normalizing this ratio to BSA, the associated criterion cutoff value was >708 (sensitivity of 100%, specificity 80%). Lastly, 8-OHdG levels were closely related with the development of radiation-induced toxicities.

Disulfidptosis-related long non-coding RNAs predict prognosis and indicate therapeutic response in non-small cell lung carcinoma

Abstract Objectives Disulfidptosis is a novel form of cell death, whose modulation in tumor cells may present a promising therapeutic strategy for cancer treatment. However, the role of disulfidptosis-related long non-coding RNAs (lncRNAs) in non-small cell lung carcinoma (NSCLC) remains poorly elucidated. This study aims to investigate the prognostic significance of disulfidptosis-related lncRNAs (DRLs) and reveal their relationship to the immune microenvironment of NSCLC. Methods DRLs were identified through co-expression analysis of NSCLC transcriptomic data obtained from the Genomic Data Commons (GDC) data portal. The DRLs prognostic signature (DRLPS) was established using the least absolute shrinkage and selection operator (LASSO) and Cox regression analyses. Samples were separated into high-DS and low-DS groups based on the median disulfidptosis score (DS) of DRLPS. Integrated analyses were then implemented to unveil the association between DRLs and NSCLC microenvironment. These involved the evaluation of functional enrichments, immune cell infiltrations, genetic alterations, and drug sensitivity. Results A prognostic signature was developed based on six prognostic DRLs, which are AL606489.1, LINC00857, AP003555.1, AP000695.1, AC113346.1, and LINC01615. The Kaplan–Meier survival curves demonstrated the significant association between DRLPS and NSCLC prognosis. The functional enrichment assessment revealed the pivotal involvement of DRLs in immune regulation and metabolism in NSCLC. The low-DS and high-DS subgroups of NSCLC patients exhibited distinct differences in terms of immune infiltration and tumor mutation burden. The potential to predict immunotherapy benefit and drug sensitivity in NSCLC treatments was observed in DRLPS. Conclusions In this study, disulfidptosis-related lncRNAs were identified and their roles in NSCLC were revealed. A novel prognostic signature with the potential to predict drug response in NSCLC treatment was developed.

PAHPhysRAD: A Digital Imaging and Communications in Medicine Research Tool for Segmentation and Radiomic Feature Extraction

Introduction: Segmentation and analysis of organs at risks (OARs) and tumor volumes are integral concepts in the development of radiotherapy treatment plans and prediction of patients’ treatment outcomes. Aims: To develop a research tool, PAHPhysRAD, that can be used to semi- and fully automate segmentation of OARs. In addition, the proposed software seeks to extract 3214 radiomic features from tumor volumes and user-specified dose-volume parameters. Materials and Methods: Developed within MATLAB, PAHPhysRAD provides a comprehensive suite of segmentation tools, including manual, semi-automatic, and automatic options. For semi-autosegmentation, meta AI’s Segment Anything Model was incorporated using the bounding box methods. Autosegmentation of OARs and tumor volume are implemented through a module that enables the addition of models in Open Neural Network Exchange format. To validate the radiomic feature extraction module in PAHPhysRAD, radiomic features extracted from gross tumor volume of 15 non-small cell lung carcinoma patients were compared against the features extracted from 3D Slicer™. The dose-volume parameters extraction module was validated using the dose volume data extracted from 28 tangential field-based breast treatment planning datasets. The volume receiving ≥20 Gy (V20) for ipsilateral lung and the mean doses received by the heart and ipsilateral lung, were compared against the parameters extracted from Eclipse. Results: The Wilcoxon signed-rank test revealed no significant difference between the majority of the radiomic features derived from PAHPhysRAD and 3D Slicer. The average mean lung and heart doses calculated in Eclipse were 5.51 ± 2.28 Gy and 1.64 ± 1.98 Gy, respectively. Similarly, the average mean lung and heart doses calculated in PAHPhysRAD were 5.45 ± 2.89 Gy and 1.67 ± 2.08 Gy, respectively. Conclusion: The MATLAB-based graphical user interface, PAHPhysRAD, offers a user-friendly platform for viewing and analyzing medical scans with options to extract radiomic features and dose-volume parameters. Its versatility, compatibility, and potential for further development make it an asset in medical image analysis.

