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Abstract:
Introduction Pain is the most common symptom in cancer patients and it is also the most common symptom in lung cancer patients.[1]The majority of patients with lung cancer present with advanced stage of the disease at diagnosis. Symptoms may result from local effects of the tumor, from regional or distant spread or from distant effects not related to metastases-paraneoplastic syndromes. Pain in these patients may be associated with depression, fatigue [2] and may affect quality of life and patients’ performance status. Early palliative care including pain management may increase their survival. [3] Pain can be classified by type of pain or according to the origin of the pain. The location or origin of the pain determines the type of pain, thoracic or extrathoracic. Pain Pain is often multifactorial in origin and needs to be addressed in each aspect. It can be acute or chronic. Acute pain can be caused by hemorrhage into a tumor, bone pain secondary to a pathological fracture, visceral pain, ie. from acute intestinal obstruction or perforation of a viscous. Its duration is limited and predictable. Chronic pain is differentiated by its longevity. It is estimated that approximately 75% of cancer patients live with chronic pain. [4] It must be approached with dual aim: relieving the pain as well as preventing further recurrences of pain. Pathophysiology of Pain Physiological pain is termed nociceptive pain due to the stimulation of the sensory nociceptors located in tissues when damaged. They are somatic, visceral, neuropathic and psychogenic pains. [5] Neuropathic pain is associated with a loss of opioid receptors in sensory afferents and an increased release of glutamate in the dorsal horn. The resultant hyperexcitability causes spontaneous pain and hyperalgesia and allodynia in areas adjacent to the nerve damage. There are three main causes of pain in patients with advanced lung cancer: Skeletal metastatic disease 34%, Pancoast tumor 31%, chest wall disease 21%. [6] Principles of Pain Management The World Health Organization analgesic ladder for cancer pain relief provides a stepwise approach to managing pain in cancer patients. [7] Step 1 includes paracetamol or non-steroidal anti-inflammatory drugs. Step 2- weak opioids, ie. codeine. Step 3- strong opioids, ie. morphine. Non-opioid and adjuvant treatments can be added to steps 2 and 3. Different routes of the administration of analgesics and their side effects management will be described. Their advantages and disadvantages of each route of administration will be pointed out. The need of adjuvant treatments such as tricyclic antidepressants and anticonvulsants, corticosteroids, topical analgesics, treatments of nausea, constipation, etc., are an integral part of pain management. Interventional procedures help reduce the doses of analgesics and their side effects. [8] Special mention will be about skeletal metastases and bone targeted agents such as zoledronic acid and denosumab, which have shown ability to reduce the pain and analgesic consumption in lung cancer patients. [9] Complementary therapies which help to control pain will also be mentioned.ie. Acupuncture,[10] psychological methods of care, etc. Conclusion An active multidisciplinary approach is required to manage pain in patients with advanced lung cancer. Multifactorial pain is frequent and may require several different analgesics, along with general palliative care and even special interventional procedures. Patients with advanced lung cancer live longer as there are more treatment options. It is of utmost importance to preserve a good quality of life with a better performance status to enable them to receive now further available therapies. [1] Caraceni A, Portenoy RK. An international survey of cancer pain characteristics and syndromes. IASP Task Force on Cancer Pain. Pain. 1999;82 (32) :263-74. [2] Laird BJ, Scott AC, Colvin LA, et al. Pain, depression, and fatigue as a symptom cluster in advanced cancer. J. Pain Symptom Manage. 2011;42(1): 1-11. [3] Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733-42. [4] Ferrell BR, Juarez G. Borneman T. Use of routine and breakthrough analgesia in care. Oncol Nurs Forum. 1999;26(10):1655-61. [5] Portenoy RK, Lesage P. Management of cancer pain. Lancet. 1999;353 (9165):1695-700. [6] Watson PN, Evans RJ. Intractable pain with lung cancer. Pain. 1987; 29(2):163-73. [7] Geneva W. World Health Organisation. Cancer Pain Relief. 1996 [8] Vranken JH, Zuurmond WW, de Lange JJ. Continuous brachial plexus block as treatment for the Pancoast syndrome. Clin J Pain . 2000;16(4):327-33 [9] Rosen LS, Gordon D, Tchekmedyian S, et al. Zoledronic acid versus placebo in the treatment of skeletal metastases in patient with lung cancer and other solid tumors: a phase III, double-blind, randomized trial—the Zoledronic Acid Lung Cancer and Other Solid Tumors Study Group. J Clin Oncol. 2003;21(16):3150-7. [10] Cassileth BR, Deng GE, Gomez JE, Johnstone PA, Kumar N, Vickers AJ. Complementary therapies and integrative oncology in lung cancer. ACCP evidence-based clinical practice guidelines (2[nd] edition). Chest. 2007;132(Suppl3):340S-54.

Abstract:
The International Consensus Conference definition of cancer cachexia is a multifactorial syndrome defined by an ongoing loss of skeletal muscle mass with or without fat mass that cannot be fully reversed by conventional nutritional support and leads to progressive functional impairment.[1] As clinicians, we define cachexia clinically based on weight loss of 5% or greater or body mass index <20 kg/m[2], with 2% weight loss. On physical exam, we recognize cachexia based on gross loss of muscle mass and weakness, often associated with physical findings such as temporal wasting. However, these patients with physical stigmata of cachexia are a small subgroup of the total population. If one assesses objective measures of muscle mass, approximately half of patients with advanced lung cancer will have muscle wasting at diagnosis and 2/3 of patients will develop it during their treatment course. This muscle wasting or sarcopenia, occurs across all weight groups, including those with normal weight, overweight and obesity.[2] These patients would not be recognized clinically to be cachetic. Yet, they have significant clinical consequences from muscle wasting. The use of standardized CT for the quantitative assessment of skeletal muscle and other body tissues has helped us better understand the importance of muscle and its impact on cancer outcomes.[3] Muscle wasting is associated with an increased risk of dose limiting chemotherapy toxicity, shorter time to disease progression and reduced overall survival. Clinically, the cancer patient with cachexia undergoes a progressive decline in muscle mass with associated anorexia, fatigue and reduced quality of life. Patient reported outcomes include weakness, declining muscle strength, reduced mobility and impact on physical performance. At a molecular level, this loss of muscle mass is associated with a number of biochemical changes in enzymes, regulatory proteins, altered metabolism, increased markers of inflammation and impaired immunity. The driving force for muscle wasting in cancer patients is the competition for nutrients between the cancer and the host often complicated by decreased protein/caloric intake. However, the mechanisms that both incite and promote the ongoing process of muscle loss are complex and include factors associated with direct muscle atrophy, including the release of cytokines such as tumor necrosis alpha and interleukin 6, as well as myostatin and activin. One strategy that might ameliorate the cachexia process include therapeutic approaches that block these cytokine mediated pathways and several agents are in development.[4] Another approach has been to try to increase muscle growth signaling through anabolic pathways such as selective androgen receptor modulators (SARM) and ghrelin minetics. A first in class SARM, enobosarm has shown promising results with improvement of muscle mass and physical function in patients with cachexia.[5] Subsequent phase III trials in patients with advanced lung cancer receiving chemotherapy have shown increase in muscle mass in the enobosarm treatment group versus placebo, but physical function testing using stair climb measurement were inconsistent.[6] Meanwhile, trials of anamorelin, a ghrelin receptor agonist have also demonstrated improvement in skeletal muscle mass. In phase III trials in patients with advanced lung cancer and cachexia, improvement in skeletal muscle mass has been seen along with positive effects on improved appetite and weight gain. Again, functional improvement as measured by hand grip strength was not observed.[7] It is not clear why there is a lack of association of these promising agents that increase muscle mass, with functional improvement. This may reflect issues regarding the patient population, the objective test being used, the duration of treatment or other factors. However, these phase III trials in advanced lung cancer represent an important step forward in our understanding of cachexia and possible therapeutic interventions. Currently, as we are moving forward with the development of new agents for cachexia, it is important for us to recognize the magnitude of the problem in our patients. Until CT imaging becomes a standard clinical technique for assessment of muscle mass, we need to rely on our standard clinical approaches of history and physical exam. Perhaps most importantly, is our documentation of the degree of weight loss in our patients as a routine measure at baseline and during treatment just as we assess other patient reported outcomes such as pain, fatigue and functional status. Incorporating weight loss along with body mass index can be a very powerful tool for predicting outcome and survival for our patients.[8] Moreover, it can help us address potential interventions that may be of benefit for them. While current pharmacologic interventions are of limited benefit, exercise and nutritional support are both important interventions for our patients, along with continuing monitoring of appetite, weight and functional performance during treatment.[9] Cancer treatment itself can be associated with an increase in muscle mass, particularly in patients whose tumors respond well to therapy. However, for those patients who progress through therapy, the toxicity of our treatment only compounds the ongoing cachexia process. Better cancer therapeutics combined with optimum supportive care remain the goal of management. 1. Fearon K, Strasser F, Anker SD, et al. Definition and classification of cancer cachexia: an international consensus. Lancet Oncol. 2011 May;12(5):489-95. 2. Prado CM, Lieffers JR, McCargar LJ, et al. Prevalence and clinical implications of sarcopenic obesity in patients with solid tumours of the respiratory and gastrointestinal tracts: a population-based study. Lancet Oncology. 2008; 9(7):629-35. 3. Prado CM, Antoun S, Sawyer MB, Baracos VE. Two faces of drug therapy in cancer: drug-related lean tissue loss and its adverse consequences to survival and toxicity. Curr Opin Clin Nutr Metab Care. 2011;14:250–254. 4 Cohen S, Nathan JA, Goldberg AL. Muscle wasting in disease: molecular mechanisms and promising therapies. Nat Rev Drug Discov. 2015 Jan;14(1):58-74. 5. Dobs AS, Boccia RV, Croot CC, et al. Effects of enobosarm on muscle wasting and physical function in patients with cancer: a double-blind, randomised controlled phase 2 trial. Lancet Oncol. 2013 Apr;14(4):335-45. 6. Crawford J, Prado C, Johnston M, Gralla R, Taylor R, Hancock M, Dalton J. Study design and rationale for the phase 3 clinical development program of enobosarm, a selective androgen receptor modulator, for the prevention and treatment of muscle wasting in cancer patients (POWER Trials). Cur Oncol Rep (2016) 18:37. 7. Temel JS, Currow DC, Fearon K, et al. Phase III trials of anamorelin in patients with advanced non-small cell lung cancer (NSCLC) and cachexia (ROMANA 1 and 2). J Clin Oncol 33, 2015 (suppl; abstr 9500) 8. Martin L, Senesse P, Gioulbasanis I, Antoun S, et al. Diagnostic criteria for the classification of cancer-associated weight loss. J Clin Oncol. 2015 Jan 1;33(1):90-9. 9. Crawford J. Clinical results in cachexia therapeutics. Current Opinion in Clinical Nutrition & Metabolic Care. 19(3):199-204, May 2016.

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Abstract:
Case report A 55-year-old lady was diagnosed with small cell lung cancer in late 2008. She had been a long-time cigarette smoker without, any other significant medical history. She was a housewife, deeply religious and dedicated mother to 2 children. As a first treatment for her cancer, she received radiotherapy on the right apex and mediastinum, concomitantly with chemotherapy (cisplatin plus etoposide), early in 2009. Six months later, she presented a very painful right shoulder and chest wall. Chemotherapy was resumed, with some improvement of the pain, but late in 2009, radiotherapy had to be administered to the chest for uncontrolled pain; oral etoposide was given without much benefit. The pain progressively increased and the patient was complaining of increasing shortness of breath. As the tumour was clearly progressing, in 2010, with further lung, bone and liver involvement, a decision was made to discontinue any specific oncological treatment. Both symptoms pain and dyspnea increased in intensity and became uncontrollable late in 2010; the patient and her family requested sedation at any cost. The patient was started on palliative sedation and died peacefully after 2 days; with her family present. Supportive and palliative treatments for pain Table 1 summarizes the time evolution of the patient and the corresponding interventions as far as analgesics and co-analgesics are concerned. Management of dyspnea over the course of her disease, the patient experienced progressive dyspnea which could be managed with oxygen, corticoids, benzodiazepines and bronchodilatating aerosols, as well as physical therapy and hypnosis. Dyspnea became major and beyond control the day prior to the last hospitalization and was a reason for accelerated sedation. Figure 1 Management of depression The patient had multiple reasons for being severely depressed: her mother was experiencing lung cancer at the same time ; the patient was concerned about becoming increasingly a burden for her family; she was aware of her worsening condition and realizing that her life would end soon; she was extremely anxious to have to die in intractable pain. The management of the patient’s depression included the following: monthly consultation with an onco-psychiatrist and weekly visits to a psychologist-social worker ; psychotropic drugs ; several sessions of hypnosis. Palliative sedation That the control of the patient’s pain and/or dyspnea might require palliative sedation has been discussed since 2010 (time of worsening of her symptoms) between the patient, her family and the caregivers. The patient and her family spoke openly about end-of-life issues, always emphasizing not to let the patient die in severe pain. After making the decision to resort to sedation in case of intractable symptoms, the patient and her family expressed a sense of relief that her suffering could and would be alleviated. When the patient expressed unbearable pain and dyspnea, the mobile nursing team started her on midazolam, scopolamine and methadone by sub-cutaneous route, with no clear-cut response; the patient was brought to the hospital, where the same medications were given intravenously, with the addition of haloperidol. No attempt to lift the sedation process (respite sedation) was made, according to the patient’s will. The patient was able to rest comfortably and died peacefully after 2 days, with her family at her side. Discussion In case of dyspnea due to lung cancer progression, corticosteroids, morphine and oxygen are used since many years ; novel options were introduced timidly during the last years. These new options include non-invasive ventilation, high-flow oxygen and rational use of medications usually prohibited in patients with respiratory distress, such as benzodiazepines, antidepressants and synthetic opioids [1]. The World Health Organization (WHO) scale for cancer-related pain proves to be an effective approach to pain management in cancer patients [2], and many variations based on it have been proposed [3]. However, these approaches represent pragmatic and empiric attitudes that are rarely evaluated in prospective studies. There is also a lack of consensus about the use of co-analgesia and other supportive approaches for refractory pain [5]; although pragmatic recommendations exist, a comprehensive algorithm for the management of refractory pain is still lacking. Based on the experience in our supportive care unit, we proposed a comprehensive model for the progressive management of pain in cancer patients (Figure 1). Finally, the approach to pain (or other symptoms) that is beyond medical control, fortunately a relatively rare situation, has not been clearly defined [6;7]. Palliative sedation or euthanasia is always an emotionally and ethically challenging event for all involved and implies to meet the needs of the patient and family but also those of the caregivers [8; 9; 10] and requires repeated and professional counselling with the patient and family as well as regular debriefing sessions with the medical and nursing teams. Although the decision to offer and provide palliative sedation or euthanasia (if requested by the patient and not illegal) is never easy, it should be seen, however, as the medical duty to safeguard the patient’s autonomy, the principle of individual freedom to make choices. Figure 2 References 1. Cabezón-Gutiérrez L, Khosravi-Shahi P, Custodio-Cabello S, Muñiz-González F, del Puerto Cano-Aguirre M, Alonso-Viteri S. Opioids for management of episodic breathlessness or dyspnea in patients with advanced disease. Support Care Cancer 2016;24:4045-55 2. Meuser T, Pietruck C, Radbruch L, Stute P, Lehmann KA, Grond S. Symptoms during cancer pain treatment following WHO-guidelines: a longitudinal follow-up study of symptom prevalence, severity and etiology. Pain 2001; 93:247-57 3. Zech DF, Grond S, Lynch J, Hertel D, Lehmann KA. Validation of World Health Organization Guidelines for cancer pain relief: a 10-year prospective study. Pain 1995; 63:65-76 4. Swarm RA, Abernethy AP, Anghelescu DL, et al. Adult cancer pain. J Natl Compr Canc Netw 2010;8:1046-86 5. Lee M, Silverman SM, Hansen H, Patel VB, Manchikanti L. A comprehensive review of opioid –induced hyperalgesia. Pain Physician 2011; 14:145-61 6. Council on Scientific Affairs, American Medical Association. Good care of the dying patient. JAMA 1996;275:474-8 7. Field MJ, Cassel CK, eds. Approaching death: improving care at the end of life. Washington DC: : National Academy Press, 1997 8. de Graeff A, Dean M. Palliative sedation therapy in the last weeks of life : a literature review and recommendations for standards. J Palliat Med 2007; 10:67-85 9. Olsen ML, Swetz KM, Mueller PS. Ethical decision-making with end-of-life care: palliative sedation and withholding or withdrawing life-sustaining treatments. Mayo Clinic Proc 2010;85:949-54 10. Lossignol D. End-of-life sedation: is there an alternative? Curr Opin Oncol. 2015;27(4): 358-64

