Resected Early-stage Non-small Cell Lung Cancer Research Articles

EGFR mutation correlates with uninflamed phenotype and weak immunogenicity, causing impaired response to PD-1 blockade in non-small cell lung cancer

ABSTRACTPatients with EGFR mutations showed unfavorable response to programmed cell death-1 (PD-1) blockade immunotherapy in non-small cell lung cancer (NSCLC). Yet the underlying association between EGFR mutation and immune resistance remains largely unclear. We performed an integrated analysis of PD-ligand 1(PD-L1)/CD8 expression and mutation profile based on the repository database and resected early-stage NSCLC in Guangdong Lung Cancer Institute (GLCI). Meanwhile, 2 pool-analyses were set to clarify the correlation between EGFR mutation and PD-L1 expression, and the association of EGFR status with response to anti-PD-1/L1 therapy. Pool-analysis of 15 public studies suggested that patients with EGFR mutations had decreased PD-L1 expression (odds ratio: 1.79, 95% CI: 1.10–2.93; P = 0.02). Analysis of The Cancer Genome Atlas (TCGA) and the GCLI cohort confirmed the inverse correlation between EGFR mutation and PD-L1 expression. Furthermore, patients with EGFR mutation showed a lack of T-cell infiltration and shrinking proportion of PD-L1+/CD8+ TIL (P = 0.034). Importantly, patients with EGFR mutations, especially the sensitive subtype, showed a significantly decreased mutation burden, based on analysis of the discovery and validation sets. Finally, a pool-analysis of 4 randomized control trials confirmed that patients with EGFR mutation did not benefit from PD-1/L1 inhibitors (Hazard ratio [HR] = 1.09, P = 0.51) while patients with EGFR wild-type did (HR = 0.73, P < 0.00001). This study provided evidence of a correlation between EGFR mutations and an uninflamed tumor microenvironment with immunological tolerance and weak immunogenicity, which caused an inferior response to PD-1 blockade in NSCLCs.

Survival impact of postoperative therapy modalities according to margin status in non–small cell lung cancer patients in the United States

ObjectiveUnlike complete (R0) resection guidelines, current National Comprehensive Cancer Network (NCCN) adjuvant therapy guidelines after incomplete (R1/R2) resection of non–small cell lung cancer (NSCLC) are based on low-level evidence. We attempted to validate them. MethodsPatients with pathologic stage I-IIIA NSCLC from 2004 to 2011 in the National Cancer Database were stratified by margin status, NCCN-specified stage groupings, and adjuvant therapy exposure (none, radiotherapy, chemotherapy, or both). Five-year overall survival (OS) and hazard ratios, adjusted for patient and institutional characteristics, were compared. We used a parallel analysis of R0 resections to validate our methodology. ResultsWe analyzed 3461 R1/R2, and 78,979 R0 resections. After R0 resection, the NCCN-recommended option was associated with the best survival across all stage groups, supporting our analytic approach. Patients with R1/R2 stage IA treated with radiation had a 26% OS, compared with 58% with no treatment (P = .003). In patients with stage IB/IIA(N0) R1/R2, radiation was associated with a 25% OS compared with 47% with no treatment (P = .025) and 62% with chemotherapy (P < .007). Chemoradiation was not associated with a survival benefit in either group. Patients with IIA(N1)/IIB and IIIA had better survival with chemotherapy or chemoradiation. No group had a survival benefit with radiation alone. ConclusionsNCCN adjuvant therapy guidelines after complete resection, based on high-level evidence, are validated, but not guidelines for patients with incompletely resected early-stage NSCLC, which are based on low-level evidence. Monomodality postoperative radiotherapy was not validated for any stage. Specific studies are needed to determine optimal management after incomplete resection.

ED08.04 Perspectives of Targeted Therapies and Immunotherapy in Completely Resected NSCLC

ED08.04 Perspectives of Targeted Therapies and Immunotherapy in Completely Resected NSCLC

OA20.06 Prospective ImmunogenomiC PrOfiling of Non-Small Cell Lung Cancer - The ICON Project