Evaluation of the effects of postoperative pleural empyema on survival rates of patients after pneumonectomy due to non-small cell lung cancer.

Postpneumonectomy empyema (PPE) is a severe and often fatal complication of pneumonectomy, but some benefits of PPE were reported in patients who underwent either lobe or an entire lung resection due to lung cancer. To compare the survival outcomes of patients with non-small-cell lung carcinoma (NSCLC), who developed PPE after pneumonectomy with uneventful recoveries available in our center's database. Outcomes of 928 pneumonectomies performed due to NSCLC between 1995 and 2009 were evaluated. The selection of the control group took into account the requirements for propensity score matching in terms of follow-up period, age, sex, tumor histopathology, TNM classification and the side of surgery. Thirty-two patients with a PPE syndrome and 96 patients without complications after pneumonectomy were included. The estimated 5- and 10-year survival rates were 71% and 59%, respectively. The average and median survival was almost two- and three-fold longer compared to the group with uneventful recoveries. A 2-fold lower cancer-related mortality rate and a 1.5-fold higher cancer-unrelated mortality rate were noted in the PPE group as opposed to the group without complications. Having recovered from PPE, the patients had their risk of death reduced by 2.5-fold and 3.5-fold due to all causes and cancer, respectively. Pleural empyema in NSCLC patients who underwent pneumonectomy seems to improve the survival outcomes compared to patients with uneventful recoveries.

Body composition radiomic features as a predictor of survival in patients with non-small cellular lung carcinoma: A multicenter retrospective study

ObjectivesThis study combined two novel approaches in oncology patient outcome predictions—body composition and radiomic features analysis. The aim of this study was to validate whether automatically extracted muscle and adipose tissue radiomic features could be used as a predictor of survival in patients with non-small cell lung cancer. MethodsThe study included 178 patients with non-small cell lung cancer receiving concurrent platinum-based chemoradiotherapy. Abdominal imaging was conducted as a part of whole-body positron emission tomography/computed tomography performed before therapy. Methods used included automated assessment of the volume of interest using densely connected convolutional network classification model - DenseNet121, automated muscle and adipose tissue segmentation using U-net architecture implemented in nnUnet framework, and radiomic features extraction. Acquired body composition radiomic features and clinical data were used for overall and 1-y survival prediction using machine learning classification algorithms. ResultsThe volume of interest detection model achieved the following metric scores: 0.98 accuracy, 0.89 precision, 0.96 recall, and 0.92 F1 score. Automated segmentation achieved a median dice coefficient >0.99 in all segmented regions. We extracted 330 body composition radiomic features for every patient. For overall survival prediction using clinical and radiomic data, the best-performing feature selection and prediction method achieved areas under the curve–receiver operating characteristic (AUC-ROC) of 0.73 (P < 0.05); for 1-y survival prediction AUC-ROC was 0.74 (P < 0.05). ConclusionAutomatically extracted muscle and adipose tissue radiomic features could be used as a predictor of survival in patients with non-small cell lung cancer.

Comprehensive molecular analysis of driver mutations in non-small cell lung carcinomas and its correlation with PD-L1 expression, An Indian perspective