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Abstract:
In the diagnosis of lung cancer the primary diagnostic approach is microscopic evaluation of tissue biopsy. However, in many cases the only material for microscopic evaluation is cytological one. There are numerous types of cytological material in evaluation of lung tumors including sputum, bronchial brush, bronchial washing, transthoracic and transbronchial fine needle aspirates. Historically sputum was the most common diagnostic material but at present the most common types of cytological specimen are bronchial brush, and transthoracic or transbronchial FNAB. Nowadays worked out and recognized cytological criteria allows not only to diagnose carcinoma but in majority of cases to specify the histologic type of a tumor. This approach to microscopic diagnosis of lung carcinoma was incorporated to the latest WHO classification of lung tumors (ref). The key reason that cytodiagnosic criteria and terminology were included into WHO classification was that in about 30% cases of lung tumors the cytological specimen is the only material for microscopic evaluation. Similarly to evaluation of small tissue biopsies in cytopathology, in doubtful cases, immunocytochemistry may be implemented to determine histologic type of tumor. Most useful in evaluation of cytological specimen are IHC antibodies with nuclear presentation. (e.g. p40 for squamous cell carcinoma and TTF1 for adenocarcinoma). Cytological material may be utilized in evaluation and in differential diagnosis between primary and metastatic lung tumor. The panel of the antibodies (e.g. CDX2, PSA, Melan A ) may be used to indicate location of primary tumors mainly adenocarcinomas. Since cytological smears are of limited diagnostic value for immunocytochemistry, the so-called cell blocs technique is recommended. This technique allows to use larger panel of antibodies for immunohistochemical evaluation. Cytology become very useful for clinical staging of lung carcinoma routinely utilizing EBUS and EUS technique for obtaining material from parahilar and mediastinal lymph nodes. Cytological criteria are similar to that used for specimens obtained by transthoracic FNAB. In our center practice cooperation with adequately trained thorax surgeons provides adequate material for microscopic evaluation from EBUS and EUS obtained specimens in 94% cases. Currently one of the important task for pathologist in evaluating material from lung carcinoma is adequate selection of the material for molecular test. In case of lung carcinoma or to be specific lung adenocarcinoma â material is selected for evaluation of EGFR and K-RAS mutation. In our experience cytological material particularly fine needle aspirates - fulfill such demands. Percentages of tumors cells in the sample is often even higher than in tissue sections especially in fine needles of peripherally location lesions. Cytological material may be useful in evaluation of EGFR and K-RAS mutation as well as in determination of presence of translocations of ALK and ROS1 using FISH technique. Evaluation of ALK and ROS1 translocation remained in the hands of cytopathologists since the crucial point is the location of translocation in nuclei of tumors cells. Latest challenge for pathologists evaluating lung carcinoma specimen is to determine predictive criteria for immunotherapy in those tumors. At the moment it seems that cytological material may be not satisfactory for adequate evaluation of immunocytochemical expression of PD-L1 and PD-1. In summary cytological material from lung carcinoma is useful in establishing the firm microscopic diagnosis of malignancy, to determine histologic type and to be used for molecular tests. It also allows to differentiated between primary and metastatic lung malignancies as well as determined primary location of metastatic lung carcinoma. Cytological specimens obtained by EBUS and EBUS techniques are very useful in clinical staging of lung carcinoma. Reference Travis WD, Brambilla E, Burke AP, Marx A, Nicholson AG eds. WHO Classification of Tumours of the Lung, Pleura, Thymus and Heart. 4[th] ed. Lyon, France: IARC Press; 2015

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Abstract:
Epidermal growth factor receptor (EGFR) activating mutations in the tyrosine kinase domain serve as predictive biomarkers for EGFR-tyrosine kinase inhibitor (EGFR-TKI) treatment outcome for patients with advanced non-small cell lung cancer (NSCLC).[1] However, due to the invasive procedures required to obtain tumor tissues, not all patients can provide enough high-quality tissues for EGFR mutation analysis. Circulating free DNA (cfDNA) in plasma provides a noninvasive substitute for tumor tissues. Several studies have reported a concordance rate between tumor and plasma > 90%, even reaching 97%, demonstrating the feasibility of detecting EGFR mutations in cfDNA.[2-4]EGFR mutation status detection in cfDNA has been approved by the European Society for Medical Oncology and by China to be used with EGFR-TKI treatment for NSCLC.[5,6] In addition to providing pretreatment information, plasma-based EGFR mutation detection makes it possible to monitor dynamic changes in this mutation during treatment. Several studies have reported a quantitative change in EGFR mutations during EGFR-TKI treatment by comparing pre- and post-treatment plasma, in which various types of plasma EGFR mutations were found.[7,8] The quantity of the plasma EGFR mutation sometimes decreases, or sometimes decreases slowly or rapidly. Patients whose plasma EGFR mutations decrease rapidly usually exhibit a better response to EGFR-TKI treatment.[8] However, these studies were not based on prospective clinical trials, therefore the number of patients who had serial plasma specimens tested during EGFR-TKI treatments was limited, and very few plasma specimens were collected as part of a pre-planned schedule. The only recent study on plasma EGFR mutation changes based on a prospective clinical trial was reported by Mok et al.[9] In this phase III trial (FASTACT-2), patients received gemcitabine/platinum plus sequential erlotinib or placebo. EGFR mutation-specific cfDNA levels decreased at cycle 3 and increased at the time of disease progression. Positive plasma EGFR mutant DNA at cycle 3 predicted a worse clinical outcome. In this study, the treatment was chemotherapy plus EGFR-TKI or placebo, not EGFR-TKI, and there was no information on the plasma EGFR mutation at other time points except at baseline, cycle 3, and at disease progression. The dynamic changing types of plasma EGFR mutations during the whole course of EGFR-TKI treatment and its correlation with clinical outcomes were not determined. To measure changes of plasma EGFR L858R mutation during EGFR-TKI treatment, and to determine its correlation with the response and resistance to EGFR-TKI, we conducted a study. This study was a pre-planned exploratory analysis of a randomized phase III trial conducted from 2009 to 2014 comparing erlotinib with gefitinib in advanced NSCLC harboring EGFR mutations in tumor (CTONG0901). Serial plasma samples were collected as a pre-planned schedule. This trial was conducted in Guangdong Lung Cancer Institute, China. Totally, 256 patients were enrolled in CTONG0901. One hundred and eight patients harbored L858R mutation in tumors and 80 patients provided serial blood samples as pre-planned scheduled. Patients were randomized to receive erlotinib or gefitinib. Serial plasma L858R in 80 patients was detected using quantitative polymerase chain reaction. Changing types of plasma L858R were analyzed using Ward's Hierarchical Clustering Method. Progression-free survival (PFS) and overall survival (OS) were compared between different types. As a whole, the quantity of L858R decreased and reached the lowest level at the time of best response to EGFR-TKI. In 61 patients, L858R increased to its highest level when disease progressed (Ascend Type), while in 19 patients, L858R maintained a stable level when disease progressed (Stable Type). Median PFS was 11.1 (95%CI, 6.6–15.6) and 7.5 months (95%CI, 1.4–13.6) in patients with Ascend and Stable Types, respectively (P = .023). Median OS was 19.7 (95%CI, 16.5–22.9) and 16.0 months (95%CI, 13.4–18.5), respectively (P = .050). This is the first report finding two different changing types of plasma L858R mutation during EGFR-TKI treatment based on a prospective randomized study. Different changing types were correlated with benefits from EGFR-TKI. The impact of plasma L858R levels at disease progression on subsequent treatment strategy needs further exploration. This study was recently published in Journal of Hematology&Oncology.[10] In summary, liquid biopsy is very promising in monitoring dynamic changes of driver genes in advanced NSCLC, which promotes the development of precision medicine. References 1. Mok TS, Wu YL, Thongprasert S, et al. Gefitinib or carboplatin-paclitaxel in pulmonary adenocarcinoma. N. Engl. J. Med. 2009;361(10):947-957. 2. Kimura H, Suminoe M, Kasahara K, et al. Evaluation of epidermal growth factor receptor mutation status in serum DNA as a predictor of response to gefitinib (IRESSA). Br. J. Cancer. 2007;97(6):778-784. 3. Douillard JY, Ostoros G, Cobo M, et al. Gefitinib treatment in EGFR mutated caucasian NSCLC: circulating-free tumor DNA as a surrogate for determination of EGFR status. J. Thorac. Oncol. 2014;9(9):1345-1353. 4. Couraud S, Vaca-Paniagua F, Villar S, et al. Noninvasive diagnosis of actionable mutations by deep sequencing of circulating free DNA in lung cancer from never-smokers: a proof-of-concept study from BioCAST/IFCT-1002. Clin. Cancer Res. 2014;20(17):4613-4624. 5. European Medicines Agency. Summary of Product Characteristics 2014 [EB/OL], 10/14 update. http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-_Product_Information/human/001016/WC500036358.pdf. 6. Iressa 250mg Leaflet professional China. CN52-086A. 20150203. . 7. Sacher AG, Oxnard GR, Mach SL, et al. Prediction of lung cancer genotype noninvasively using droplet digital PCR (ddPCR) analysis of cell-free plasma DNA (cfDNA). Paper presented at: Journal Of Clinical Oncology 2014. 8. Marchetti A, Palma JF, Felicioni L, et al. Early Prediction of Response to Tyrosine Kinase Inhibitors by Quantification of EGFR Mutations in Plasma of NSCLC Patients. J. Thorac. Oncol. 2015;10(10):1437-1443. 9. Mok T, Wu YL, Lee JS, et al. Detection and Dynamic Changes of EGFR Mutations from Circulating Tumor DNA as a Predictor of Survival Outcomes in NSCLC Patients Treated with First-line Intercalated Erlotinib and Chemotherapy. Clin. Cancer Res. 2015;21(14):3196-3203. 10. Zhou Q, Yang JJ, Chen ZH, et al. Serial cfDNA assessment of response and resistance to EGFR-TKI for patients with EGFR-L858R mutant lung cancer from a prospective clinical trial. Journal of Hematology&Oncology. 2016;9:86.

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Background:
To assess the ability of droplet digital PCR and ARMS technology to detect epidermal growth factor receptor (EGFR) T790M mutations from circulating tumor DNA (ctDNA) in advanced non-small cell lung cancer (NSCLC) patients with acquired EGFR-TKI resistance. A sensitive and convenient method for detecting T790M mutation would be desirable to direct patient sequential treatment strategy.

Methods:
To assess the ability of droplet digital PCR and ARMS technology to detect epidermal growth factor receptor (EGFR) T790M mutations from circulating tumor DNA (ctDNA) in advanced non-small cell lung cancer (NSCLC) patients with acquired EGFR-TKI resistance. A sensitive and convenient method for detecting T790M mutation would be desirable to direct patient sequential treatment strategy.To assess the ability of droplet digital PCR and ARMS technology to detect epidermal growth factor receptor (EGFR) T790M mutations from circulating tumor DNA (ctDNA) in advanced non-small cell lung cancer (NSCLC) patients with acquired EGFR-TKI resistance. A sensitive and convenient method for detecting T790M mutation would be desirable to direct patient sequential treatment strategy.

Results:
A total of 108 patients were enrolled in this study. 108 patient plasma samples were detected by ddPCR and 75 were detected by ARMS. And 16 patients experienced re-biopsy were detected T790M status by ARMS method. 43.7% (47/108) had acquired T790M mutation by ddPCR. In 75 patient plasma samples, comparing ddPCR with ARMS, the rates of T790M mutation were 46.7% (35/75) and 25.3% (19/75) by ddPCR and ARMS, respectively. Of all, 16 patients both had tumor and plasma samples, the T790M mutation rates were 56.3% (9/16) by ARMS in tissue and 50.5% (8/16) by ddPCR in plasma ctDNA. Among them, there were two ctDNA T790M mutations by ddPCR but T790M gene negative in tumor tissue by ARMS method. For all patients, the median PFS and OS were 12.3 months and 32.8 months, respectively. The patients with T790M-positive tumors had a longer time to disease progression after treatment with EGFR-TKIs (median, 13.1 months vs 10.8 months; P=0.010) and overall survival (median, 35.3 months vs 30.3 months; P=0.214) compared with those with T790M-negative patients.

Conclusion:
Our study demonstrates dPCR assay provide feasibility and sensitive method in detecting EGFR T790M status in plasma samples from NSCLC patients with acquired EGFR-TKI resistance.And T790M-positive patients have better clinical outcomes to EGFR-TKIs than patients with T790M negative.

Background:
Next generation sequencing (NGS) has been increasingly used in oncology practice but proven practically difficult when serial tumor specimens are needed. The objectives of this study were to determine feasibility and explore clinical utility of serial NGS analyses of circulating tumor DNA (ctDNA) in patients (pts) with advanced solid tumors undergoing treatment.

Methods:
ctDNA digital NGS was performed by a CLIA-certified lab (70-gene panel with mutant allele fraction (MAF) quantification). ctDNA results were retrospectively analyzed and decreases/increases/stability of molecular tumor load (MTL) defined here as MAFs of truncal driver mutations were correlated with clinical and radiographic response to treatment (response, progression, or stable disease, respectively).

Results:
From Jan 2015 to July 2016, 38 consecutive pts with advanced lung tumors (84% LUAD, 5% LUSC, 5% SCLC, 5% NOS) receiving treatment (Table) had serial ctDNA analyses (median 2, range 2-7). ctDNA alterations were detected at least once in 37 (97.4%) pts. Changes in MTL correlated with or predicted all (95% CI, 82.0-99.8%) radiological and/or clinical responses except for the patient with no genomic alteration detected. MTL results clarified response status when radiographic responses were difficult to assess in 9 (28%) of pts with either complex pleural disease (n=6), pneumonitis during PD-1 inhibitor therapy (2). Two MTL change patterns were observed: 1) clonal changes while receiving targeted therapy, including EGFR (12), ALK (3), MET (2), ERBB2 (2); 2) global changes to PD-1 inhibitors, chemotherapy or radiation. Representative tumor response maps will be presented. Table. Summary of tumor types and cancer treatment.

Cancer Type	Targeted Therapy	Immunotherapy	Chemotherapy	Radiation	TOTAL
LUAD	14	8	7	3	32
LUSC	1	1	0	0	2
SCLC	0	0	2	0	2
NOS	1	0	1	0	2
All	16	9	10	3	38

Conclusion:
Serial liquid biopsies and ctDNA digital NGS are feasible and clinically useful in monitoring MTL and genomic alterations during cancer treatment, especially in situations when radiographic responses are equivocal. Prospective evaluation of impact on clinical decision making is warranted.

Background:
Programmed death-ligand 1 (PD-L1) is known to be over-expressed in non-small cell lung cancer (NSCLC). However, the impact of chemotherapy on the altered status of PD-L1 expression has not been examined for NSCLC. The present study was intended to examine the impact of neoadjuvant chemotherapy on PD-L1 expression and its prognostic significance in lung squamous cell carcinoma (SCC).

Methods:
Matched tumor samples were obtained from SCC patients prior to and after neoadjuvant chemotherapy. The expression of PD-L1 was evaluated by immunohistochemistry. Survival analysis was performed by the Kaplan-Meier method.

Results:
A total of 76 eligible SCC patients were recruited. There were 51 males and 25 females with a median age of 60 (39-72) years. The smoking status was former (n=46) and never (n=34). Prior to neoadjuvant chemotherapy, PD-L1 expression was identified in 52.6% (40/76) of SCC patients while 61.8% (47/76) were positive for PD-L1 expression after neoadjuvant chemotherapy . Nine patients switched from negative to positive while another two patients’ samples showed the reverse of the above result. Multivariate analysis demonstrated that postoperative expression of PD-L1 was an independent prognostic factor for overall survival (HR=0.50, P=0.003), but not for PD-L1 expression prior to neoadjuvant chemotherapy.

Conclusion:
Neoadjuvant chemotherapy may up-regulate the expression of PD-L1. As compared with the status of PD-L1 expression prior to chemotherapy, the postoperative expression of PD-L1 is a better prognostic factor for overall survival in SCC.

Abstract not provided

Abstract not provided

Background:
Patients with advanced non-small-cell lung cancer (NSCLC) harboring sensitive epithelial growth factor receptor (EGFR) mutations invariably develop acquired resistance to EGFR tyrosine kinase inhibitors (TKIs). Although previous research have identified several mechanisms of resistance, the systematic evaluation using next generation sequencing (NGS) to establish the genomic mutation profiles at the time of acquired resistance has not been conducted.