Previous attempts to define tumor and stromal immunologic environment in non-small cell lung cancer (NSCLC) utilized archival tissue. We established prospective comprehensive immonogenomic profiling protocol in NSCLC (ICON Project). The goal is to integrate immunomic, genomic, transcriptomic, proteomic, demographic, clinical, pathologic, and outcome data from 100 surgically resected early stage NSCLC. Tumor and normal lung tissue are collected at the time of surgery, blood samples before and after surgery. Tumor samples are processed for tumor infiltrating lymphocyte (TILs) isolation and expansion; development of patient derived xenografts (PDX), immunohistochemical immune markers, and immunopeptidome profiling. Blood samples are analyzed with flow cytometry. 57 patients with median age of 65 years (27 males) have been enrolled within 5 months, of which 33 (66%) contributed samples to the study. Four were never smokers, with others being former or current smokers. Majority (N=27) had adenocarcinoma, 4 squamous cell carcinoma, and 2 pleomorphic carcinoma. 15 patients had stage I, 11 stage II, and 7 stage III disease; 5 patients received induction chemotherapy. Median tumor size was 3.5 cm and 29 underwent R0 and 4 R1 resection. Pre-REP TIL expansion was successful in the majority of samples (68.2%, n=22). Twelve PDX models with a take rate of 40% have been generated. Interim analysis of tumor samples by IHC demonstrated higher median distribution of all cell types: CD3+ T cells, cytotoxic T cells CD8+, PD1+ cells, tumor associated macrophages (TAM) CD68+, TAM CD68+PD-L1+, CD20+B cells, memory T cells CD45R0, natural killer cells CD57+, regulatory FOXP3+ T cells, and cytotoxic granzyme B cells (cells/mm2) in the stroma as compared to the tumor compartment. Intra-tumoral regulatory FOXP3+T cells were more abundant in squamous cell carcinomas compared to adenocarcinomas (median 312 vs 51 cells/mm2, p = 0.05). Higher concentration of intra-tumoral CD68+PD-L1+ expressing cells was observed following neoadjuvant chemotherapy (median 97 vs 60 cells/mm2 no chemo; p= 0.077), as was the concentration of memory T cells CD45R0 (median 129 vs 30 cells/mm2, no chemo; p = 0.077). Mass spectrometry-based immunopeptidome analysis identified several thousand peptides, of which 4 promising antigens have been chosen for further development as immunotherapeutic T-cell targets. The ICON is an ongoing, ambitious prospective project that aims to define the baseline immunologic characteristics of surgically resectable NSCLC. The rapid enrollment illustrates the enthusiasm for tumor immunoprofiling amongst patients and physicians alike. Data from this patient cohort will serve as a baseline comparison for upcoming neoadjuvant immunotherapy trials.

Clinical implications of sarcopenia in patients undergoing complete resection for early non-small cell lung cancer

ObjectivesSarcopenia is characterized by progressive and generalized loss of skeletal muscle mass and strength. We aimed to investigate sarcopenia in patients with stage I non-small cell lung cancer (NSCLC) who underwent complete resection, and the relationship of sarcopenia with clinicopathological factors. MethodsAll consecutive patients who underwent lung resection between January 2005 and December 2008 were enrolled in this retrospective study. Eligible patients were assigned to one of 2 groups according to the presence or absence of sarcopenia, as assessed by the sum of cross-sectional areas of skeletal muscles in the region of the third lumbar vertebra (L3) on preoperative computed tomography (CT). ResultsSixteen of 52 male (30.8%) and 22 of 38 female (57.9%) patients were identified with sarcopenia (p=0.01). Patients with sarcopenia were more likely to have a low body mass index (BMI) (p<0.0001). Kaplan-Meier analysis showed that patients with sarcopenia had a significantly worse outcome than patients without sarcopenia (5-year-survival: 72.8% vs 85.8%, respectively, p=0.028). Multivariate analysis found that sarcopenia was a significant independent prognostic factor (hazard ratio: 7.09, p=0.0008). ConclusionsSarcopenia identified on a cross-sectional CT image of the L3 level was associated with poor outcome with completely resected early-stage NSCLC.

Video-assisted thoracoscopic surgery lobectomy for lung cancer versus thoracotomy: a less decrease in sVEGFR2 level after surgery.