BackgroundThe understanding of molecular mechanisms involved in non-small cell lung carcinoma (NSCLC) has revolutionized significantly in the recent years. These have helped to develop personalized management strategies by identifying specific molecular alterations such as mutations in EGFR, ROS1, BRAF, ERBB2, MET, ALK, and KRAS genes. These mutations are targetable ensuring a better clinical outcome. Next-generation sequencing (NGS) methodology is the recommended technique for the identification of driver mutations in the five hot-spot genes (EGFR, ALK, ROS1, MET, and BRAF) involved in the NSCLC. NGS has numerous advantages including multiplexing, tissue conservation, identification of rare and novel variants, and reduced cost over the sequential single gene testing. Herein, we sought to demonstrate the mutational profile in NSCLC and their clinicopathologic correlation in a contemporary cohort of Indian NSCLC patients. Additionally, we studied the correlation of oncogenic driver mutations with PD-L1 status in these patients. Materials and MethodsFive fifty-two stage IV NSCLC patients (adenocarcinoma=490; squamous cell carcinoma=51; adenosquamous carcinoma=5; large cell carcinoma=2; sarcomatoid carcinoma=3; spindle cell carcinoma=1) underwent broad molecular profiling by a custom-made, targeted DNA- and RNA-based five hot-spot genes lung cancer panel (EGFR, ALK, ROS1, BRAF, and MET), compatible with the NGS Ion S5 system. The mutations were correlated with the clinicopathologic characteristics. Additionally, PD-L1 expression status, available on 252 tumors, was correlated with the oncogenic drivers. ResultsValidation of the 5 gene panel yielded the following results: a) specificity of 99.74%; b) sensitivity of 100% for single nucleotide variants (SNVs) (>5% variant allele frequency, VAF), indels (>10% VAF) and fusions; c) 100% intra- and inter-run reproducibility; d) 88% inter-laboratory agreement. Validated panel was then used to analyze clinical samples. Sixty percentage tumors harbored either one (54.71%) or multiple (3.26%) mutations. EGFR and BRAF V600E mutations, ALK and ROS1 rearrangements, and MET exon 14 skipping mutation were observed in 38.41% (n = 212) and 2.72% (n = 15) patients, 12.14% (n = 67) and 3.62% (n = 20) patients, and 1.09% (n = 6) patients, respectively. EGFR exon 19 deletion accounted for 52.83% of all mutations, followed by L858R (35.85%), T790M (5.19%), exon 20 insertions (6.6%), and other rare mutations (G719X, L861Q, S768I) (9.91%). Concurrent EGFR with ALK, EGFR with ROS1, EGFR with MET, and EGFR with BRAF were observed in 10, 4, 1, and 3 patients, respectively. PD-L1 was expressed in 134 patients (53.2%). Exon 19 deletion was more prevalent in PD-L1 negative tumors whereas exon 21 substitution (L858R) was seen more in PD-L1 positive tumors. ConclusionsThis is one of the largest cohorts of NSCLC for comprehensive targeted mutational profiling and correlation with the PD-L1 expression. The mutations are more prevalent in non-smoker females for all genes, except ALK (non-smoker males). MET and BRAF mutations are more common in elderly population whereas EGFR mutations, and ALK and ROS1 genes rearrangements are more prevalent in younger population. The most common histopathologic subtype/feature associated with various mutations was as follows: acinar with EGFR, solid with ALK, macronucleoli with ROS1, signet ring with MET, and micropapillary with BRAF.

A Combination of Alectinib and DNA-Demethylating Agents Synergistically Inhibits Anaplastic-Lymphoma-Kinase-Positive Anaplastic Large-Cell Lymphoma Cell Proliferation.

The recent evolution of molecular targeted therapy has improved clinical outcomes in several human malignancies. The translocation of anaplastic lymphoma kinase (ALK) was originally identified in anaplastic large-cell lymphoma (ALCL) and subsequently in non-small cell lung carcinoma (NSCLC). Since ALK fusion gene products act as a driver of carcinogenesis in both ALCL and NSCLC, several ALK tyrosine kinase inhibitors (TKIs) have been developed. Crizotinib and alectinib are first- and second-generation ALK TKIs, respectively, approved for the treatment of ALK-positive ALCL (ALK+ ALCL) and ALK+ NSCLC. Although most ALK+ NSCLC patients respond to crizotinib and alectinib, they generally relapse after several years of treatment. We previously found that DNA-demethylating agents enhanced the efficacy of ABL TKIs in chronic myeloid leukemia cells. Moreover, aberrant DNA methylation has also been observed in ALCL cells. Thus, to improve the clinical outcomes of ALK+ ALCL therapy, we investigated the synergistic efficacy of the combination of alectinib and the DNA-demethylating agent azacytidine, decitabine, or OR-2100 (an orally bioavailable decitabine derivative). As expected, the combination of alectinib and DNA-demethylating agents synergistically suppressed ALK+ ALCL cell proliferation, concomitant with DNA hypomethylation and a reduction in STAT3 (a downstream target of ALK fusion proteins) phosphorylation. The combination of alectinib and OR-2100 markedly altered gene expression in ALCL cells, including that of genes implicated in apoptotic signaling, which possibly contributed to the synergistic anti-ALCL effects of this drug combination. Therefore, alectinib and OR-2100 combination therapy has the potential to improve the outcomes of patients with ALK+ ALCL.