Methods:
In our single center, we performed NGS of a pre-defined set of 416 cancer-related genes in a cohort of 97 patients with NSCLC harboring TKI-sensitive EGFR mutations at the time of acquired resistance to first-generation EGFR-TKIs between January 2015 to December 2015.

Results:
In 97 samples we found total 345 gene alterations (mean 3.6 mutations per patient, range 1-10). Fifty-six patients (57.7%) still exhibit EGFR-sensitive mutations as pretreatment, 93 patients (95.9%) exhibit at least one mutation except for previous existed EGFR-sensitive mutations. In all the 97 patients, most frequently mutated genes were TP53 (59.8%), T790M (28.9%), TET2 (11.3%), EGFR amplification (10.3%), PIK3CA (8.2%), BIM (8.2%), KRAS (7.2%), APC (7.2%), RB1 (7.2%), HER2 (6.2%), DNMT3A (6.2%) and MET (5.2%).

Conclusion:
NGS in this study uncovered many new genetic alterations potentially associated with EGFR TKI resistance and provided information for the further study of drug resistance and corresponding relevant tactics against the challenge of disease progression.

Background:
Pulmonary adenoid cystic carcinoma (PACC) is one of the rare malignancies, that primary from glandular tissues of lung. Currently, the treatment of PACC relies on surgery and local radiotherapy. However the therapy for advanced PACC patients is limited. A larger number of studies demonstrated that advanced PACC patients obtained little benefit from chemotherapy. Moreover, only a few case reports revealed PACC patients were appropriate for target therapy. Using high-flux and high-resolution techniques to detect the genomic alterations of PACC could provide theoretical foundation for the precision therapy of PACC.

Methods:
8 PACC patients who received surgical resection between January 2013 to December 2015 were enrolled. The tumor tissues from different locations and blood samples were collected. The oncoscreen[TM] panel by Illumina platform, which utilizing probe hybridization to gathering 287 exon regions and 22 intron regions, were used to detect the gene mutation status of PACC. And the embryonal system mutations were filtered by contrasting the gene mutation status of the leukocytes. The tumor heterogeneity was revealed by comparing the gene mutation status in different areas of the same PACC, and the phylogenetic relationships were analyzed to disclose the evolving and developing progression of PACC.

Results:
There were 69 gene mutations together among 8 patients including 29 samples. Each patient has 8.6 mutations averagely. The high-frequency mutations were PAK3-D219E, FBXW7-D112E, TET2-T418I, KAT6A-E796A, and MET-R1005Q. However, the common mutations in other NSCLC, like EGFR, KRAS, ALK, etc., weren’t happened in this group of PACC. In this study, the spatial heterogeneity was discovered in PACC, not only in the mutation site, but also in the mutant abundance. Moreover, the phylogenetic relationships revealed that the clonal evolution and development existed in PACC.

Conclusion:
The status of genomic alterations in PACC was different from the other non-small cell lung cancer (NSCLC). PACC showed obvious spatial heterogeneity and clonal evolution.

Background:
Amplification of the mesenchymal-epithelial transition factor (MET) gene plays a vital role in non-small cell lung cancer (NSCLC). The anti-MET therapeutic strategies are still unclear in epidermal growth factor receptor (EGFR) mutant patients and EGFR-naive patients. Aims of our study are to discuss role of MET amplification in Chinese NSCLC patients, and evaluate the antitumor activity of crizotinib (MET inhibitor) in Chinese NSCLC patients with MET gene amplification.

Methods:
From Jun 2015 to Jan 2016, we detected 11 metastatic NSCLC patients with MET amplification by fluorescence in situ hybridization (FISH). MET amplification was defined as gene focal amplification or high polysomy (at least 15% cells with ≥5 copy numbers). Patients with MET de novo amplification received crizotinib, patients with concomitant MET acquired amplification and EGFR mutation received combined therapy of EGFR-tyrosine kinase inhibitors (TKIs) (gefitinib, erlotinib, icotinib)and crizotinib. All enrolled subjects received tumor measurement according to RECIST1.1

Results:
The frequency of MET de novo amplification was 54.5%(6/11), and that of concomitant MET acquired amplification and EGFR mutation was 45.5%(5/11) respectively. 4 of 6 patients with MET de novo amplification received crizotinib, 2 patients had partial response (PR), 1 patient had stable disease (SD), 1 patient died due to heart disease. Response rate (RR) of crizotinib was 50%(2/4). Encouraging response was observed in one case, a CT scan performed 31 days after starting crizotinib revealed 42.2% decrease in tumor measurement, until now, a 7-month CT revealed 60.0% decrease. 3 of 5 patients with concomitant MET acquired amplification and EGFR mutation received the combined therapy of EGFR-TKIs and crizotinib. 1 patient achieved PR, 2 patients had SD. RR of combined therapy was 33.3%(1/3). Dramatic response was observed in one case with combined therapy, a 2-month CT revealed 31.0% decrease in tumor measurement.

Conclusion:
According to our study, patients with MET amplification benefited from crizotinib, and RR was inspiring. Patients with concomitant MET acquired amplification and EGFR mutation need combined targeted therapy.

Background:
A significant portion of patients with non-small cell lung cancer (NSCLC) develop brain metastasis. Patients with brain metastasis suffer from poor prognosis with a median survival of less than 6 months and low quality of life with limited treatment options. First generation EGFR tyrosine kinase inhibitors (EGFR TKIs) have demonstrated significant clinical benefit for patients with EGFR-mutant NSCLC. However, their effect on brain metastasis is limited due to poor drug penetration into the brain. Epitinib is an EGFR TKI designed to improve brain penetration. A Phase I dose escalation study on epitinib has been completed and the recommended Phase 2 dose (RP2D) determined (Y-L Wu, 2016 ASCO). This Phase I dose expansion study was designed to evaluate the efficacy and safety of epitinib in EGFR-mutant NSCLC patients with brain metastasis.

Methods:
This is an ongoing open label, multi-center Phase I dose expansion study. EGFR-mutant NSCLC patients with confirmed brain metastasis, either prior EGFR TKI treated or EGFR TKI treatment naïve, were enrolled to receive oral epitinib 160 mg per day. Patients with extra-cranial disease progression while on treatment with an EGFR TKI were excluded. Tumor response was assessed per RECIST 1.1.

Results:
As of 31 May, 2016, 27 patients (13 EGFR TKI pretreated, 14 EGFR TKI treatment naïve) have been enrolled and treated with epitinib. The most frequent adverse events (AEs) were skin rash (89%), elevated ALT (41%)/AST (37%), hyper-pigmentation (41%) and diarrhea (30%). The most frequent Grade 3/4 AEs were elevations in ALT (19%), gamma-GGT (11%), AST (7%), hyperbilirubinemia (7%) and skin rash (4%). There have been no Grade 5 AEs to date. Among the 24 efficacy evaluable patients (11 TKI pretreated, 13 TKI naïve), 7 (7/24, 29%) achieved a partial response (PR), including 1 unconfirmed PR. All PRs occurred in EGFR TKI treatment naïve patients (7/13, 53.8%). Of the 24 evaluable patients, 8 (5 EGFR TKI treatment naïve, 3 EGFR TKI pretreated) had measurable brain metastasis (lesion diameter>10 mm per RECIST 1.1) with 2 PRs (both EGFR TKI treatment naïve patients, 2/5, 40%).

Conclusion:
Epitinib 160mg per day treatment in EGFR-mutant NSCLC patients with brain metastasis demonstrated clinical activity both extra- and intra-cranial. Epitinib was well tolerated. The data to date appears encouraging and warrants further development of epitinib.

Background:
Recent studies have identified that the degree of tumor infiltrating lymphocyte (TIL) infiltration and PD-L1 expression in the tumor microenvironment (TME) are significantly correlated with the clinical outcomes of anti-PD-1/PD-L1 therapies. Here we conducted this study to verify the distribution of PD-L1/CD8[+] TIL expression and its clinical significance in non-small cell carcinoma (NSCLC). Potential mechanism predicted for PD-1 blockade was explored in depth as well.

Methods:
Immunohistochemistry was performed to detect PD-L1 and CD8 expression in NSCLC. The Kaplan–Meier (KM) survival curve was used to estimate disease free survival (DFS) and overall survival (OS). Gene Set Enrichment Analysis (GSEA) was used to determine potentially relevant gene expression signatures.

Results:
288 cases with stage I-IIIA NSCLC were evaluated for PD-L1 and CD8+ TIL staining. Dual positive PD-L1 and CD8 (PD-L1+/CD8+) represents a predominant subtype in NSCLC, accounting for 36.5% (105/288), followed by PD-L1-/CD8- (24.3%, 70/288), PD-L1-/CD8+ (26.0%, 75/288) and PD-L1+/CD8- (13.2%, 38/288). Survival analysis of DFS (p=0.031) and OS (p=0.002) showed a significant difference between four subgroups. Furthermore, we analyzed the correlation between expression types of PDL1/CD8 and mutation burden and angtigen presentation. We can identified dual positive PD-L1 and CD8 was significant with increased mutation burden (p<0.001), high frequency of mismatch repair (MMR) related gene mutation. More interestingly, tumor with dual positive PD-L1 and CD8 manifested a remarkable activated angtigen presentation and T cell receptor signature compared with other subgroups.

Conclusion:
Dual positive PD-L1 and CD8 was identified as a predominant subtype in NSCLC and correlates with increased immunogenicity. These findings provide the evidence that combined analysis of PD-L1 and CD8 in NSCLC may be a promising way to predict PD-1 blockade immunotherapy.

Background:
RET fusion gene is identified as a novel oncogene in a subset of non-small cell lung cancer (NSCLC). However, few data are available about the prevalence, clinicopathologic characteristics, genetic variability and therapeutic options in RET-positive lung adenocarcinoma patients.

Methods:
For 615 patients with lung adenocarcinoma, RET status was detected by reverse transcription-polymerase chain reaction (RT-PCR). Next-generation sequencing (NGS) and FISH were performed in positive cases. Thymidylate synthetase (TS) mRNA level was assayed by RT-PCR. Overall survival (OS) was evaluated by Kaplan-Meier method and compared with log-rank test.

Results:
Twelve RET-positive patients were identified by RT-PCR. However, one patient failed the detection of RET arrangement by FISH and NGS. Totally, 11 patients (1.8%) confirmed with RET rearrangements by three methods , including six females and five males with a median age of 54 years. The presence of RET rearrangement was associated with lepidic predominant lung adenocarcinoma subtype in five of 11 patients. RET rearrangements comprised of nine KIF5B–RET and two CCDC6–RET fusions. Four patients had concurrent gene variability by NGS detection,including EGFR(n=1),MAP2K1 (n=1), CTNNB1 (n=1) and AKT1 (n=1) . No survival difference existed between RET-positive and negative patients (58.1 vs. 52.0 months, P=0.504) . The median progression-free survival of first-line pemetrexed/platinum regimen was 7.5 months for four recurrent cases,and longer than RET-negative patients(7.5 vs.5.0 months, P=0.026). . The level of TS mRNA was lower in RET-positive patients than that in those RET-negative counterparts (239±188×10[-4] vs. 394±457×10[-4],P=0.019) .

Conclusion:
The prevalence of RET fusion is approximately 1.8% in Chinese patients with lung adenocarcinoma. RET arrangement is characterized by lepidic predominance and a lower TS level. RET-rearranged patients may benefit more from pemetrexed-based regimen.

Background:
ROS1 gene-rearrangement in non-small cell lung cancer (NSCLC) patients has recently been identified as a driver gene and benefited from crizotinib treatment. However, no data is available for ROS1-positivity NSCLC about chemotherapeutic options and prognostic data. We investigated pemetrexed-based treatment efficacy in ROS1 translocation NSCLC patients and determined the expression of thymidylate synthetase (TS) to provide a rationale for the efficacy results.

Methods:
We determined the ROS1 status of 1750 patients with lung adenocarcinoma. Patients’ clinical and therapeutic profile were assessed. In positive cases, thymidylate synthetase (TS) mRNA level was performed by RT-PCR. For comparison, we evaluated the TS mRNA status and pemetrexed-based treatment efficacy from 170 NSCLC patients with anaplastic lymphoma kinase (ALK) translocation(n=46), EGFR mutation (n=50), KRAS mutation (n=32) and wild-type of EGFR/ALK/ROS1/KRAS (n = 42).

Results:
Thirty-four ROS1 translocation patients were identified at two institutions. Among the 34 patients, twelve with advanced stage or recurrence were treated with pemetrexed-based first-line chemotherapy. The median progression-free survivals of pemetrexed-based first-line chemotherapy in ROS1 translocation, ALK translocation, EGFR mutation, KRAS mutation and EGFR/ALK/ROS1/KRAS wild-type patients were 6.8, 6.7, 5.2, 4.2 and 4.5 months, respectively (P=0.003). The TS mRNA level was lower in patients with ROS1-positive than ROS1-negative patients (264±469×10[-4] vs. 469 ± 615×10[-4] , P=0.03), but similar with ALK-positive patients (264±469×10-4 vs. 317±524×10[-4], P=0.64).

Conclusion:
Patients diagnosed with ROS1 translocation lung adenocarcinoma may benefit from pemetrexed-based chemotherapy. TS mRNA level enables the selection of therapeutic options for ROS1translocation patients.

Background:
According to the 2015 World Health Organization classification of lung tumors, pulmonary Large cell neuroendocrine carcinoma (PLCNC) is grouped with the small cell lung cancer (SCLC) and carcinoid as pulmonary neuroendocrine carcinoma(PNC) for the common features of neuroendocrine characteristics . Molecular profiles and prognosis of primary pulmonary neuroendocrine carcinoma(PNC) are not well investigated currently. We conducted present study to evaluate genomic abnormality and survivals in patients with primary PNC.

Methods:
Tumor samples of PNC after completely resection from Zhejiang Cancer Hospital were collected from 2008 to 2015. Nine driver genes including six mutation (EGFR, KRAS, NRAS, PIK3CA, BRAF, HER2) and three fusions (ALK, ROS1, RET) were evaluated by RT-PCR. Survival analysis was evaluated using the Kaplan-Meier method.

Results:
Totally, 108 patients with pathologic confirmed PNC were enrolled. Samples included 52 PLCNC, 44 small cell lung cancer (SCLC) and 12 carcinoid. Twelve patients were found to harbor genomic aberrations (11.1%). The most frequent gene abnormality was PIK3CA (n=5,4.6%),followed with EGFR (n=3,2.8%), KRAS (n=2,n=1.9%), ALK (n=1,0.9%), RET (n=1,0.9%). No ROS1,BRAF,NRAS and HER2 mutations were observed. The frequencies of gene aberrations in PLCNC, SCLC and carcinoid were 15.4%,6.8% and 8.3%,respectively. Sixty-seven patients were with recurrence or metastasis after surgery, including 32 PLCNC, 33 of SCLC, and two of carcinoid (both were atypical carcinoid). Among the 32 patients with PLCNC,none received molecular targeted treatment,28 received first-line chemotherapy,including 18 of etoposide/platinum regimen and 10 of other platinum-based treatment. The progression free survival in patients with etoposide/platinum regimen was longer than patients with non-etoposide/platinum treatment (4.8 vs.3.4 months,P=0.019) . Survival difference was observed among the PLCNC,SCLC and carcinoid group (37.0 vs. 34.0 vs.not reached, P=0.035), but no difference existed between the PLCNC and SCLC group (P=0.606).

Conclusion:
Common genomic abnormality is rare in PNC patients and most frequently observed in PLCNC. Patients with carcinoid had a superior survival than PLCNC and SCLC.

Background:
This study aimed to assess the ability of different technology platforms to detect epidermal growth factor receptor (EGFR) mutations including L858R, E19-dels, T790M, and G719X from circulating tumor DNA (ctDNA) in patients with non-small cell lung cancer (NSCLC).

Methods:
Plasma samples were collected from 20 patients with NSCLC including detailed clinical information along with data regarding treatment response. ctDNA was extracted from 10 mL plasma using the QIAamp Circulating Nucleic Acid Kit (Qiagen). Extracted ctDNA was analyzed using two real time-amplification refractory mutation system-quantitative PCR platforms (cobas® EGFR Mutation Test: cobas; and AmoyDx® EGFR 29 Mutations Detection Kit: ADx), one digital platform (Droplet Digital[TM] PCR, ddPCR: Bio-rad), and one next-generation sequencing platform (firefly NGS: Accuragen).