Angiogenic and anti-angiogenic factors play an important role in tumor biology and tumor recurrence after surgical resection. Antiangiogenic factors such as vascular endothelial growth factor (VEGF)-receptor 1 (sVEGFR1) and sVEGFR2, two soluble form receptor proteins of VEGF, are critical for angiogenesis. VEGF can be sequestered by soluble forms of these receptors, which result in decreasing VEGF amount available to bind to its receptor on vascular endothelial cell surface. This study aimed to investigate the influences of video-assisted thoracoscopic surgery (VATS) lobectomy and open by thoracotomy for early stage non-small cell lung cancer (NSCLC) on postoperative circulating sVEGFR1 and sVEGFR2 levels. Forty-eight lung cancer patients underwent lobectomy through either VATS (n=26) or thoracotomy (n=22). Blood samples were collected from all patients preoperatively and postoperatively on days 1, 3 and 7. ELISA analysis was used to determine the plasma levels of sVEGFR1 and sVEGFR2. Data are reported as means and standard deviations, and were assessed with the Wilcoxon signed-Rank test (P<0.05). For all patients undergoing lobectomy, postoperative sVEGFR1 levels on days 1 and 3 were markedly increased, while postoperative sVEGFR2 levels on days 1 and 3 were significantly decreased. Moreover, VATS group had significantly higher plasma level of sVEGFR2 postoperative in comparison with open thoracotomy (OT) on day 1 (VATS 6,953±1,535 pg/mL; OT 5,874±1,328 pg/mL, P<0.05). Major pulmonary resection for early stage NSCLC resulted in the increased sVEGFR1 and decreased sVEGFR2 productions. VATS is associated with enhanced anti-angiogenic response with higher circulating sVEGFR2 levels compared with that with OT. Such differences in anti-angiogenic response may have an important effect on cancer biology and recurrence after surgery.

KRAS mutation is a weak, but valid predictor for poor prognosis and treatment outcomes in NSCLC: A meta-analysis of 41 studies.

Mutation of oncogene KRAS is common in non-small cell lung cancer (NSCLC), however, its clinical significance is still controversial. Independent studies evaluating its prognostic and predictive value usually drew inconsistent conclusions. Hence, We performed a meta-analysis with 41 relative publications, retrieved from multi-databases, to reconcile these controversial results and to give an overall impression of KRAS mutation in NSCLC. According to our findings, KRAS mutation was significantly associated with worse overall survival (OS) and disease-free survival (DFS) in early stage resected NSCLC (hazard ratio or HR=1.56 and 1.57, 95% CI 1.39-1.76 and 1.17-2.09 respectively), and with inferior outcomes of epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKIs) treatment and chemotherapy (relative risk or RR=0.21 and 0.66 for objective response rate or ORR, 95% CI 0.12-0.39 and 0.54-0.81 respectively; HR=1.46 and 1.30 for progression-free survival or PFS, 95%CI 1.23-1.74 and 1.14-1.50 respectively) in advanced NSCLC. When EGFR mutant patients were excluded, KRAS mutation was still significantly associated with worse OS and PFS of EGFR-TKIs (HR=1.40 and 1.35, 95 % CI 1.21-1.61 and 1.11-1.64). Although KRAS mutant patients presented worse DFS and PFS of chemotherapy (HR=1.33 and 1.11, 95% CI 0.97-1.84 and 0.95-1.30), and lower response rate to EGFR-TKIs or chemotherapy (RR=0.55 and 0.88, 95 % CI 0.27-1.11 and 0.76-1.02), statistical differences were not met. In conclusion, KRAS mutation is a weak, but valid predictor for poor prognosis and treatment outcomes in NSCLC. There's a need for developing target therapies for KRAS mutant lung cancer and other tumors.

Prognostic Significance of CD31 Expression in Patients with Non-Small-Cell-Lung Cancer

Non-small cell lung cancer (NSCLC) is the primary cause of cancer related death worldwide. After resection of early stage NSCLC, the benefit of adjuvant chemotherapy for patient survival still remains unclear and investigations for further risk stratification are needed for an improved treatment decision. Microvessel density (MVD) influences both the nutrition of the cancer and the access to the bloodstream for the development of distant metastasis. The aim of this study was to examine the prognostic significance of microvessel density by CD31 staining in patients with resected stage IA-IIIB NSCLC. We used immunohistochemistry (IHC) of CD31 to examine the microvessel density in a cohort of 69 patients who had undergone radical resection for NSCLC. Correlation of IHC values and standard clinicopathologic parameters was analyzed as well as influence on long term survival. Survival analysis revealed a significant better overall survival for patients with higher median microvessel density (log rank p = 0.031) independent of clinicopathologic parameters. Regarding primary cancer related death, the survival was again significantly longer in patients with high CD31 count (log rank p = 0.036). A higher microvessel density was a strong predictor for a longer tumor related survival and could be used for therapeutic decisions of adjuvant chemotherapy after resection of early stage NSCLC.