Osimertinib as a Potential Targeted Therapy for Non-Small Cell Lung Carcinoma (NSCLC) Patients with EGFR Exon 20 T790M

BACKGROUND: Emergence of drug resistance due to epidermal growth factor receptor (EGFR) Exon 20 T790M poses a challenge in the effective management of non-small cell lung carcinoma (NSCLC). Significant breakthrough in the management of NSCLC with a specific genetic alteration causes substantial condition improvement in patients whose cancer progressed after first-generation tyrosine kinase inhibitor treatment and who developed tumors with EGFR Exon 20 T790M mutation. The present study analyzed a cohort of NSCLC patients and investigated the incidence of the EGFR Exon 20 T790M status with Osimertinib therapy, along with its impact on survival rates.METHODS: This was a retrospective cohort study on 22 NSCLC subjects who were genetically examined for EGFR status from plasmic cell free total nucleic acid. Subjects with EGFR Exon 20 T790M mutation were treated with/without Osimertinib. Demographic and clinical data were descriptively summarized, and the differences of each variable and correlation between survival rate and EGFR Exon 20 T790M were analyzed.RESULTS: Subjects with (n=13) and without (n=9) EGFR Exon 20 T790M had survival rates of 10.77±2.45 and 4.78±1.48, respectively (p=0.000). Based on 1-year survival status of subjects with EGFR Exon 20 T790M, there were 3 Osimertinib-treated survivors and 2 Osimertinib-treated non-survivors. Eight subjects with EGFR Exon 20 T790M and without Osimertinib treatment did not survive (p=0.001).CONCLUSION: Since the treatment of Osimertinib demonstrated a noteworthy survival rate among NSCLC subjects with EGFR Exon 20 T790M, thus Osimertinib could be suggested as a potential targeted therapy for NSCLC subjects with EGFR Exon 20 T790M.KEYWORDS: non-small cell lung carcinoma, EGFR, Exon 20, T790M, osimertinib

A Novel Dual-labeled Peptide for Multimodal Imaging of EGFR with L858R Mutation.

The development of molecular imaging agents targeting epidermal growth factor receptor (EGFR) with L858R mutation may help with the selection of non-small cell lung carcinoma (NSCLCL) patients who may benefit from EFGR tyrosine kinase inhibitor (TKI) therapy. In this study, we developed 99mTc STHHYYP-GHEG-ECGK-tetramethylrhodamine (STHHYYP-ECGK-TAMRA) to target EGFR with L858R mutation in NSCLC tumors and verified its probability as a molecular imaging agent. Fmoc solid-phase peptide synthesis was used to synthesize STHHYYP-ECGKTAMRA. 99mTc labelled STHHYYP-ECGK-TAMRA was prepared. Gamma imaging, fluorescent imaging and biodistribution were performed in murine models bearing NCI-H1975 and NCI-H1650 tumors. The binding affinity value (Kd) of 99mTc STHHYYP-ECGK-TAMRA was estimated to be 130.6 ± 29.2 nM in NCI-H1975 cells. The gamma camera images showed a substantial uptake of 99mTc STHHYYP-ECGK-TAMRA in the NCI-H1975 tumor. The % injected dose/gram of the NCI-H1975 tumor tissue was 2.77 ± 0.70 and 3.48 ± 1.01 at 1 and 3 h, respectively. Specific binding of 99mTc STHHYYP-ECGK-TAMRA to L858R-mutated EGFRpositive NCI-H1975 cells and tumors was demonstrated in in vivo and in vitro studies. The results suggest that 99mTc STHHYYP-ECGK-TAMRA is a good candidate agent for dualmodality imaging targeting EGFR with L858R mutation.