Results:
If a positive result was obtained from any one of the four platforms, the sample was categorized as positive. We identified 15 EGFR mutations in 20 patients with NSCLC using the four platforms, for which 7, 11, 10, and 12 mutations were detected by ADx, cobas, ddPCR, and firefly NGS, respectively. Among the 15 EGFR mutations, six and seven EGFRalterations demonstrated an allele frequency of more or less than 1% (group A or B, respectively), and two exhibited unknown allele frequency. In group A, 5, 5, 5, and 6 EGFR mutations were detected by ADx ,cobas, ddPCR, and firefly NGS, respectively. The positive coincidence rate of any two platforms ranged from 66.7% to 100% and the kappa value varied from 0.787 to 1.000 in group A. In group B, 1, 5, 5, and 6 EGFR mutations were detected and the positive coincidence rate of any two platforms ranged from 16.7% to 100% and the kappa value varied from 0.270 to 1.000. The output of cobas, ddPCR, and firefly NGS were highly correlated, whereas ADx displayed weak concordance with these three platforms in group B. In addition, we identified 75 wild-type loci when EGFR alleles identified as negative by one or more platforms were considered as negative. ADx, cobas, ddPCR, and firefly NGS uncovered 73, 69, 70, and 68 EGFR wild-type loci, respectively. The concordance and negative coincidence rates between any two platforms were over 90%.

Conclusion:
The detection rate and concordance were probably affected by the abundance of EGFR mutations and the sensitivity of different platforms. Three platforms, including cobas, ddPCR, and firefly NGS, exhibited higher positive coincidence and detection rates when the allele frequency was lower than 1%.

Background:
We aimed to investigate the feasibility of droplet digital PCR (ddPCR) for the detection of epidermal growth factor receptor (EGFR) mutations in circulating free DNA (cfDNA) from cerebrospinal fluid (CSF) and plasma of advanced Lung Adenocarcinoma (ADC) with brain metastases (BM).

Methods:
Fourteen advanced ADC patients with BM carrying activating EGFR mutations in tumour tissues were enrolled in this study, and their matched CSF and plasma samples were collected. EGFR mutations were detected by the Amplification Refractory Mutation System (ARMS) in tumour tissues. EGFR mutations, including 19del, L858R, and T790M were examined in cfDNA isolated from 2milliliter CSF or plasma by ddPCR assay. The clinical response was assessed according to Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1 guidelines. Overall survival (OS) and progression free survival (PFS) after the diagnosis of BM were also evaluated.

Results:
Out of 14 patients, eleven were females and three males aged from 34 to 74 years old (median age of 55 years old). In all of cases, CSF cytology were negative. In ddPCR assays, EGFR mutations were detected in CSF of three patients (21.4%; one of 19del and two of L858R), and in plasma of six patients (42.9%; one of 19del, one of L858R, one of T790M, two of L858R&T790M, and one of 19del&T790M). All EGFR T790M mutations were found during or after EGFR-TKIs treatments. The three patients with activating EGFR mutations in CSF achieved partial response (PR) of BM after treated with combination of WBRT and EGFR-TKIs. The median OS and PFS after the diagnosis of BM were 18.0 months and 9.0 months, respectively.

Patient	Tissue EGFR	CSF EGFR	Plasma EGFR	Systematic Treatment	BM Treatment
1	19del	WT	T790M	Erotinib+Chemotherapy	WBRT+Gamma knife
2	19del	WT	19del	Erotinib+Chemotherapy	WBRT
3	L858R	L858R	L858R	Gefitinib+Chemotherapy	WBRT
4	L858R	WT	WT	Gefitinib+Chemotherapy	WBRT
5	19del	WT	WT	Gefitinib+Chemotherapy	WBRT
6	L858R	WT	L858R/T790M	Erotinib+Chemotherapy	WBRT
7	L858R	WT	WT	Gefitinib	WBRT
8	19del	19Del	19Del/T790M	Gefitinib	WBRT
9	L858R	WT	WT	Erotinib+Chemotherapy	NONE
10	19del	WT	WT	Erotinib+Chemotherapy	WBRT
11	19del	WT	WT	Icotinib+Chemotherapy	WBRT
12	L858R	WT	L858R/T790M	Chemotherapy	WBRT
13	L858R	L858R	WT	Icotinib	WBRT
14	19del	WT	WT	Gefitinib+Chemotherapy	WBRT

Conclusion:
It was feasible to test EGFR mutation in CSF. CSF may serve as liquid biopsy of advanced ADC with BM by enabling measurement of cfDNA within CSF to characterize EGFR mutations.

Background:
In patients with advanced non–small-cell lung cancer (NSCLC) harboring epidermal growth factor receptor (EGFR) activating mutations, EGFR-tyrosine kinase inhibitors (TKIs) are recommended as first-line treatment due to favorable clinical efficacy. However, acquired resistance inevitably develops after median progression-free survival (PFS) of 9-14 months. Among the mechanisms of acquired resistance, small-cell lung cancer (SCLC) transformation was reported to account for nearly 5%. However, the molecular details underlying this histological change and resistance to EGFR-TKI therapy remain unclear.

Methods:
15 out of 233 (6.4%) patients were confirmed to develop SCLC transformation after failure to EGFR-TKI. We analyzed the clinical parameters of these patients by using chi-square test and Kaplan-Meier analysis. To explore gene alterations that might contribute to SCLC transformation, next generation sequencing (NGS) was performed on four pairs of matched pre- and post-transformation tumor tissue samples. We further performed NGS on 11 matched circulating tumor DNA (ctDNA) to explore the potential mechanism of resistance to EGFR-TKI.

Results:
The median age of SCLC transformed patients was 53 years. 93.3% (14/15) patients harbored EGFR exon19 deletion. The median PFS and overall survival (OS) of SCLC-transformed patients treated with EGFR-TKI compared to those without transformation were 11.7 versus 11.9 months (P=0.473) and 29.4 versus 24.3 months (P=0.664), respectively. All 4 patients developed loss of heterozygosity of TP53/RB1 after transformation. Besides, increased copy number of five proto-oncogenes were identified in post-transformation tissue samples. Three patients developed EGFR T790M mutation in the post-transformation ctDNA rather than their tissue samples.

Conclusion:
SCLC transformation was commonly seen in patients harboring EGFR exon 19 deletion. The clinical outcomes of TKI and OS in SCLC transformed patients were similar to non-transformed patients. The loss of heterozygosity of TP53 and RB1along with increased copy number of proto-oncogenes may lead to the SCLC transformation. The mechanisms of acquired resistance to TKI during SCLC transformation might be the emergence of classic drug resistance mutations, which was undetectable due to the intra-tumor heterogeneity.

Abstract not provided

Background:
Lung tumours often exhibit large and unpredictable motion that can severely compromise radiotherapy outcomes. Markerless tumour tracking can enable wide access to motion-adaptive radiotherapy, negating the risks and costs associated with implanting markers. The main barrier to markerless tumour tracking is the inferior tumor visibility on x-ray images due to overlapping anatomic structures. The aim of this study is to develop a markerless tumor tracking method for lung radiotherapy using intrafraction x-ray imaging.

Methods:
The markerless tumour tracking method (Figure1a) consists of four steps: (1) Building a tumour and anatomic model from the cone-beam CT (CBCT) acquired prior to treatment, (2) Using the anatomic model to remove the contribution of anatomic structures on intrafraction x-ray images, (3) Locating the tumour on the intrafraction 2D x-ray image via template matching using the tumour model, (4) Determining the tumour 3D position by a Kalman filter. The proposed method was retrospectively validated on (i) 11 CBCT scans from four patients with central tumours, and (ii) a kV fluoroscopic scan during a stereotactic ablative radiotherapy (SABR) treatment from the Light SABR trial (NCT02514512). Tracking errors were estimated using the motions of markers or beacons implanted near the tumours. Figure 1



Results:
Markerless tumour tracking successfully tracked tumours in all cases at every imaging angle. The mean 3D tracking error ranged from 1.8-4.1mm for the 11 CBCT scans, and was 3.0mm for the SABR case. Compared with the current standard of care, i.e. a single estimation of tumour position prior to treatment from the pre-treatment CBCT, markerless tumour tracking reduced tumour localization error by 0.9-7.9mm. Tracking errors in the left-right, superior-inferior, and anterior-posterior directions are shown in Figure1b.

Conclusion:
A markerless tumour tracking method was developed and shown to improve tumour localization accuracy in 12 lung cancer cases. This method can potentially enable wide access to motion-adaptive radiotherapy.

Background:
MLC tracking is an emerging technology to improve tumor targeting and reduce normal tissue irradiation during radiotherapy. The purpose of this work is to present the early clinical experience from the first-in-human trial of real-time tumor targeting via MLC tracking for stereotactic ablative body radiotherapy (SABR) of lung cancer.

Methods:
Full ethics approval through an Australian ethics board has been received for recruitment of 20 patients with stage 1 lung cancer or lung metastases into the MLC tracking clinical trial (NCT02514512). To date, seven recruited patients have each had three electromagnetic beacons inserted near the tumor. An MLC tracking SABR plan was generated with planning target volume (PTV) expanded 5mm from end-exhale tumor volume (GTV). For comparison a conventional motion-encompassing SABR plan was generated with PTV expanded 5mm from a 4DCT-derived internal target volume. Treatment was delivered using a standard linear accelerator using in-house developed software to continuously adapt the MLC motion based on the Calypso beacons’ movement. Tumor motion, treated volume and reconstructed delivered dose were compared between MLC tracking and conventional motion-encompassing treatment planning.

Results:
All seven patients have been treated successfully with MLC tracking (29 successful fractions). The MLC tracking PTV for all patients has been smaller than with ITV based planning (range 12% to 41% reduction, or 2 to 18 cm[3] with MLC tracking). Subsequent reductions in normal lung dose were observed. Tumor motion was seen to vary in motion range from the planning 4DCT during treatment; significantly, larger motion was observed during treatment that exceeded standard PTV boundaries. Reconstruction of delivered treatments confirmed the accurate delivery of MLC tracking, with 100% prescribed dose delivered to the GTV.Figure 1



Conclusion:
The first treatments with MLC tracking have been successfully performed in seven lung cancer patients. Reductions in treated volumes were observed, which translated to reductions in delivered lung dose.

Background:
Objectives: In lung cancer patients treated with image-guided radiotherapy we use daily Cone-Beam CT (CBCT) guidance for setup verification and to check on intra-thoracic anatomical changes (ITACs). ITACs like tumor baseline shifts, the occurrence or dissolving of an atelectasis, tumor progression or regression, pleural fluid- and infiltrative changes have been reported in 72% of lung cancer patients (Kwint M R&O 2014) during the course of irradiation. A traffic light protocol has been in use by the radiation technologists since 2010 to classify anatomical changes seen on the CBCT with anticipated different influences on the dose distribution using 4 action levels. The purpose of this study was to quantify how often the ITACs occurred in daily clinical practice and for which action level.

Methods:
All lung cancer patients irradiated in 2015 (excluding stereotactic treatments) with a dose >44 Gy were included. All patients had a daily CBCT guided online correction protocol and the traffic light action level of each CBCT was recorded. The following action levels have been defined: code red for immediate consultation with the physician before beam-on, code orange for a decision on the notification of the physician before the next fraction, code yellow to inform the physician; no action is required- and green for no change so no intervention necessary. We also analyzed the percentage of patients that received a new planning-CTscan and/or a new treatment plan.

Results:
In 2015 a total of 299 lung cancer patients were conventionally irradiated with radical intent and 5971 CBCT scans were made. Of these CBCTs 51% were scored as code green, 24% as code yellow, 24% as code orange and code red in less than 1% of the CBCTs. Forty patients (13%) had a new treatment plan, of which 34 patients (11%) had a new planning CT-scan and 6 patients (2%) had a new treatment plan on the original planning CT-scan.

Conclusion:
Image-guided irradiation for 299 conventionally fractionated lung cancer patients (>44 Gy) in 2015 revealed lTACs in 25% of the CBCT’s made and a physician’s decision on the notification was necessary. A total of 13% of the patients treated received an unscheduled adaptive treatment plan during the course of treatment. The traffic light protocol in daily clinical workflow worked well as a tool to prioritize a physician’s decision based on the ITACs seen on the CBCT images.

Abstract not provided

Background:
Nivolumab has been recently approved by the FDA as a 2[nd]-line treatment of NSCLC. The data regarding its efficacy in the real-life setting is lacking.

Methods:
260 consecutive patients with advanced NSCLC treated with nivolumab at five cancer centers in Israel between January 2015 and March 2016 were observed for OS and toxicity. OS was analyzed by the Cox proportional-hazards regression model.

Results:
Patient baseline characteristics: median age 67y (range 41-99); males 68%; smokers 76%; ECOG PS ≥2 46%; Non-sq/Sq/other 70%/23%/7%; KRASm/EGFRm/ALK+/other genetic aberration/none/NA 7%/5%/0%/4%/42%/42%; brain metastases 21%; liver metastases 21%; treatment (Tx) line: 1st/2nd/3rd+-line/NA 6%/64%/26%/4%. Median duration of follow-up was 4.3 mo (range 0.1-13.8); median Tx duration was 2.7 mo (range 0.1-15.5); median number of Tx cycles delivered was 6 (range 1-26). 130 (50%) patients died; median OS comprised 6.6 mo (95%CI 5.6-8.4). In univariate and multivariate analysis, the only variable which significantly correlated with OS was ECOG PS (table 1). Median OS of patients with ECOG PS 0/1 and ECOG PS ≥2 comprised 8.6 mo and 3.5 mo, respectively. Safety data is presented in table 2. Figure 1Figure 2





Conclusion:
Nivolumab has reasonable efficacy and good safety profile in the real-life setting. ECOG PS ≥2 is associated with poor prognosis.

Background:
Patients with non-small cell lung cancer (NSCLC) display a wide spectrum of oncologic outcomes, suggesting significant underlying biologic diversity. However, current radiotherapeutic management is largely homogeneous for a given stage, To advance genotype-directed radiotherapy in NSCLC, we sought to identify genetic determinants of radioresistance by leveraging cancer genomic data with a recently developed high-throughput platform for measuring radiation survival.

Methods:
We used our recently validated high-throughput proliferation assay to profile 104 lung cancer cell lines, including 89 NSCLC and 15 small cell lung cancer (SCLC) lines, for radiation survival. Survival curve analyses permitted quantitative assessment of radiosensitivity. Genomic correlates of radiosensitivity were explored by calculating the information-based similarity metric and correlating genomic parameters by accessing Oncomap data from the Cancer Cell Line Encyclopedia, the COSMIC database of the Cancer Genome Project, and The Cancer Genome Atlas.

Results:
Radiation survival across lineages reflected clinical experience regarding differential response to fractionated radiation inasmuch as lung squamous cell carcinoma and adenocarcinoma (ACA) had similar radiosensitivity, whereas SCLC and carcinoid were, respectively, more and less radiosensitive. Importantly, radiosensitivity varied more within a lineage than across lineages, with a 6-fold difference in integral survival among ACA lines. Correlation with cancer genomic data revealed BRAF mutations within the most resistant ACA lines (P = 0.0097, FDR = 0.957). A majority of the mutations identified by our analysis have been previously annotated by The Cancer Genome Atlas lung ACA dataset and all hypermorphic mutations identified were located in the highly conserved kinase domain. The majority of mutations have been known to enhance kinase activity in melanoma in a fashion analogous to the well-known BRAF V600E mutation. In line with these findings, we showed that kinase domain mutations were hypermorphic as measured by MEK and ERK1/2 phosphorylation. We also showed that exposure of wild type BRAF cells to radiation results only in a transient activation of MEK and ERK1/2. The MEK inhibitor selumetinib selectively decreased the growth of cells with kinase domain BRAF mutations and sensitized these cells to radiation.

Conclusion:
BRAF mutations are associated with radiation resistance in lung ACA. Our data nominates MEK inhibitors, a drug class currently in clinical use, as a targeted therapeutic in select BRAF-mutant lung ACA. Further investigation has the potential to yield an additional genotype-directed therapy that could impact up to 4-6% of patients with lung ACA, a frequency comparable to that of ALK rearrangements (4%) or EGFR mutations (10%).

Abstract not provided

Background:
FDG-PET/CT is the gold-standard for non-small cell lung cancer (NSCLC) diagnosis, staging and tumour delineation prior to chemo-radiation therapy (CRT). FDG-PET is superior to CT for subsequent response assessment. Sequential interim metabolic and proliferative tumour response assessment with FDG and 3'-Fluorothymidine (FLT) respectively, prior to and during CRT is novel and may predict outcome.

Methods:
Patients with FDG-PET-stage I-III NSCLC who were prescribed radical chemo-RT (60 Gy in 30 fractions @ 5/wk) were enrolled. FDG and FLT PET/CT scans were performed at baseline and at weeks 2 and 4 of CRT. Intra-treatment tumour response judged by reduction in FDG and FLT uptake was categorised as complete (CR)/partial response (PR), stable (SD) or progressive disease (PD) using EORTC criteria. Overall Survival (OS) and Progression Free Survival (PFS) were measured relative to intra-treatment scan dates and plotted using Kaplan-Meier curves. Univariate Cox regressions were used to calculate associations between 1. SUVmax of baseline FDG and FLT GTV and 2. intra-treatment FDG and FLT response with patient outcomes (OS and PFS).