Mortality in early-stage, surgically resected non-small cell lung cancer less than 3 cm of size: Competing risk analysis

Background and objectiveSurvival studies of non-small cell lung cancer (NSCLC) are usually based on the Kaplan–Meier method. However, other factors not covered by this method may modify the observation of the event of interest. There are models of cumulative incidence (CI), that take into account these competing risks, enabling more accurate survival estimates and evaluation of the risk of death from other causes. We aimed to evaluate these models in resected early-stage NSCLC patients. Patients and methodThis study included 263 patients with resected NSCLC whose diameter was ≤3cm without node involvement (N0). Demographic, clinical, morphopathological and surgical variables, TNM classification and long-term evolution were analyzed. To analyze CI, death by another cause was considered to be competitive event. For the univariate analysis, Gray's method was used, while Fine and Gray's method was employed for the multivariate analysis. ResultsMortality by NSCLC was 19.4% at 5 years and 14.3% by another cause. Both curves crossed at 6.3 years, and probability of death by another cause became greater from this point. In multivariate analysis, cancer mortality was conditioned by visceral pleural invasion (VPI) (p=0.001) and vascular invasion (p=0.020), with age>50 years (p=0.034), smoking (p=0.009) and the Charlson index≥2 (p=0.000) being by no cancer. ConclusionsBy the method of CI, VPI and vascular invasion conditioned cancer death in NSCLC>3cm, while non-tumor causes of long-term death were determined.

Cons: long-term CT-scan follow-up is not the standard of care in patients curatively treated for an early stage non-small cell lung cancer.

About 25% of patients with early stage (I, II, IIIA non-N2) non-small cell lung cancer (NSCLC) qualify for a treatment with curative intent, consisting of either radical surgical resection or radical radiotherapy. The former consists of at least an anatomical lobectomy, the latter is nowadays mainly given at ablative doses with stereotactic techniques (SABR). Radically treated patients may develop either locally or distantly relapsing lung cancer, or a second primary (lung) cancer. Besides, they retain a significant excess conditional mortality with an increasing relative contribution of cardiovascular and respiratory co-morbidity (1). Recurrence dynamics of resected early-stage NSCLC displays a multipeak pattern, which supports the hypothesis of a metastasis growth model previously described for early-stage breast cancer (2). An initial surge in the hazard rate 9 months after surgery, is followed by two smaller peaks at the end of the second and fourth years, respectively ( Figure 1 ). This pattern is dominated by distant metastatic events which decrease over time and are virtually absent after 5 years. Two distinguishable peaks are noted for local recurrence in the first and second years, but this is rare thereafter. The risk of local or distant recurrence is 10-38%, mainly dependent of stage and highest in pII-III NSCLC. This risk can be moderately reduced by the administration of postoperative platinum-based chemotherapy, with an average increase in 5 year survival of 5% (3). In contrast, the hazard rate for second primary lung cancer exhibits a more uniform pattern over time, is 1% to 4% per patient per year in most series (4) and increases even after 5 years. The median time interval between the two tumours is 14.5 months (5,6). Lastly, these patients are at risk of developing a second primary nonrespiratory cancer: the most frequently diagnosed tumours are located in the head and neck and the urinary tract.

Keratin 34betaE12/keratin7 expression is a prognostic factor of cancer-specific and overall survival in patients with early stage non-small cell lung cancer

Background. Carcinomas and their metastases often retain the keratin patterns of their epithelial origin, and are therefore useful as lineage-specific markers in diagnostic pathology. Recently, it has become clear that intermediate filaments composed by keratins play a role in modulation of cell proliferation, migration, and possibly cancer invasion, factors impacting prognosis in early stage non-small cell lung cancer (NSCLC).Material and methods. Tumor tissue from a retrospective Danish cohort of 177 patients with completely resected NSCLC, stage I-IIIA tumors, were analyzed for keratin 7 (K7) and keratin 34βE12 expression by immunohistochemistry and validated in a comparable independent Norwegian cohort of 276 stage I-IIIA NSCLC patients.Results. Based on keratin 34βE12/K7 expression, three subgroups with significantly different median cancer-specific survival rates were identified (34βE12+/K7+, 168 months vs. 34βE12+/K7+, 73 months vs. 34βE12-/K7+, 30 months; p = 0.0004). In multivariate analysis, stage II-IIIA (HR 2.9), 34βE12+/K7+ (HR 1.90) and 34βE12-/K7+ (HR 3.7), were prognostic factors of poor cancer-specific survival (CSS) (p < 0.001). Validation in the Norwegian cohort confirmed that stage II-IIIA (HR 2.3), 34βE12+/K7+ (HR 1.6), and 34βE12-/K7+ (HR 2.0) were prognostic factors of poor CSS (p < 0.05). Multivariate Cox proportional-hazard analysis demonstrated that 34βE12+/K7 + and 34βE12+/K7 + status was significantly associated with poor overall survival (p < 0.05).Conclusion. Keratin 34βE12/K7 expression is a prognostic parameter in resected early stage NSCLC that allows identification of high-risk NSCLC patients with poor cancer-specific and overall survival.