Desmoplasia in non-small cell lung carcinomas is associated with low programmed death-ligand 1 expression and the absence of tumor-infiltrating lymphocytes.

Programmed death-ligand 1 (PD-L1) is the most widely utilized predictive marker used to identify non-small cell lung carcinoma (NSCLC) patients most suitable for immunotherapy approaches. The relationship between PD-L1 expression, the presence of CD8+ T cells, and other clinicopathological characteristics of NSCLC patients has not been elucidated yet. In this retrospective study, we immunohistochemically determined PD-L1 expression (using clone 22C3) and CD8+ T cell count (using clone c8/144B) in surgical resection specimens from 698 advanced NSCLC patients. Results of PD-L1 expression and CD8+ T cell count were correlated to various clinicopathological characteristics, including the presence of desmoplasia in NSCLC. Regarding the immunological attributes of the tumor microenvironment, we identified major differences between desmoplastic and non-desmoplastic areas in NSCLC. Tumor areas without desmoplasia were significantly more often PD-L1 positive than tumor cell clusters encased in a dense collagenous stroma (p=0.004). Furthermore, the desmoplastic stroma contained significantly less often an immune cell infiltrate rich in CD8+ T cells (p<0.001). Also, the positivity of PD-L1 significantly correlated with advanced N-stage (p<0.001) and poor differentiation in adenocarcinomas (p=0.032) but not with other clinicopathological characteristics. In conclusion, to our knowledge, this is the first study that points to major differences in terms of immunological attributes between desmoplastic and non-desmoplastic areas in NSCLC. The desmoplastic component, therefore, may represent an immunologically distinct tumor area in which PD-L1 immunohistochemistry and CD8+ T cell count should be evaluated separately.

Deubiquitinating enzyme JOSD2 affects susceptibility of NSCLC cells to anti-cancer drugs through DNA damage repair.

To investigate the effects of deubiquitinating enzyme Josephin domain containing 2 (JOSD2) on susceptibility of non-small cell lung carcinoma (NSCLC) to anti-cancer drugs and its mechanism. The transcriptome expression matrix and clinical data of NSCLC were downloaded from the Gene Expression Omnibus database. Principal component analysis and limma analysis were used to investigate the deubiquitinating enzymes up-regulated in NSCLC tissues. Kaplan-Meier analysis was used to investigate the relationship between the expression of deubiquitinating enzymes and overall survival of NSCLC patients. Gene ontology enrichment and gene set enrichment analysis (GSEA) were used to analyze the activation of signaling pathways in NSCLC patients with high expression of JOSD2. Gene set variation analysis and Pearson correlation analysis were used to investigate the correlation between JOSD2 expression levels and DNA damage response (DDR) pathway. Western blotting was performed to examine the expression levels of JOSD2 and proteins associated with the DDR pathway. Immunofluorescence and quantitative analysis were used to detect the sub-localization of JOSD2. Sulforhodamine B staining was used to examine the sensitivity of JOSD2-knock-down NSCLC cells to DNA damaging drugs. Compared with adjacent tissues, the expression level of JOSD2 was significantly up-regulated in NSCLC tissues (P<0.05); and the expression of JOSD2 was significantly correlated with poor prognosis in NSCLC patients (P<0.05). Compared to tissues with low expression of JOSD2, the DDR-related pathways were significantly activated in NSCLC tissues with high expression of JOSD2 (P<0.05). In addition, the expression of JOSD2 was positively correlated with the activation of DDR-related pathways (P<0.01). Compared with control group, overexpression of JOSD2 significantly promoted the DDR in NSCLC cells. In addition, DNA damage agent significantly increase the nuclear localization of JOSD2, whereas depletion of JOSD2 significantly enhanced the sensitivity of NSCLC cells to DNA damaging agents (P<0.05). Deubiquitinating enzyme JOSD2 regulates the malignant progression of NSCLC by promoting DNA damage repair pathway, and depletion of JOSD2 significantly enhances the sensitivity of NSCLC cells to DNA damage agents.