Results:
Sixty patients were recruited between 2009-13; male 62%; median age 66 years, adenocarcinoma (42%). Two-year OS and PFS were 0.51 and 0.26 respectively. Of 332 PET/CT scans analysed, study scans provided additional information to FDG~BL~ in 21 (35%) patients. Distant metastasis was detected in 3 patients on FLT~BL~ and in 2 patients on FDG/FLT~wk2~ changed treatment intent to palliative. Loco-regional progression during RT was observed in 5 (8%) patients, prompting larger RT fields. FLT~wk2~ response (SD vs CR/PR vs PD) was associated with OS [HR (95%CI) 1 vs 2.02 (0.87, 4.65) vs 20.09 (4, 114), p=0.012] and PFS [1 vs 2.01 (0.92,4.37) vs 32.41 (3,348), p=0.024]. Associations between the baseline FDG and FLT SUV~max ~and patient outcomes were not significant, including OS where FDG SUVmax HR [95% CI] was 1.04 [0.98, 1.10], p=0.25 and FLT SUVmax HR [95% CI] was 1.07 [0.93, 1.22], p=0.33.

Conclusion:
Tumour response on FLT~wk2~ was associated with OS and PFS. The possible association between worse clinical outcomes and early suppression of FLT uptake during CRT may be a result of repair of tumour DNA damage. Baseline FLT, FLT~wk2~ and FDG~wk2~ detected rapid distant and loco-regional progression in 10 (17%) patients prompting changes in treatment intent and RT fields.

Background:
Treatment-related toxicity is more common following stereotactic ablative radiotherapy (SABR) for central lung tumors, than is the case for peripheral tumors [Tekatli 2015]. Further reductions in doses to critical central structures are possible using respiration-gated SABR delivery, but insertion of fiducial markers for gating is also associated with toxicity. We describe a novel approach for clinical delivery of breath-hold gated SABR under continuous MRI-guidance.

Methods:
The MRIdian® system permits tumor visualization at 4 frames/second during treatment delivery, with radiation beam-holds whenever the target is outside a prespecified gating window. The gating procedure is as follows: a 17 second inspiration breath-hold MR scan is performed for planning before each SABR fraction (resolution 1.6×1.6×3.0 mm). Image registration is performed, and contours adapted when necessary. A 3mm PTV margin is added, and planned dose distribution recalculated for the ‘anatomy of the day’, and reoptimized. A sagittal plane is chosen for tumor tracking and gating, with a planning target margin of 3 mm. The sagittal tracking view from the MRIdian console is projected on a MR-safe monitor (Cambridge Research), and patients can continuously observe the tracking image using a mirror inside the bore.

Results:
Since May 2016, 30 fractions of MR-guided gated delivery have been performed in 5 cancer patients with 6 central tumors. All MR-based breath-hold PTV’s were smaller (mean 19.8 ± 13.3 cc) than a conventional free-breathing, motion-encompassing approach (mean 36.1 ± 21.9 cc). Plans of a single case are shown in Figure 1. Video-assisted visual feedback achieved a breath-hold gating efficiency of 52% (range 27-88%).Figure 1



Conclusion:
For high-risk SABR cases, use of MR-guided, video-assisted breath-hold gated SABR delivery constitutes a novel treatment method, allowing for minimization of mobility- and setup margins, and for improved verification of SABR delivery. Data from additional patients undergoing treatment will be presented.

Background:
Worldwide lung cancer is the biggest cause of cancer mortality (Cancer Research UK, 2012) and is the UK’s second most commonly diagnosed malignancy (Macmillan Cancer Support, 2013). Early detection and treatment significantly improves five year survival rates but curative treatments can impact on patients’ health and wellbeing. To date little research has been conducted to establish the support needs and recovery patterns of health and wellbeing among lung cancer patients treated with curative intent radiotherapy. This limits our ability to identify those most at risk of poorer health and wellbeing outcomes and target services effectively to support patients better. This study assesses the feasibility of collecting patient reported outcomes measures (PROMs) and clinical details to understand recovery after curative intent radiotherapy treatment for lung cancer.

Methods:
This mixed methods study used a prospective, longitudinal cohort design. Eligible patients awaiting curative intent radiotherapy were recruited from six UK sites between October 2015 and June 2016. Questionnaires were completed before undergoing radiotherapy and 3 months later. The questionnaires included validated patient reported outcome measures, including quality of life, symptoms, social support, wellbeing and socio-demographic details. Participants’ medical details were collected by healthcare professionals (HCPs) including cancer type, stage, treatment, and comorbid conditions. Study procedures were evaluated in a qualitative process evaluation.

Results:
Of 229 eligible patients, 136 consented to the study with 73% uptake of those approached. A further 13 patients provided reduced consent to collect demographic and medical information only. Preliminary results: response rates 76% at baseline and 65% at 3 months. Of baseline responders: 59% were male; the median age was 70 years; 29% lived alone; 61% were home owner-occupiers and 20% were current smokers. Baseline EORTC-QLQ-C30 results showed a mean global health status score of 56.6 and patients were most affected by dyspnoea and fatigue with mean scores of 48.8 and 45.0. These are in line with expected scores based on reference data. To date 9 HCPs, 7 patients and 2 stakeholders have been interviewed as part of the process evaluation, study processes and procedures are deemed acceptable to participants.

Conclusion:
This study demonstrates it is feasible to recruit a cohort of lung cancer patients prospectively to assess wellbeing and patterns of recovery following radiotherapy. This novel approach to understanding lung cancer patients’ experiences of survival will enhance our ability to target appropriate and timely support to those most at risk of poorer health and wellbeing.

Abstract not provided

Background:
Our laboratory has demonstrated the augmented anti-tumor efficacy of intrapleurally administered cancer-antigen mesothelin (MSLN)-targeted chimeric antigen receptor (CAR) T cells (Sci Transl Med 2014), and translated the approach to a clinical trial (NCT02414269) for thoracic malignancies. We hypothesized that regionally administered MSLN CAR T cells can circulate systemically to achieve abscopal anti-tumor efficacy in an antigen-specific manner, and the abscopal efficacy can further be promoted by tumor-targeted radiation therapy (RT).

Methods:
Using optimized protocols that would permit non-necrotic, well-vascularized tumor growth in pleura, chest wall, peritoneum and flank, tumors were established in immunodeficient (NOD/SCID gamma) mice using mesothelioma or lung adenocarcinoma (LAC) cells. Tumor burden progression, MSLN-targeted CAR T-Cell accumulation at primary and distant tumors was monitored by noninvasive bioluminescence imaging (BLI) and tumor volume measurements.

Results:
A single dose of MSLN CAR T cells administered intrapleurally proliferated (Figure 1A left panel), circulated extrapleurally and accumulated at abscopal sites, including the lymph nodes, chest wall, peritoneum, and flank within 3-5 days, with subsequent T-cell proliferation at abscopal sites (Figure 1A right panel). Primary tumor-targeted, single-dose, thoracic RT prior to T-cell administration augmented T-cell accumulation as demonstrated by BLI (Figure 1B) and tumor T-cell quantification (p<0.01). In a mouse model of primary pleural, abscopal antigen-expressing and non-expressing flank tumors (Figure 1C), a single, low-dose, non-cytotoxic thoracic RT enhanced abscopal site CAR T-cell accumulation that resulted in tumor regression (p=0.01; Figure 1D). Figure 1



Conclusion:
Regionally administered mesothelin-targeted CAR T cells proliferate and eradicate the primary tumor, accumulate and demonstrate anti-tumor efficacy at abscopal sites prior to eradication of the primary tumor in an antigen-specific manner. A single low-dose primary tumor-targeted radiation therapy promotes scopal and abscopal anti-tumor efficacy. These results provide rationale to initiate a clinical trial of combination regional therapies with radiation therapy and CAR T cells.

Abstract:
The targeted therapy based on genotyping has become an important treatment approach for advanced non-small cell lung cancer (NSCLC), especially adenocarcinoma. It is reported that nearly fifty to sixty percent of Asian patients with lung adenocarcinoma could have survival benefit from the first generation epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKI) and Anaplastic Lymphoma kinase (ALK)-TKI. However, the targeted therapy has apparently reached a plateau due to the drug resistance. The spatial and temporal heterogeneity of tumors are regarded as the foundation of both primary and acquired resistance. Multiple studies show that the mechanism of acquired resistance to first generation EGFR-TKI is complicated, including T790M mutation, PI3KCA mutation, c-MET amplification, and histologic transformation from NSCLC to SCLC et al, some of which could co-exist in the same patient. Although the third generation EGFT-TKI targeted at T790M mutation has been proved with dramatic efficacy, most patients become resistant after 10 months of therapy, the mechanism of which is even more complicated. Recently, by conducting next generation sequencing (NGS) through peripheral blood samples of patients treated with AZD9291 and CO1686 in clinical trials, newly drug-resistant mutations such as C797S and C693I have been found and functionally verified. This has laid a solid foundation for developing the fourth generation medicine in future undoubtedly. In the meanwhile, the resistant mechanism to ALK-TKI is also very complex. Multiple drug-resistant mutations could not only occur in ALK kinase domain, but also in alternative signal pathways. Therefore, we should establish a real-time, dynamic and quantitative detecting system for multiple targetable genes to fulfill detecting and monitoring the drug resistance during treatment, and on the other hand, to explore novel drug-resistant mutations through NGS of peripheral blood samples in future. Checkpoint inhibitors have been studied and utilized in various cancers, which has changed the perennially stagnant situation of immunotherapy and opened a new chapter in the treatment of cancers. Studies have shown an objective response rate of approximately 20%-30% with a prolonged survival period of 3-6 months to a series of programed death (PD1)/ programed death-ligand 1(PD-L1) inhibitors immunotherapy in lung cancer patients, with adenocarcinomas, squamous cell carcinomas and small cell carcinomas. While the biggest challenge of immunotherapy currently is to establish a powerful predictive system for efficacy. The existing researches mostly focus on exploring whether the PD-L1 expression or tumor infiltrating lymphocytes (TIL) status could predict the efficacy of PD1/PD-L1 inhibitors. The results varied from different agents of PD1/PD-L1 inhibitors and results of different trails. For instance, PD-L1 expression was associated with response to Nivolumab in patients with lung adenocarcinoma, while this kind of relationship was not observed in squamous cell NSCLC. The inconsistency between different trails may be attributed to the heterogeneity of PD-L1 expression, the unstandardized sample collecting and storing, and issue in IHC evaluation system. So the future investigation should lay more emphasis on overcoming tumor heterogeneity, standardization and optimization of detection techniques and sample collections, based on which we are looking forward to more effective predictive biomarkers. Both tumor and host microenvironment should be equally important as the foundation of precision medicine for cancer. More and more studies show that mutation loads of somatic cells contribute to immunogenicity of tumors, so as to be associated with the efficacy of checkpoint inhibitors. One research showed that different types of mutations, such as EGFR mutation, ALK fusion gene and PI3KCA mutation, possess different levels of mutation loads. And another research indicated that lung adenocarcinoma with higher neoantigen-load responded better to checkpoint inhibitors than the lower ones. There has been a study to calculate mutation loads and neoantigens in adenocarcinoma or squamous carcinoma by whole Exome sequencing based on the Cancer Genome Atlas (TCGA). The future studies should pay close attention to exploring the dynamic change patterns of mutation loads and neoantigens prior and during the treatment strategies, including PD-1/PD-L1 inhibitors immunotherapy, targeted therapy and traditional chemotherapy, and also to investigate the relationship between regulatory immune factors in the microenvironment, to further establish the predictive system for immunotherapy integrating PD-L1、PD-L2, TIL mutation loads of somatic cells, and neoantigens which are in great expectations.

Abstract:
Targeted therapies or immune checkpoint inhibitors may be the adequate treatment in some patients with advanced non-small cell lung cancer (NSCLC). So far, certain biomarkers are known which may predict tumor response to these drugs. Of major importance is the detection of activating epidermal growth factor receptor (EGFR) mutations. They occur more frequently in the asian compared to the caucasian population and are usually found within exon 18-20 of the EGFR gene. Most of them are either a deletion at exon 19 or the L858R point mutation at exon 21. Activating EGFR mutations are predominantly detected in female patients with adenocarcinoma histology and never (or low) smoking history. The efficacy of first (erlotinib, gefitinib) and second (afatinib) generation EGFR tyrosine kinase inhibitors (TKI) in patients with advanced NSCLC and an activating EGFR mutation was demonstrated in several clinical studies. However, at some time during treatment with a first- or second generation TKI usually resistance to these drugs occurs which is mediated by the EGFR T790M mutation in about 50%. Recent trials demonstrated that third generation EGFR TKIs like osimertinib and olmutinib may be effective in T790M mutation positive patients with an overall objective tumor response rate of about 60%. Another molecular aberration which is of importance for treatment decision in patients with advanced NSCLC is the rearrangement of the anaplastic lymphoma kinase (ALK) gene. It was demonstrated that patients with an ALK rearrangment do benefit from therapy with the ALK inhibitor crizotinib. Second generation ALK inbibitors (e.g. alectinib, brigatinib, ceritinib) can overcome resistance which may be mediated by secondary ALK mutations. Moreover, third generation ALK inhibitors (e.g. lorlatinib) were developed and are currently being tested. Similar to patients with an ALK rearrangement also patients with a ROS1 rearrangement may benefit from treatment with crizotinib. The relevance of other molecular characteristics like KRAS or BRAF mutations, c-met amplification and HER2 abnormalities as potential biomarkers for targeted therapies is currently under investigation. Programmed death 1 (PD-1) immune checkpoint inhibitor antibodies like nivolumab or pembrolizumab are used in the clinical routine, however, only about 20% of patients do benefit from this treatment. To use resources as effective as possible, a biomarker to predict tumor response to these type of drugs would be enormous helpful in order to save costs. So far, the impact of expression of the PD ligand 1 (PD-L1) regarding clinical benefit to PD1 and PD-L1 inhibitor therapy was, besides efficacy of these drugs in comparison to chemotherapy, investigated in several randomized clinical trials. While in the CheckMate 017 study the overall survival of squamous cell carcinoma patients treated with nivolumab was independent from PD-L1 expression on tumor cells, in the CheckMate 057 study there seems to be some association between the PD-L1 expression level and the overall survival of adenocarcinoma patients treated with nivolumab. In the KEYNOTE-010 trial especially patients (both squamous cell and adenocarcinoma histology) with high (≥ 50% score) PD-L1 expression on tumor cells did benefit from treatment with pembrolizumab. PD-L1 expression on tumor cells as well as on tumor infiltrating immune cells were investigated in patients treated with the PD-L1 inhibitor atezolizumab in the POPLAR study. The overall survival benefit from atezolizumab increased with increasing PD-L1 expression on tumor cells, tumor infiltrating immune cells or both. Overall, currently the impact of PD-L1 expression and the use of certain cut-off levels to predict response to PD-1 and PD-L1 inhibitors is still under discussion. Different findings may, at least partly, be explainded by the use of variables regarding tissue fixation and storage as well as by different antibodies for detection of PD-L1. Alternative biomarker approaches are currently being investigated. In particular, the mutational load as well as the number of predicted neoantigens may be of importance. An association between a higher nonsynonymous mutation burden in tumors and an improved objective reponse, durable clinical benefit as well as progression-free survival in patients treated with pembrolizumab was reported and, in addition, the efficacy was associated with the molecular smoking signature, higher neoantigen burden and DNA repair pathway mutations. Overall, additional studies are necessary to definitely define the impact of PD-L1 expression as biomarker for PD-1 and PD-L1 inhibitors as well as to investigate the value of alternative biomarkers. In conclusion, strong biomarkers are able to predict response to certain therapies. Thus, ineffective treatment strategies may be prevented and resources including costs may be saved. So far, a few biomarkers are known which are very well established in the clinical routine and are important for treatment decisions in NSCLC patients. Regarding immunotherapy, it seems that the expression of PD-L1 may has some impact to predict response to PD-1 and PD-L1 inhibitors, however, its role needs to be completely clarified. Several candidate biomarkers exist, however, their impact needs to be futher investigated.