Defining the High-Risk Population for Mortality After Resection of Early Stage NSCLC

BackgroundStudies examining morbidity after lobectomy for early stage non–small-cell lung cancer (NSCLC) demonstrate a > 50% incidence of complications in patients aged ≥ 65 years. Factors that affect 30-day mortality (30-DM), however, are less well defined. Materials and MethodsThe National Cancer Data Base was used to identify patients age ≥ 19 years with stage I NSCLC between 2003 and 2011. Data from patients undergoing lobectomy or sublobar resection was abstracted. Univariable and multivariable logistic regression analyses were performed for predictors of 30-DM. ResultsA total of 71,175 patients met inclusion criteria. Of these, 81% underwent lobectomy and 19% underwent sublobar resection. The median age was 68 years. Charlson-Deyo (CD) comorbidity score was 0 in 49% of patients and 1 or higher in 51%. The rate of 30-DM was 2.2%. On multivariable analysis, younger age, CD score of 0, female sex, tumor size ≤ 3 cm, and treatment at an academic center was associated with lower 30-DM (P < .001). A model of 30-DM incorporating age, comorbidity, and extent of surgery was created. In patients aged < 75 years without comorbidities, 30-DM was 1.3%. However, in elderly patients (≥ 75 years old) with CD score of 2, this rate quadrupled to 5.8% (P < .01). Lobectomy patients in this group had higher 30-DM compared to sublobar resection patients (6.6% vs. 3.9% respectively, P < .01). ConclusionThe 30-DM rate following sublobar or lobar resection in this national sample was low. Extent of resection appears to influence 30-DM in the elderly. Elderly patients with a CD score of 2 undergoing lobectomy represent a high-risk group for 30-DM.

Defining the role of tyrosine kinase inhibitors in early stage non-small cell lung cancer.

Historical, the non-small cell lung cancer (NSCLC) was as a united disease entity and the chemotherapy to the metastatic cancer had limited results. Recent studies for the metastatic non-small cell lung cancer led to the ascertainment that the NSCLC does not constitute exclusively a disease entity, but different neoplasms guided from different molecular paths, different biological behavior and at extension requires different confrontation. Thus the new direction for the therapeutic approach of NSCLC is henceforth the most individualized approach based on the activated molecular paths of tumor. Distinct subtypes of NSCLC are driven by a specific genetic alteration, like EGFR, ALK, ROS1 or BRAF mutations, and these genetic alterations are sensitized to the inhibition of specific oncogenic pathways. The benefit from the use of tyrosine kinase inhibitors in patients with EGFR mutations it was confirmed by six randomized studies of phase III that investigated the role of gefitinib, erlotinib and afatinib. In these studies the response rates vary in the impressive percentages from 55% to 86% and were connected with a remarkable median progression free survival of approximately 8 to 13 months, and with better quality of life compared to that of chemotherapy. In early stages NSCLC is needed the individualization of systemic treatment in order to reduce toxicity that is observed in the classic chemotherapy and to impact outcome. The role of EGFR TKI's has been evaluated in the adjuvant chemotherapy in early stage resected NSCLC. The data from these studies suggest that adjuvant TKI therapy might not increase the overall survival, but delay the recurrences. Prospective trials restricted to EGFR or ALK driven NSCLC subsets potentially offering the opportunity for a definitive answer in early disease adjuvant setting (ALCHEMIST) or as induction treatment before stage III chemo-radiotherapy (RTOG 1210/Alliance 31101), are ongoing. Ongoing prospective trials may offer the opportunity for a definitive answer of the role of tyrosine kinase inhibitors in induction treatment before chemo-radiotherapy or in early disease adjuvant therapy.

Mortalidad en carcinoma pulmonar no microcítico resecado, con tamaño máximo de 3 cm y sin afectación ganglionar: análisis de riesgos competitivos

Background and objectiveSurvival studies of non-small cell lung cancer (NSCLC) are usually based on the Kaplan-Meier method. However, other factors not covered by this method may modify the observation of the event of interest. There are models of cumulative incidence (CI), that take into account these competing risks, enabling more accurate survival estimates and evaluation of the risk of death from other causes. We aimed to evaluate these models in resected early-stage NSCLC patients. Patients and methodThis study included 263 patients with resected NSCLC whose diameter was≤3cm without node involvement (N0). Demographic, clinical, morphopathological and surgical variables, TNM classification and long-term evolution were analysed. To analyse CI, death by another cause was considered to be competitive event. For the univariate analysis, Gray's method was used, while Fine and Gray's method was employed for the multivariate analysis. ResultsMortality by NSCLC was 19.4% at 5 years and 14.3% by another cause. Both curves crossed at 6.3 years, and probability of death by another cause became greater from this point. In multivariate analysis, cancer mortality was conditioned by visceral pleural invasion (VPI) (P=.001) and vascular invasion (P=.020), with age>50 years (P=.034), smoking (P=.009) and the Charlson index≥2 (P=.000) being by no cancer. ConclusionsBy the method of CI, VPI and vascular invasion conditioned cancer death in NSCLC>3cm, while non-tumor causes of long-term death were determined.

Abstract 1184: Modeling mechanisms of resistance of epidermal growth factor receptor (EGFR) mutations to targeted drugs through patient-derived xenografts (PDX) of non-small cell lung cancer (NSCLC)

Abstract Background: Resistance to small molecule EGFR tyrosine kinase inhibitors (TKIs) is seen in some NSCLC patients with activating EGFR mutations. We evaluated in vivo PDX models for their utility in studying EGFR-targeted drug resistance mechanisms. Methods: Surgically resected early stage NSCLC tumors were implanted into non-obese diabetic severe combined immune deficient (NOD-SCID) mice. Tumors were passaged and expanded in new mouse hosts once the humane endpoint of 1.5 cm maximum diameter was reached. EGFR TKI treatment was initiated at an average tumor volume of 150mm3. Treatments included daily oral gavage with first and second generation EGFR TKIs, and with weekly intraperitoneally administered cetuximab. Results: Of the 55 NSCLC tumors with EGFR activating mutations, only 6 engrafted (11%) and could be propagated beyond the first passage, and 4 have been studied for their responsiveness to EGFR-targeted agents. Model 148, developed from a patient who received pre-operative erlotinib, showed intrinsic pan-resistance to all EGFR-targeted therapies despite having an L858R mutation. The corresponding patient did not respond to erlotinib, relapsed after surgery and did not receive additional TKI therapy. Model 137, with an exon19 E746-A750 deletion, recapitulated the patient's response to gefitinib at relapse; this model was sensitive to first and second generation EGFR TKIs. Model 192 also has the exon19 E746-A750 deletion, however it did not recapitulate the patient's observed sensitivity to erlotinib. Selection for a MET amplified population during engraftment may be the cause for the disparate drug sensitivities. Model 164 has a double exon19 L747-T751 deletion and T790M EGFR mutation. Neither patient nor xenograft responded to erlotinib; the xenograft responded to cetuximab. Resistance developed over time to a second generation EGFR TKI; this resistant phenotype was not stable as each subsequent passage of the ‘resistant’ tumor exhibited the same initial response pattern. Two potential mechanisms for this transient sensitivity are currently being investigated: epigenetic mechanisms and intratumoural mutational heterogeneity. Conclusions: PDX models may provide important insight into biomarkers and mechanisms of resistance to targeted therapies, and provide a means to test novel treatment strategies to improve future treatment efficacies. Citation Format: Erin L. Stewart, Celine Mascaux, Shingo Shakashita, Devang Panchal, Dennis Wang, Ming Li, Nhu-An Pham, Natasha Leighl, Geoffrey Liu, Frances A. Shepherd, Ming-Sound Tsao. Modeling mechanisms of resistance of epidermal growth factor receptor (EGFR) mutations to targeted drugs through patient-derived xenografts (PDX) of non-small cell lung cancer (NSCLC). [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 1184. doi:10.1158/1538-7445.AM2014-1184

Transcriptomic Architecture of the Adjacent Airway Field Cancerization in Non–Small Cell Lung Cancer