Abstract not provided

Abstract:
Monitoring of treatment efficacy and treatment-related toxicity –both in the real-world and the clinical trial setting- is a crucial, complex and constantly evolving aspect in the field of modern personalized oncology. The expansion of our lung cancer armamentarium, due to continuous implementation of novel (and costly) targeted and immunotherapeutic agents, along with their companion diagnostics, has inevitably led not only to substantial improvements in clinical outcomes, but also to increasing demands for a more accurate prediction and prevention of toxicities and more robust evaluation of cost-effectiveness. Furthermore, transition to targeted therapies displaying modes of action and biologic behavior vastly distinct to those of traditional cytotoxic agents, has necessitated the need to revisit our concept of what constitutes “tumor response” in lung cancer treatment (and solid tumors in general). Vital issues that need to be urgently -albeit concertedly- addressed include –but are not limited to- the need to adapt response evaluation criteria, monitoring tools and techniques to this rapidly changing landscape of lung cancer treatment and to increase our focus towards a patient-centered standard of care. Monitoring of treatment efficacy using imaging modalities Monitoring of tumor size changes -as evidenced on quantitative imaging modalities such as CT and MRI scans and typically assessed by the unidimensional RECIST criteria- remains the cornerstone of treatment response evaluation and decision-making in oncology practice and a strong surrogate endpoint for overall survival in clinical trials. Limitations of this approach are, nevertheless, significant and increasingly recognized. First, measurement inaccuracies and considerable inter-observer variability should be pointed out. Second, considerable time and cycles of cytotoxic drugs are needed prior to the appearance of any clinically meaningful tumor size changes on standard imaging studies, meaning that a reduction of tumor volume alone may not represent an early indicator of treatment response. Third, antitumor activity of targeted agents, which may not necessarily result in significant tumor size modification, cannot be accurately assessed or predicted with the use of these conventional strategies; multiparametric imaging –evaluating both anatomical and functional parameters of tumors-is thus required for optimal assessment of tumor behavior (stability, progression or regression). Within this context, functional imaging modalities (i.e. dynamic contrast-enhanced MRI, diffusion weighted imaging or FDG-PET and FLT-PET ) with the potential to visualize physiologic changes in the molecular level, have been investigated for their ability to influence decision-making by predicting or monitoring response to molecularly targeted agents or their value as surrogate outcome measures in the trial setting. Notably, FDG-PET is increasingly used for the evaluation of treatment response (mainly with PET response criteria /PERCIST) in lung cancer, while it is generally acknowledged that combined use of both RESIST and PERSIST criteria might lead to increased accuracy of prediction of treatment response in the earlier treatment stages. Evidently, earlier recognition of tolerance to treatment is vital for reduction of unnecessary toxicity and increase of cost-effectiveness. The barriers of complexity, high cost and limited availability, with regard to the above functional imaging techniques, should nevertheless also be emphasized. Evaluation of response to immune checkpoint inhibitors represents an emerging challenge in the field of immuno-oncology; since the specific patterns of tumor response to these agents cannot be accurately described using conventional imaging criteria, immune-related response criteria (irRC) were first defined in 2009, so as to provide a “common language”, enabling the application of a unified assessment of response to immunotherapy. Controversy with regard to the use of bidimensional measurements (according to the WHO criteria) in the irRC nevertheless ensued; immune-related RECIST 1.1 criteria are now increasingly used in clinical studies. Immune-related response evaluation remains to be implemented in routine practice and seems to represent an emerging endpoint in clinical trials. Monitoring of treatment efficacy using non-imaging modalities Monitoring of response to biomarker-driven therapies targeting specific molecular alterations in the lung cancer genome remains a major challenge in the field of personalized oncology, mainly due to shortage of tissue for the performance of genetic profiling of tumors. Liquid biopsies –detecting circulating tumor cells/CTCs and fragments of cell-free circulating tumor DNA/ctDNA- carry much promise for becoming an excellent and non-invasive alternative to tissue-based testing for the identification of genetic mutations with prognostic or therapeutic relevance. As a blood-based biomarker, ctDNA analysis offers the potential of serial investigations at any time point during the course of treatment, and thus of real-time dynamic monitoring of treatment response and early identification of acquired resistance to treatment or even early detection of recurrence (ideally prior to visible tumor size changes on imaging). The first liquid biopsy test approved by the FDA as a companion diagnostic, cobas[®] EGFR Mutation Test v2, is now increasingly used in routine practice for EGFR mutation testing in patients with advanced non-small cell lung cancer, expanding the access of this population to potential disease-modifying treatments. Comprehensive molecular profiling of tumors using next-generation sequencing (NGS) analysis of ctDNA is another major advancement in personalized lung cancer oncology, with tremendous potential for monitoring of dynamic tumor behavior in response to targeted therapy. Other simple and innovative tools for monitoring of treatment response are also being explored. For example, recent data showed that breath analysis using nanoarray technology may represent a quick and patient-friendly monitoring tool for earlier recognition of treatment failure and thus potentially serve as a surrogate marker for response to lung cancer therapy. Monitoring of treatment-related toxicity Subjective toxicity -which cannot be assessed by current toxicity scales- is frequently under-reported in clinical trials, with important negative implications on drug safety evaluations and patient care in general. Recent data highlight the need to improve the current system of toxicity assessment in the trial setting, mainly via implementation of patient-reported outcomes (PROs). Self-reported (and, ideally, real-time) monitoring of toxicity is increasingly investigated in the setting of routine oncology practice as well. As of yet it remains to be firmly established whether this system may significantly contribute to earlier identification and better management of adverse events, improved patient-physician communication and higher quality of life. Suggested reading 1.Nishino M, Hatabu H, Johnson BE, McLoud TC. State of the art: response assessment in lung cancer in the era of genomic medicine. Radiology 2014; 271: 6-27. 2.Bennett CW, Berchem G, Kim YJ, El-Khoury V. Cell-free DNA and next-generation sequencing in the service of personalized medicine for lung cancer. Oncotarget 2016; doi: 10.18632/oncotarget.11717. 3.Nishino M, Giobbie-Hurder A, Gargano M, Suda M, Ramaiya NH, Hodi FS. Developing a common language for tumor response to immunotherapy: immune-related response criteria using unidimensional measurements. Clin Cancer Res 2013; 19: 3936-43. 4.Di Maio M, Basch E, Bryce J, Perrone F. Patient-reported outcomes in the evaluation of toxicity of anticancer treatments. Nat Rev Clin Oncol 2016; 13: 319-25.

Abstract:
Background More than 30 years have passed since industrialized countries started to strictly regulate the use of asbestos, including, in several of them, introducing a total ban on import of raw material and of asbestos-containing products. The use of the International Classification of Diseases (ICD) to classify deaths from mesothelioma has been a source of concern in the past because, before the 10[th] version of ICD (ICD-10), no specific code existed for this type of neoplasm, and analyses based on entities such as ‘pleural cancer’ were subject to misclassification. Since the late 1990s ICD-10 has been used for death certification in many developed countries. Methods We analyzed age-specific mesothelioma mortality rates (all sites), calculated on the basis of the data of the WHO Mortality Database, among men from Canada (2000-2011), USA (1999-2013), Japan (1995-2008), France (2000-2011), Germany (1998-2013), Italy (2003-2012), the Netherlands (1996-2013), Poland (1999-2013), United Kingdom (2001-2013) and Australia (1998-2011), based on ICD-10, to identify temporal patterns following reduction of asbestos exposure. Results Mortality in the age groups 35-54 and 55-64 decreased throughout the study period in all countries (median decrease, 7.9% per year and 4.1% per year, respectively) except in Poland and (up to 2007) in Japan, two countries which started from lower rates. In the age group 65-74, mortality decreased in the USA and, since 2009, in the Netherlands, was stable in Australia, and increased in other countries (median increase, 3.0% per year). In the age group above age 74, a decrease was apparent only in the USA after 2003 (median increase in the other countries, 3.5% per year). Conclusions Our analysis, based on consistent mortality data for mesothelioma, provide strong evidence for a decrease in mortality in the young age groups in most high-income countries: these birth cohorts experienced reduced opportunity for exposure to asbestos during their occupational life. In the case of older age groups, whose members had greater opportunity of exposure, in particular to amphiboles, the evidence of a decrease in mortality is present only in a few countries. Overall, these results stress the importance of early-life exposure circumstances to determine mesothelioma risk throughout life.

Abstract:
Epidemiology: MPM, representing around 90% of all mesothelioma cases diagnosed, is an aggressive tumour with a poor prognosis, and relatively few treatment options. The association of mesothelioma with asbestos exposure is well established. The latency period, the interval between first asbestos exposure to the diagnosis is long (around 40 years), and explains why in many instances the effect of banning asbestos from the workplace has yet to be seen. At the same time there is evidence accumulating that non-occupational asbestos exposure may significantly contribute to mesothelioma incidence [1] and it is most worrying that unrestricted use of this carcinogen is allowed in Russia and most Asian, African and South American countries. Unfortunately the multilateral treaty to promote shared responsibilities in relation hazardous chemicals (Rotterdam convention) has become paralyzed by the veto of asbestos producers and considering the rapid surge of asbestos consumption in developing countries the end of the mesothelioma epidemic is not in sight [2]. Molecular biology: Major efforts have been undertaken to explore the genomic alterations responsible for the development of malignant pleural mesothelioma. Recent next-generation sequencing efforts have confirmed the frequent loss of tumour suppressor genes identified in earlier studies. Deletion and loss of function mutation of CDKN2A, NF2 and BAP1 are common molecular events in MPM, but the overall mutational load tends to be lower in MPM than in lung cancer. Mutation, aberrant splicing, and gene fusions occur in additional genes such as SF3B1, TRAF7 and SETD2, but at lower frequency [3]. Expression analyses suggest that there are subgroups of tumours both within and between the traditional histopathological subtypes of MPM [3, 4], and this has potential implication for prognosis. Although still to be published, the results from a TCGA mesothelioma study paint a similar picture of the mutational and transcriptional landscape. Investigation of microRNA expression reveals a general downregulation of microRNAs with tumour suppressor activities. In addition to miR-31, frequently co-deleted with CDKN2A, the miR-15/16 family is consistently downregulated in MPM tumours. This family controls expression of targets such Bcl-2, CCND1 and VEGF, and thus plays a role in the regulation of proliferation, apoptosis and angiogenesis. Recent data suggest that these microRNAs also play role in controlling the levels of PD-L1 expression in MPM cells [5], targeted by immune checkpoint inhibitors. Treatment Options: MPM is notoriously refractory to localized and systemic treatment. Meta-analyses (multivariate analyses) of large series of patients confirm that the prognosis of the select group of patients able to undergo radical surgery is significantly better than without surgery [6]The debate about the extent of radical surgery has for some time been governed by the significant risks associated with radical surgery as noted in the MARS trial. Therefore, when radical multimodality treatment approaches are considered, it seems prudent to involve an experienced team at a high volume centre. While the important palliative role of radiotherapy in MPM has been accepted by the oncological community, consolidation radiotherapy after radical surgery [7] has not been shown to provide major benefits in terms of local control. To define the role of (intensity modulated) accelerated radiotherapy in MPM comparative studies are needed. The impressive data (median overall survival of 51 months) from the SMART study [8] combining pre-operative intensity modulated radiation therapy (IMRT) immediately followed by extra-pleural pneumonectomy in 62 patients MPM patients with epithelial histology suggests that such an approach may have the potential to become an alternative for induction chemotherapy followed by radical surgery. Almost every chemotherapy agent has been tested in MPM. Cisplatin, methotrexate, pemetrexed and the anthracyclines doxorubicin and daunorubiucin were most active, but single agent activity seldomly exceeded a 20% response rate. A systematic review of the chemotherapy literature carried out in the early 2000s concluded that combination therapy was likely to be more effective than single agent therapy [9]and shortly thereafter Vogelzang’s randomized comparison between cisplatin and cisplatin/pemetrexed confirmed cisplatin/pemetrexed as the new therapy standard. Thirteen years later this standard has been augmented by a large comparative French intergroup study revealing that the addition of bevacizumab to the cisplatin/pemetrexed standard is associated with a 2.7 months advantage in median overall survival [10]. However, it important to note that a not insignificant number of negative phase II and III studies with a range of inhibitors of growth factors including EGFR, VEGF and PDGF had preceded this positive result. Other targeted agents investigated in phase II and III studies including bortezomib, vorinostat, everolimus, and defactinib, the inhibitor of the NF2/mTOR/FAK pathway, have also failed to show notable activity in pre-treated MPM patients [11]. It has become clear that MPM is an immunogenic tumour type and the preliminary data showing responses after immune checkpoint (PD-L1) inhibition [12] seem to indicate that reversing the immunosuppression induced by advancing disease is likely to represent a major step forward. However, monotherapy with Tremelimumab, inhibitor of CTLA-4 and considered active in phase II studies, failed to produce a survival benefit over placebo in 2[nd] and 3[rd] line, underlining the importance of comparative studies [13]. Independent research groups have reported ‘spontaneous’ regression of MPM, revealed a relation between infiltrating lymphocytes and plasma cells and prognosis and presented promising early clinical results with mesothelin-targeting antibodies [11]. Most recently dendritic cell vaccination combined with pulsed (metronomic) cyclophosphamide to deplete regulatory T cells resulted in prolonged tumour control in a limited group of MPM patients [14]. It is not excluded that targeting multiple compartments involved in immune surveillance will lead to increased efficacy. Early signs of efficacy of experimental treatment with tumour suppressive microRNAs packaged in minicells [15, 16] and the interaction between the microRNA 15/16 family and PD-L1 expression point to the complexity of immune checkpoint regulation and underlines the need for additional translational studies to unravel the resilient drug resistance mechanisms operable in MPM. 1. Marinaccio, A., et al., Malignant mesothelioma due to non-occupational asbestos exposure from the Italian national surveillance system (ReNaM): epidemiology and public health issues. Occup Environ Med, 2015. 72(9): p. 648-55. 2. Takahashi, K., P.J. Landrigan, and R. Collegium, The Global Health Dimensions of Asbestos and Asbestos-Related Diseases. Ann Glob Health, 2016. 82(1): p. 209-13. 3. Bueno, R., et al., Comprehensive genomic analysis of malignant pleural mesothelioma identifies recurrent mutations, gene fusions and splicing alterations. Nat Genet, 2016. 48(4): p. 407-16. 4. de Reynies, A., et al., Molecular classification of malignant pleural mesothelioma: identification of a poor prognosis subgroup linked to the epithelial-to-mesenchymal transition. Clin Cancer Res, 2014. 20(5): p. 1323-34. 5. Williams, M., et al., Tumour suppressor microRNAs regulate PD-L1 expression in malignant pleural mesothelioma., in International Mesothelioma Interest Group (iMig) 2016. 2016: Birmingham 6. Linton, A., et al., Factors associated with survival in a large series of patients with malignant pleural mesothelioma in New South Wales. Br J Cancer, 2014. 111(9): p. 1860-9. 7. Stahel, R.A., et al., Neoadjuvant chemotherapy and extrapleural pneumonectomy of malignant pleural mesothelioma with or without hemithoracic radiotherapy (SAKK 17/04): a randomised, international, multicentre phase 2 trial. Lancet Oncol, 2015. 16(16): p. 1651-8. 8. de Perrot, M., et al., Accelerated hemithoracic radiation followed by extrapleural pneumonectomy for malignant pleural mesothelioma. J Thorac Cardiovasc Surg, 2016. 151(2): p. 468-73. 9. Berghmans, T., et al., Activity of chemotherapy and immunotherapy on malignant mesothelioma: a systematic review of the literature with meta-analysis. Lung Cancer, 2002. 38(2): p. 111-121. 10. Zalcman, G., et al., Bevacizumab for newly diagnosed pleural mesothelioma in the Mesothelioma Avastin Cisplatin Pemetrexed Study (MAPS): a randomised, controlled, open-label, phase 3 trial. Lancet, 2016. 387(10026): p. 1405-14. 11. Schunselaar, L.M., et al., A catalogue of treatment and technologies for malignant pleural mesothelioma. Expert Rev Anticancer Ther, 2016. 16(4): p. 455-63. 12. Alley, E.W., et al., Clinical safety and efficacy of pembrolizumab (MK-3475) in patients with malignant pleural mesothelioma: Preliminary results from KEYNOTE-028. Cancer Research, 2015. 76(18): p. CT 103. 13. Kindler, H.L., et al., Tremelimumab as second- or third-line treatment of unresectable malignant mesothelioma (MM): Results from the global, double-blind, placebo-controlled DETERMINE study. Journal of Clinical Oncology, 2016. 34(15 (May Suppl)): p. #8502. 14. Cornelissen, R., et al., Extended Tumor Control after Dendritic Cell Vaccination with Low-Dose Cyclophosphamide as Adjuvant Treatment in Patients with Malignant Pleural Mesothelioma. Am J Respir Crit Care Med, 2016. 193(9): p. 1023-31. 15. Reid, G., et al., Clinical development of TargomiRs, a miRNA mimic-based treatment for patients with recurrent thoracic cancer. Epigenomics, 2016. 8(8): p. 1079-85. 16. Kao, S.C., et al., A Significant Metabolic and Radiological Response after a Novel Targeted MicroRNA-based Treatment Approach in Malignant Pleural Mesothelioma. Am J Respir Crit Care Med, 2015. 191(12): p. 1467-9.