Earlier work identified specific tumor-promoting abnormalities that are shared between lung cancers and adjacent normal bronchial epithelia. We sought to characterize the yet unknown global molecular and adjacent airway field cancerization (FC) in early-stage non-small cell lung cancer (NSCLC). Whole-transcriptome expression profiling of resected early-stage (I-IIIA) NSCLC specimens (n = 20) with matched tumors, multiple cytologically controlled normal airways with varying distances from tumors, and uninvolved normal lung tissues (n = 194 samples) was performed using the Affymetrix Human Gene 1.0 ST platform. Mixed-effects models were used to identify differentially expressed genes among groups. Ordinal regression analysis was performed to characterize site-dependent airway expression profiles. All statistical tests were two-sided, except where noted. We identified differentially expressed gene features (n = 1661) between NSCLCs and airways compared with normal lung tissues, a subset of which (n = 299), after gene set enrichment analysis, statistically significantly (P < .001) distinguished large airways in lung cancer patients from airways in cancer-free smokers. In addition, we identified genes (n = 422) statistically significantly and progressively differentially expressed in airways by distance from tumors that were found to be congruently modulated between NSCLCs and normal lung tissues. Furthermore, LAPTM4B, with statistically significantly increased expression (P < .05) in airways with shorter distance from tumors, was upregulated in human immortalized cells compared with normal bronchial epithelial cells (P < .001) and promoted anchorage-dependent and -independent lung cancer cell growth. The adjacent airway FC comprises both site-independent profiles as well as gradient and localized airway expression patterns. Profiling of the airway FC may provide new insights into NSCLC oncogenesis and molecular tools for detection of the disease.

Chronic Obstructive Pulmonary Disease in Stage I Non-small Cell Lung Cancer That Underwent Anatomic Resection: The Role of a Recurrence Promoter

Background: Despite the use of anatomic resection, the post-surgical recurrence rate remains high in early-stage non-small cell lung cancer (NSCLC). Chronic inflammation plays a role in the mechanism that promotes tumor initiation. This study aimed to investigate the association between recurrence outcome and chronic inflammation-related co-morbidities in early-stage resected NSCLC. Methods: A review of medical records for recurrence outcome and co-morbidities, in terms of chronic obstructive pulmonary disease (COPD), DM, asthma and cardiovascular diseases, was performed with 181 patients with stage I NSCLC that underwent anatomic resection. Results: Subjects with T descriptors as T2a disease (49.5 vs. 28.0%, p < 0.05) and the presence of COPD (42.4 vs. 20.7%, p < 0.01) had a higher risk of tumor recurrence. Univariate analysis for recurrence-free survival showed T descriptor as T2a (21.5 months vs. NR, p < 0.05) and the presence of COPD (20.5 months vs. NR, p < 0.01) as significant factors predicting reduced survival. The presence of COPD (HR: 1.98; 95% CI, 1.29–.02, p < 0.01) and T descriptor as T2a (HR: 2.01; 95% CI, 1.04–3.91, p < 0.05) remain independent predictors of reduced recurrence-free survival in the Cox regression model. Patients with COPD were at higher risk of brain recurrence (OR: 7.88; 95% CI, 1.50–41.3, p < 0.01). In contrast, patients without COPD showed a tendency toward recurrence in bone and liver (OR: 4.13; 95% CI, 1.08–15.8, p = 0.05). Conclusion: Subjects with COPD and T2a disease had a higher risk of recurrence. The role of COPD as a recurrence promoter merits further prospective investigation.

Metformin and Not Diabetes Influences the Survival of Resected Early Stage NSCLC Patients.

Published data suggest that diabetes influences survival of patients with lung cancer. The anti-cancer effect of metformin confounds this association. We sought to study the association of diabetes and metformin with survival in patients undergoing resection of stage I non-small cell lung cancer (NSCLC). Pathologic stage I NSCLC patients undergoing anatomic resection from 2002 to 2011 were studied. A diagnosis of diabetes and diabetic medication use were identified through records. Univariate and multivariate analyses examined the association of diabetes and metformin usage with overall survival (OS). 409 eligible patients were included in the analysis - excluding patients with neoadjuvant therapy, more than one lung cancer, or resection less than lobectomy. 71 (17.4%) patients were diabetics and 41 (10.0%) used metformin. With a median follow up of 44 months, univariate analysis demonstrates that diabetes had no effect on OS (P=0.75); however, metformin use was associated with improved OS (median survival not reached vs. 60 months; P=0.02). Metformin use remained an important predictor of good survival in multivariate analysis (HR=3.08; P<0.01) after adjusting for age, gender, pathologic stage, histology and smoking status. Metformin use rather than diabetes is associated with improved long-term survival in Stage I NSCLC patients.

Association between Genetic Variants in Pre-MicroRNAs and Survival of Early-Stage NSCLC

MicroRNAs (miRNAs) are an abundant class of small non-protein-coding RNAs that function as negative gene regulators. Recent evidence indicates that altered miRNA expression plays an important role in the initiation and progression of lung cancer. Single nucleotide polymorphisms (SNPs) in pre-miRNAs could alter miRNAs processing, or expression, and hence, could influence the prognosis of lung cancer. To test this hypothesis, we evaluated the effects of four SNPs in pre-miRNAs (pre-miR-146a rs2910164, pre-miR-149 rs2292832, pre-miR-196a rs11614913, and pre-miR-499 rs3746444) on the survival outcomes of patients with early-stage non-small-cell lung cancer (NSCLC). Three hundred sixty-three patients with surgically resected NSCLC were enrolled. The four SNPs were genotyped using a polymerase chain reaction-restriction fragment length polymorphism assay. The genotype associations with overall survival (OS) and disease-free survival (DFS) were analyzed. Of the four SNPs examined, the pre-miR-149 rs2292832T>C and pre-miR-196a rs11614913C>T were found to be significantly associated with OS and DFS. The rs2292832 TC or CC genotype exhibited a significantly better OS and DFS compared with the rs2292832 TT genotype (adjusted hazard ratio [aHR] for OS, 0.66; 95% confidence interval [CI], 0.47-0.92; p = 0.01 and aHR for DFS, 0.64; 95% CI, 0.48-0.87; p = 0.004). For the pre-miR-196a rs11614913C>T, patients with the CT or TT genotype had a significantly better OS and DFS than those with the CC genotype (aHR for OS, 0.70; 95% CI, 0.49-0.99; p = 0.05 and aHR for DFS, 0.66; 95% CI, 0.48-0.90; p = 0.01). When the two SNPs were combined, OS and DFS improved in a dose-dependent manner as the number of good genotypes increased (p = 0.002 and 0.0001, respectively). These results suggest that miR-149 and miR-196a may be involved in the pathogenesis of NSCLC, and that rs2292832 and rs11614913 can be used as prognostic markers for patients with surgically resected early-stage NSCLC.

Pemetrexed-carboplatin adjuvant chemotherapy with or without gefitinib in resected stage IIIA-N2 non-small cell lung cancer harbouring EGFR mutations: A randomized phase II study.

7519 Background: Epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) show great efficacy in patients with advanced non-small cell lung cancer (NSCLC) with EGFR mutations. The BR.19 trial exploring the role of adjuvant gefitinib in resected early stage NSCLC (stage IB 49%, II 38%, III 13%) did not show significant progression-free survival (PFS) or overall survival (OS) improvement in all patients. The efficacy of gefitinib following adjuvant chemotherapy in patients with EGFR mutation is unknown. Methods: In this open-label, phase II study, patients with resected stage IIIA-N2 NSCLC harbouring EGFR mutations (either the exon 19 deletion or L858R point mutation) were randomly assigned to receive pemetrexed (500mg/m2) and carboplatin (AUC=5), administered every 21 days for 4 cycles, followed with (n=30) or without (n=30) gefitinib (250mg per day) for 6 months. The primary end point was PFS. The second end point was OS. Results: From August 2008 toSeptember 2011, 60 patients (35 males and 25 females) were included in our center. Of the 60 patients (56 adenocarcinomas, 2 squamous cell carcinomas, 2 adenosquamous carcinomas), 20 patients (33.3%) had exon 19 deletion mutation, 40 (66.7%) patients had exon 21 L858R point mutation. The most common adverse event was rash (43.3%, 13 of 30) in the pemetrexed and carboplatin (PC)-gefitinib group and the addition of gefitinib to chemotherapy was well tolerated. The PFS was significantly longer among those who received PC-gefitinib than among those who received PC alone (median,39.8 months vs 27.0 months; hazard ratio [HR],0.369; 95% confidence interval [CI], 0.161-0.847; P=0.014). There was no significant difference in OS between the two group(median,41.6 months vs 32.6 months,P=0.066). The rates of 2-year PFS and OS were 78.9% and 92.4% in PC-gefitinib group, and 54.2% and 77.4% in PC alone group, respectively. Conclusions: The addition of gefitinib to pemetrexed and carboplatin adjuvant therapy showed significant improvement in PFS for patients with resected stage IIIA-N2 NSCLC harbouring EGFR mutations.