Background:
Background: The presence of N2 lymph node (LN) involvement has strong impact on therapy and prognosis in non-small cell lung cancer (NSCLC). N2 LN metastasis may occur by skipping N1 LN stations (N2skip-met). We aim to analyze incidence, local distribution and impact of N2skip-mets in a large cohort of patients undergoing curative resection for NSCLC.

Methods:
Methods: A retrospective non-interventional singe-center cohort study was conducted, assessing all patients undergoing curative resection for NSCLC between 2006 and 2013 at our institution by reviewing medical charts. Incidence of N2skip-mets among these patients was the primary endpoint. Subsequent secondary correlation of clinical parameters was performed using uni- and multivariate logistic and cox regression models.

Results:
Results: In total, 1110 patients were enrolled, with the following pathological LN status: 789 (71%) pN0, 211 (19%) pN1, 105 (9.5%) pN2, 5 (0.5%) pN3. Histological subtype was: adenocarcinoma, n=675 (61%); squamous cell carcinoma, n=309 (28%); other, n=126 (11%). Incidence of N2skip was 55% (47/105). N2skip-mets occurred more frequently in right sided tumors (odds ratio (OR) 2.14, p=0.058) and patients with adenocarcinoma (vs. other, OR 1.54, p=0.19). Presence of N2skip-mets did not correlate with tumor size (ROC, area under curve (AUC) 0.44, p=0.32). Strikingly, presence of N2skip-mets was significantly increased in smokers (OR 3.5, 95% CI 1.38-8.83, p=0.006). Moreover, patients with N2skip-mets were more likely to develop subsequent brain mets (OR 4.13, p=0.06). Overall- and recurrence free survival will be presented at the conference.

Conclusion:
Conclusion: N2skip-mets occur in a high number of patients with N2 disease, with distinct differences in clinicopathologic features. Considering the results of this study, subclassification of N2 disease as recently proposed by the IASLC may have clinical impact in patients with resectable NSCLC.

Background:
Clinical practice involving segmental nodes (No.13) and subsegmental nodes (No.14) retrieval for pathological examination varies during lung cancer surgery. This study aims to evaluate whether omitting No.13 and No.14 node retrieval could lead to an inferior oncological outcome for pN0 non-small cell lung cancer（NSCLC）patients.

Methods:
This retrospective study analyzed 442 cases of NSCLC, both treating with R0 resection and systematic mediastinal lymphadenectomy and confirming as pN0 on postoperative pathology. Study group defined cases whose N1 nodes investigation involving from No.10 to No.14 in pathological report. In Control group, N1 nodes investigation only include No.10 to No.12. Clinical and pathological parameters of above two groups were balanced by propensity score matching based on surgical quality and the oncological outcomes between two groups were assessed by log-rank test.

Results:
Seven cases were lost during follow up and 435 cases entered final analysis (Study group, n=170 vs. Control group, n=265). A total of 5.0±3.0 nodes per case were collected from No. 13 and No. 14 in Study group, which included 3.1±1.9 nodes of No. 13 and 2.0±2.2 of No. 14. Tumor-located segments harbored 2.8±2.2 lymph nodes, compared to 2.2±2.3 from non-tumor located segments (p=0.006). After propensity score matching, 143 cases remained in each group. Overall survival (OS) and disease-free survival (DFS) were improved in Study group compared with Control group (the 5-year OS rates, 89±3% vs. 77±4%, p=0.027; the 5-year DFS rates, 81±4% vs. 67±4%, p=0.021, Figure1A,1B). In multivariate analysis, T staging and performing intrapulmonary nodes collection were the prognostic factors for pN0 cases. For the whole cohort, patients with two intrapulmonary stations collected showed better survival than those with zero intrapulmonary station retrieved（Figure1C, 1D）.

Conclusion:
Inferior oncological outcomes of pN0 cases without intrapulmonary node retrieval suggests this procedure may play a role in outcome evaluation for pN0 NSCLC patients.

Background:
Recurrence occurs in 30-50 % of patients operated for early stage non-small cell lung cancer (NSCLC), what suggests the existence of occult metastases at the time of surgery. Preoperative detection of occult micrometastases in mediastinal lymph nodes could contribute to better selection of patients apropriate for surgery. This retrospective study was undertaken to determine the prognostic significance of preoperatively detected mediastinal lymph node (LN) micrometastases in patients treated with radical surgical resection for stage I and II NSCLC.

Methods:
From January 2007 to December 2010, 82 patients with stage I and 67 patients with stage II NSCLC underwent transcervical extended mediastinal lymphadenectomy (TEMLA) and subsequent radical pulmonary resection. A total of 4841 mediastinal lymph nodes resected during TEMLA procedure and determined as metastases-free by hematoxylin and eosin staining were labelled to detect occult micrometastases (dual immunohistochemical staining with AE1/AE3 and BerEP4 antibodies).

Results:
Micrometastases were detected in mediastinal LN of 16 patients (9,7%). 11 patients had only one LN station affected (68,8%). Subcarinal LN were most frequently affected station (11 patients, 68,8%). There was significant correlation between the presence of micrometastases and tumor size. 5-year total survival was significantly better for stage I (64,1%, p=0.0001) and stage II (44,4%, p<0.05) patients without micrometastases comparing to those with micrometastases (18,8%). By multivariate analysis, only the presence of micrometastases was demonstrated to be a significant prognostic factor for 5-year total survival.

Conclusion:
Presence of micrometastases in mediastinal LN of patients with radically resected stage I and II NSCL is associated with significantly reduced 5-year total survival. Preoprative detection of micrometastases with immunohistochemical staining of mediastinal LN resected during TEMLA procedure improves staging and may contribute to better patient selection for curative surgery.

Abstract not provided

Background:
We previously reported the prognostic significance of pleural lavage cytology (PLC) in patients undergoing surgery for non-small-cell lung cancer (NSCLC). Based on a larger cohort of more than 3500 NSCLC patients, which is the largest ever reported from a single institution in the literature, we evaluated the prognostic impact of PLC on survival and recurrence.

Methods:
From January 1993 to July 2015, 3671 patients underwent R0 surgical resection for NSCLC at our institution and PLC results before (pre-) and after (post-) lung resection were both available. The cytological evaluation was classified into 3 categories: negative (-), suggestive (±), positive (+). We excluded 77 patients whose PLC results were suggestive, and 3594 patients were analyzed. The impact of PLC results on survival and recurrence was evaluated with conventional clinicopathological factors.

Results:
The overall survival (OS) of pre-PLC (+) patients was significantly inferior to that of pre-PLC (-) patients. However, the 5-year OS rate of pre-PLC (+) patients was 43%, which was significantly better than that of patients with pleural dissemination (11%). In the following analyses, we divided the patients into 3 groups according to pre/post- PLC results as follows: Pre (-)/ post (-), Group A (n=3461); pre (+)/ post (-), Group B (n=43); and post (+), Group C (n=87). Statistically significant difference was not observed between Groups A and B in OS or in recurrence-free survival (RFS) (p=1.00, 0.28, respectively). However, there were significant differences in OS and RFS between Groups B and C (p=0.01 and p=0.02), and between Groups A and C (p<0.01 and p<0.01), respectively. In univariate and multivariate analyses of clinicopathological factors including post-PLC results to identify prognosticators for OS, post-PLC(+) (hazard ratio (HR) =2.20, p<0.01), older age (≥65 years; HR=1.95, p<0.01), smoking history (+) (HR=1.48, p<0.01), elevated serum CEA level (>5.0 mg/dL; HR=1.28, p<0.01), pathological(p)T≥2 (HR=1.28, p<0.01), pN≥1 (HR=1.48, p<0.01), pStage≥II (HR=1.51, p<0.01), pl(+) (HR=1.43, p<0.01), ly(+) (HR=1.32, p<0.01), and v(+) (HR=1.53, p<0.01) were found to be significant independent unfavorable prognosticators.

Conclusion:
The prognostic impact of pre-PLC was moderate and not prohibiting lung resection. Post-PLC was shown to be a strong independent prognostic factor. Its impact on survival of NSCLC patients was very strong, and therefore should be incorporated in the future TNM classification.

Background:
We investigated whether tumor spread through air spaces (STAS) further stratifies survival beyond tumor size, T-descriptor independent of resection type (lobectomy or limited resection) and surgical margin.

Methods:
In patients with pT1a-T2bN0M0 lung adenocarcinomas (LADC, n=1399), tumor size, distance of STAS from the tumor, type of resection, surgical margin were evaluated. The patients with small (≤2cm) tumors were divided into STAS(-) (n=561) and STAS(+) (n=307) and their cumulative incidence of recurrence (CIR), and lung cancer-specific death (CID) were compared with patients with larger tumors (2-3cm, n=299) by use of competing risk analysis.

Results:
Of 1399 tumors, 521 (37%) were STAS(+). Compared to STAS(-), recurrence rates were higher with STAS(+) tumors even when the margin is ≥tumor size (Figure 1). In patients with ≤2cm STAS(+) tumors, CIR and CID are higher than in patients with larger (2-3cm) tumors (Figure 2). The poor prognostic influence of STAS(+) was evident even when analyzed by the procedure or recurrence pattern (Figure 2 table).

Conclusion:
STAS further stratifies survival beyond tumor size, T-descriptor in early-stage (pT1a-2b) lung adenocarcinoma based on the higher prognostic potential for recurrence and lung cancer-specific death independent of the type of resection or margin. Figure 1 Figure 2

Abstract not provided

Background:
No studies have reported any survival benefit in recurrent MPM. We examined the effect of nivolumab, in patients who presented with progressive disease and agreed to have biopsies taken before and during treatment.

Methods:
In this single center, phase II study, patients received nivolumab (3mg/kg q2w) until progression or toxicity. The primary endpoint was an improvement of disease control rate at 12 weeks of 20 to >40% compared to historic control according to a Simon two-stage design. A total of 33 patients were planned with paired biopsies at week -1 and 6 according to treatment start. PD-L1 status and other biomarkers were analyzed.

Results:
From 09-2015 until 06-2016, 38 patients were included with 33 having paired biopsies; 4 were not evaluable. There were no treatment related death and DCR at 12 weeks was 50%. Five patients had a confirmed PR; 12 had SD and 17 PD. Three patients showed pseudo-progression. Grade 3 toxicity occurred in 8 patients leading to discontinuation of the treatment in 4. The table shows the patients/tumor details. PD-L1 ≥1% was expressed in 9/32 evaluable patients with 2/9 having a confirmed PR at 12 weeks.

Conclusion:
Nivolumab in 2[nd] or later lines in recurrent MPM met the primary endpoint. The toxicity was mild and long lasting results were observed. A clear correlation between PD-L1 expression and response was obeserved.

	Outcome
Age	mean 66 yrs (51-81)
M/F	28 / 6
Epithelial/mixed/non epithelial	28 / 4 / 2
PR/SD/PD	5 / 12 / 17
PD-L1 + (1-10; 10-25; 25-50; >50%)	2 / 1 / 3 / 3
Correlation PR/SD/PD according to PD-L1 expression	<1% : 3/8/12 1 - 10% : 0/1/1 10-25% : 0/0/1 25-50% : 1/1/1 > 50% : 1/1/1
Correlation PR/SD/PD with histology	Epithelioid : 4/9/15 Mixed : 1/2/1 Non-epithelial : 0/1/1

Background:
Pembrolizumab showed significant activity in PD-L1+ MM in a phase IB study (Alley, 2015). We are conducting a phase II trial (NCT02399371) of pembrolizumab in previously-treated MM patients to further characterize its activity in a larger, non-selected population, determine a PD-L1 expression threshold, and interrogate the microenvironment.

Methods:
Eligible patients have histologically-confirmed pleural or peritoneal MM, measurable disease, PS 0-1, disease progression on/after pemetrexed/platinum, 1-2 prior regimens, normal organ function, and available tissue. Patients receive 200 mg pembrolizumab IV Q21 days and CT scans Q9 weeks. Primary objectives: 1) determine the objective response rate in: A] an unselected population and, B] a PD-L1 positive population; 2) determine the optimal threshold for PD-L1 expression using the 22C3 antibody-based IHC assay (Qualtek). Exploratory correlatives profile the inflammatory microenvironment via: a) multi-color immunofluorescence of tumor infiltrating lymphocytes (TILs) and macrophages, b) RNA-based inflammation signatures/pathway activation, c) characterizing underlying mutations/copy number changes. Proceeding to a 2[nd] stage requires ≥3 responses in 35 patients. If an optimal threshold for PD-L1 expression is determined, the 2[nd] stage only enrolls above that threshold.

Results:
35 patients enrolled 5/15-2/16. 1 withdrew. Male 82%; median age 63 (range 26-85); PS 0/1 63%/37%; epithelial/sarcomatoid/biphasic/NOS: 69%/26%/3%/3%; pleural/peritoneal 86%/14%; 1 prior regimen: 60%. Mean cycles: 8.5 (range 1-18). Median progression-free survival: 6.2 months (95% CI: 3.2, 8.2). Median overall survival has not been reached. Partial response: 7 (21%), stable disease (SD): 19 (56%); progression: 6 (18%); early death: 2 (6%). Ten patients received treatment beyond progression; 20% subsequently achieved SD. Grade 3/4 toxicity: pneumonitis 6%, fatigue 6%, adrenal insufficiency 6%, colitis 3%, confusion 3%, hyponatremia 3%, neutropenia 3%. Grade 1/2 immune-related toxicities: hypothyroidism 17%, rash 14%, pruritus 11%, diarrhea 9%, uveitis 6%, arthralgia 6%, hepatitis 3%, infusion reaction 3%, mucositis 3%. Grade 5 toxicities: autoimmune hepatitis 3%, unknown 3%. PD-L1 expression by tumor proportion score (N=31): none (< 1%): 55%; low (1%-49%): 19%; high (≥ 50%): 26%. PD-L1 expression did not correlate with response (ROC area 0.62; 95% CI: 0.32, 0.94).

Conclusion:
Pembrolizumab has robust activity in PD-L1 unselected, previously-treated MM patients, with a response rate of 21% and a disease control rate of 76%. An optimal PD-L1 threshold could not be established in this small sample. The 2nd stage is enrolling an additional 30 patients without PD-L1 pre-selection. Correlative studies including CD8 TILs, macrophage characterization, and presence of T-regulatory cells will be presented. Funded by a grant from the Mesothelioma Applied Research Foundation.

Background:
Malignant pleural mesothelioma (MPM) is a highly aggressive cancer with poor prognosis and limited treatment options after progression on platinum-containing chemotherapy. Pembrolizumab, a humanized anti–programmed death 1 (PD-1) antibody, has demonstrated robust antitumor activity and a favorable safety profile in multiple tumor types. Here, we present long-term overall survival (OS) data for patients with malignant pleural mesothelioma enrolled in the KEYNOTE-028 (ClinicalTrials.gov, NCT02054806) study.

Methods:
KEYNOTE-028 is a nonrandomized, multicohort phase 1b trial of pembrolizumab in patients with PD-L1–positive advanced solid tumors. 25 patients with MPM were treated with pembrolizumab in the mesothelioma cohort. Patients received pembrolizumab 10 mg/kg every 2 weeks for up to 2 years or until confirmed progression or intolerable toxicity, death, withdrawal of consent, or physician decision. Response was assessed per RECIST v1.1 by investigators every 8 weeks for the first 6 months and every 12 weeks thereafter. Primary end point was objective response rate (ORR; per RECIST v1.1, investigator assessed). Secondary end points included safety, tolerability, progression-free survival (PFS), and OS.

Results:
As of June 9, 2016, median duration of follow-up was 18.7 months (range, 1.5-24.6 months), and 4 patients (16%) are still on treatment. ORR was 28% (n = 7); 12 (48%) patients had stable disease, resulting in a disease control rate of 76%; median duration of response was 9.2 months (range, 2.4-20.5+ months); median PFS was 5.8 months (95% CI, 3.4-8.2 months), with 6- and 12-month PFS rates of 50% and 25%, respectively. Median OS was 18.0 months (95% CI, 9.4 months-not reached) with 6- and 12-month OS rates of 83.5% and 62.6%, respectively. No new safety signals have been identified. Sixteen (64%) patients experienced a drug-related adverse event (DRAE), and 5 (20%) experienced grade 3/4 DRAEs. Three patients required dose interruption because of immune-related adverse events (1 each, ALT increased, iridocyclitis, and pyrexia/arthralgia]). There was no treatment-related mortality or discontinuation due to DRAE.

Conclusion:
Single-agent pembrolizumab has significant clinical activity in patients with PD-L1–positive MPM. Responses from pembrolizumab in patients with MPM are durable; the 62.6% 12-month OS rate in this mostly pretreated patient population warrants further investigation. Long-term administration of pembrolizumab is feasible in patients with MPM, and no new safety signals were identified.

Abstract not provided

Background:
The genomic landscape of malignant pleural mesothelioma (MPM) is not well understood. Advanced high-throughput sequencing technologies allow comprehensive characterization of genetic alterations. Knowledge of the somatic mutations and the immune microenvironment in patients with MPM will help to develop effective targeted therapies.

Methods:
We examined biopsy specimens from 12 MPM patients (8 epithelioid and 4 biphasic) that were removed during maximal cyto-reductive surgery. Specimens from 3 different sites (anterior, posterior and diaphragm, a total of 36 tissue samples) were studied through whole exome sequencing, T cell receptor (TCR) repertoire analysis of tumor-infiltrating T cells (TILs), and expression levels of immune-related genes. We also performed in silico prediction of potent neoantigens derived from non-synonymous somatic mutations in each specimen. For the comparison of tumor tissues from 3 different sites, we performed hierarchical clustering to assess the tumor heterogeneity and differences in immune environment.

Results:
High mutation/neoantigen load was significantly correlated with higher clonal expansion of TILs (R=0.46) and high expression levels of immune-associated cytolytic factors, granzyme A (R=0.25) and perforin 1 (R=0.48), in tumor tissues. In the clustering analysis, heterogeneous MPM cases revealed unique neoantigens and clonotypes of TILs that were restricted to each of tumor site, suggesting infiltration of the neoantigen-specific T cells. Further sub-analysis according to histologic types showed that biphasic tumors had higher mutation/neoantigen load and stronger oligo-clonal T cell expansion (p=0.01) than epithelioid tumors.

Conclusion:
Our analysis demonstrated a significant correlation between somatic mutation/neoantigen load, clonality of TILs, and the immune-related tumor microenvironment in MPM. Our findings suggest that high mutation/neoantigen load in tumor cells might promote effective expansion and infiltration of functional (tumorocidal) T cells into the tumor bed. These findings provide a rationale for selecting MPM patients who can benefit from treatment with immune checkpoint blockades. This may accelerate development of the neoantigen targeting TCR-engineered T cell therapy for MPM.

Background:
Mesothelioma is an aggressive malignancy without curative treatment options. We have previously shown promising activity of dendritic cell (DC) immunotherapy loaded with autologous tumor cell lysate (Hegmans 2013, Cornelissen 2016). Because of quality and quantity issues (availability, standardization etc) with the autologous lysate, we have developed an off-the-shelf allogenic tumor cell lysate from human mesothelioma cell lines (Pheralys.[®]).

Methods:
Patients (pts) with advanced mesothelioma, either treatment naive, or non-progressing after chemotherapy, were included. Leucapheresis was performed to obtain an enriched monocyte fraction from which immature DC were generated which were loaded with the allogenic lysate. The DC were matured, frozen and stored. In subsequent cohorts of 3 pts 10, 25, or 50 × 10[6 ]DC were administered IV and intradermally, 3 times at a bi-weekly interval and after 3 and 6 months. Primary endpoint was toxicity occurring within 8 weeks after the first vaccination. Secondary endpoints were response rate (RR), progression free survival (PFS) and overall survival (OS). PFS and OS were determined from time of registration in the trial. Immunological read-outs were performed (DTH skin testing, peripheral blood testing).

Results:
Nine pts (median age 69yrs, 8 male, 1 female) were included. All patients developed transient grade 1-fever and a grade 1-2 injection site reaction. No dose limiting toxicities or autoimmunity signs were observed. In 2 pts (22%), both treated with 25 ×10[6] cells, a partial response (PR) was observed, the other 7 pts had stable disease as best overall response. All patients are alive with a median follow up of 11.9 months after trial inclusion(range 7.6-16.5 months). Median PFS was 8.3 months (95% confidence interval (CI) 3.7-not yet reached), PFS at 12 months was 33% (95% CI 8%-62%). Data on immunological read outs are pending.

Conclusion:
DC immunotherapy with allogenic tumor cell lysate is safe and clinically active. Data on PFS and OS are promising and still maturing. The recommended dose for future studies will be 25 * 10[6] cells based on the responses and logistic reasons (the number of monocytes obtained during leucapheresis to generate 5 vaccinations). A randomized trial comparing DC therapy with Pheralys versus best supportive care as maintenance treatment after chemotherapy is planned to start in Q1 2017.

Background:
Malignant pleural mesothelioma (MM) remains an almost universally fatal disease with limited treatment options. Preclinical models indicate the preferential oncolytic activity of the modified vaccine strain measles virus carrying the gene for the human sodium-iodine symporter (NIS) – MV-NIS. Intraperitoneal and intravenous administration of MV-NIS was recently found to be potentially effective in patients with refractory ovarian cancer and multiple myeloma. However, whether MV-NIS is directly oncolytic or triggers an anti-tumor immune response remains unclear.

Methods:
We conducted a phase I dose escalation study with 3+3 design and ongoing maximal tolerated dose (MTD) expansion cohort. MV-NIS was administered as first or second line therapy via a tunneled intrapleural catheter to patients with MM. MV-NIS dose ranged from 10[8] TICID~50~ to 9 x 10[9] TICID~50~. In the absence of dose limiting toxicity and disease progression, patients received up to 6 cycles of MV-NIS therapy (Phase I). Currently additional patients are being randomized between a single and multiple cycles. MV-NIS infection and replication are monitored by Iodine[123] SPECT/CT (Phase I only) as well as by RT-PCR and/or plaque-assay. Anti-tumor immunity is monitored in the blood and pleural fluid and patients are followed clinically by chest CT using the modified RECIST criteria.

Results:
Twelve patients (3/dose level) received MV-NIS therapy. There were no dose limiting adverse events and therapy was well tolerated. The best therapeutic response was stable disease, which was achieved at 1 month by 8/12 evaluable patients (67%). Median overall survival was 449 days (95%CI: 221, 484) (~15 months) (4/12 patients remain alive), and median progression free survival was 63 days (95% CI: 33, 174) (~2 months). MV infection and replication were detectable by RT-PCR and plaque assay in the pleural fluid between 24-72 hours after treatment. I[123] SPECT-CT demonstrated only marginal viral gene expression in a single patient treated with the highest dose level. MV-NIS therapy effectively boosted pre-existing anti-MV neutralizing antibody responses in the plasma and pleural fluid of most patients. We observed a transient inflammatory response in the pleural space after MV-NIS administration. In addition, induction or boosting of anti-tumor antibody responses was observed.

Conclusion:
The intrapleural administration of MV-NIS is safe, resulted in stable disease for 67% of patients and may be associated with favorable overall survival in MM. While there was only transient infection and viral replication, we observed the induction of anti-tumor immune responses supportive of potential long-term therapeutic impact. The study continues with the MTD expansion cohort.

Abstract not provided

Background:
Trials of chemoradiotherapy for different tumors, including lung cancer, have shown a correlation between protocol deviations and adverse outcomes. Radiation quality assurance (RTQA) was mandated for all patients treated in the PROCLAIM (NCT00686959) trial evaluating two different chemoradiotherapy regimens.

Methods:
The study was open to accrual between 2008-2012. Planned chemoradiotherapy dose was 60-66 Gy in daily 2 Gy fractions. Quality was assessed through review of radiation treatment plans and monitoring of protocol violations. Review of the radiation plan was mandated for all patients; prior to radiation start for the first enrolled patient at each site. Real-time review was performed randomly in 20% of additional patients with nonreal-time review performed for the remainder. Parameters assessed for major violations per protocol included: <95% of planned total volume (PTV) received by 93% of prescribed dose; >1 cm[3] contiguous volume within or outside the PTV received >115% of prescribed dose; V~20~ (volume of lung receiving ≥20 Gy) >38%; and maximum point dose to spinal cord of >48 Gy. Overall survival (OS) and progression-free survival (PFS) were analyzed using Kapan-Meier methodology and groups were compared by log-rank test and Cox proportional hazard modeling.

Results:
Of 598 patients randomized in 126 investigational sites, 554 received study assigned chemoradiotherapy. The median dose delivered was 66 Gy, with 92.6% of patients receiving planned chemoradiotherapy dose (60-66 Gy). A total of 40 patients, enrolled at twenty-eight sites had major RTQA violations. Seven sites enrolled ≥2 patients with major violations. Patients with major violations has a higher incidence of Stage IIIB disease (70.0% vs. 50.6%) and larger tumors (median planned PTV=653 vs. 523cc) than patients with no violations. Patients treated at sites with ≥2 patients with violations (n=86), had a lower median OS (median 21.1 vs. 29.8 months; HR 1.442) and median PFS (median 7.3 vs. 11.3 months; HR 1.345) than patients at sites where none had violations.

Conclusion:
Major chemoradiotherapy protocol violations were uncommon in the PROCLAIM study, which may be a reflection of the mandatory RTQA. Protocol violations were more frequent in patients with Stage IIIB and larger tumors, which generally require more complex chemoradiotherapy plans. The observation of discrepant outcomes at centres with multiple major RTQA violations is hypothesis-generating but should be interpreted with caution due to the small number of patients.

Background:
Anatomical change of tumor contour during radiotherapy contributes to target missing. Adaptation of tumor volume could however result in an increased incidence of recurrences in the area of target reduction. This study aims to investigate the incidence of failure of adaptive approach in evaluating the risk of local recurrence in the area excluded during replanning.

Methods:
In this prospective study, LA-NSCLC patients treated with concomitant chemoradiation underwent weekly chest-CT simulation during therapy. In case of tumor shrinkage, a new tumor volume (TV) was delineated and a new treatment plan outlined (replanning). Patterns of failure were classified as: in field (persistence or recurrence in TV post-replanning), marginal (recurrence in the area of initial TV excluded from the post-replanning TV) and out of field (recurrence outside of initial TV). Toxicity, OS, and PFS were reported.

Results:
A total of 217 NSCLC patients were treated in our centre from 2012 to 2014. In 50 cases a target volume reduction was recorded and replanning outlined. A mean initial and replanning CTV of 154.9cc and 90.7cc were reported with an average CTV shrinkage of 42% between simulation CT and replanning CT. With a median follow-up of 20.5 months, 30% of patients experienced local failure which was in field, marginal and out of filed in 20%, 6% and 4% of cases respectively. Acute G3 pulmonary and esophageal toxicity was reported in 2% and 4% of patients respectively. Figure 1 Figure 1: (A) Tumor volume delineation at first CT simulation; (B) the reduced target volume at replanning CT



Conclusion:
The possibility to reduce toxicity and the documented low rate of marginal failures makes the adaptive approach a modern option for future randomized studies. The best scenario to confirm tumor activity is its application in neoadjuvant chemoradiation trials.

Background:
Radiation (RT) associated cardiac injury in patients with lung cancer is of unclear significance. RTOG 0617 demonstrated reduced overall survival (OS) with dose-escalated RT for Stage III NSCLC, with higher heart doses predicting for worse OS. We assessed the impact of heart doses on toxicity and survival for patients enrolled on several prospective RT dose-escalation trials.

Methods:
From 1996-2009, 133 patients with Stage III NSCLC (ECOG PS 0-1) were treated on six prospective trials using induction/concurrent chemotherapy and dose-escalated conformal RT to 70-90 Gy. Broad clinical outcomes (e.g. OS) were prospectively assessed. RT plans were reviewed, cardiac structures were defined, and dose/volume metrics were computed. Patient records were retrospectively reviewed for post-RT symptomatic cardiac events (symptomatic pericardial effusion, acute coronary syndrome, and pericarditis). Baseline cardiac risk was calculated using the World Health Organization / International Society of Hypertension (WHO/ISH) score. A competing risks model accounting for the risk of death was used for statistical analysis.

Results:
112 patients were included in the final analysis. Median f/u was 19 mo. (75 mo. for the 39 patients without documented progression). Median OS and PFS were 22 and 12 mo. Median prescribed RT dose was 74 Gy. 15 patients (13%) had symptomatic cardiac events (6 pericardial effusion, 5 myocardial infarction, 2 unstable angina, 2 pericarditis) at median 26 mo. post-RT (range, 7-68). On univariate analysis, Heart mean dose (p=0.001), Heart V5Gy (p<0.001), and Heart V30Gy (p=0.002) were associated with symptomatic cardiac events, whereas baseline WHO/ISH score (p=0.204) and coronary artery disease (p=0.109) were not. Heart doses were higher in patients with vs without events (mean 22Gy vs 11Gy, V5Gy 60% vs 35%, V30Gy 35% vs 14%). On multivariate pair analysis accounting for baseline risk, heart doses remained significant predictors of cardiac events (e.g. Heart mean dose, p=0.001, HR 1.05 / 1Gy). 2-year competing risk-adjusted rate of symptomatic cardiac events was 11.1% vs 1.5% for Heart mean dose ≥15Gy vs <15Gy (p=0.003, HR 6.7). 34 patients (30%) had asymptomatic pericardial effusions. There was no association between heart doses and OS.

Conclusion:
Clinically significant symptomatic cardiac events following high-dose thoracic RT for Stage III NSCLC occurred in 13% of patients at a median 2 years post-RT, with the rate appearing to be heart dose dependent. RT-associated cardiac toxicity in the definitive treatment of Stage III NSCLC may occur earlier than historically understood, and heart doses should be minimized. Supported in part by NIH grant CA69579.

Abstract not provided

Background:
Early attempts of stereotactic body radiation therapy (SBRT) of centrally located lung tumors resulted in high toxicity, questioning the utility of the method in this situation. Since then, different risk adapted fractionation schedules with acceptable toxic effects have been reported from various institutions. However, consensus on the tolerability of centrally located structures to high-fraction doses is still lacking and the clinical toxic effects in relation to dose to organs at risk (OAR) need to be evaluated.

Methods:
We here report a first toxicity analysis of the HILUS-trial – a prospective Nordic multicenter non-randomized phase II trial of SBRT to centrally located lung tumors. Patients with a centrally located tumor (defined as ≤1cm from the proximal bronchial tree) from either a primary non-small cell lung cancer (NSCLC) or a progressive metastasis from another solid tumor were eligible for the trial. Maximum tumor diameter was 5 cm. Patients receiving concomitant systemic anticancer therapy or with tumors reaching through the wall of a main bronchus were not eligible. All the patients were treated with 7Gyx8 and stratified to either arm A (=tumors close to a main bronchus) or arm B (=tumors close to a lobar bronchus). The aim was to include 30 patients in each arm. Follow-up was conducted every 3[rd] month during the first 2 years and thereafter every 6[th] month. The trial was approved by ethical committees in each country.

Results:
Seventy-four patients (42 in arm A and 31 in arm B) were included between 2011 and 2016. Sixty-five patients experienced side effects from the study treatment; the most common being grade 1-2 dyspnea, grade 1-2 cough and grade 1-2 fatigue. Twenty-one patients (28%) experienced grade 3-5 side effects (atrioventricular block, bleeding, dyspnea, empyema, fatigue, fever, fistula, lung infection, pain, pneumonitis, pneumothorax and ventricular arrhythmia). Seven patients (6 in group A and 1 in group B) may have suffered grade 5 side effects; six patients experienced lethal hemoptysis after a median of 15.5 months (2.5-21months) and one patient suffered from a lethal pneumonitis 5 months post study treatment. Grade 4-5 side effects occurred more frequently in group A than in group B (19% vs 3%). Further analyses of risk factors for serious toxicity in relation to dose-volume parameters and patient- and tumor characteristics will be presented.

Conclusion:
SBRT of centrally located tumors may be afflicted with high risk of serious toxicity and further evaluation of clinical and dose-volume dependent risk factors are highly warranted.

Background:
Stereotactic body radiation therapy (SBRT) has emerged as an effective treatment for early-stage lung cancer. Histologic subtyping in surgically resected lung adenocarcinomas is recognized as a prognostic factor, with the presence of solid or micropapillary patterns predicting poor outcomes. Herein, we describe outcomes following SBRT for early-stage lung adenocarcinoma by histologic subtype.

Methods:
We identified 119 consecutive patients (124 lesions) with stage I-IIA lung adenocarcinoma who were treated with definitive SBRT at our institution between August 2008 and August 2015 and had undergone core biopsy. Histologic subtyping was performed according to the 2015 WHO Classification. Thirty-seven tumors (30%) were of high risk subtype, defined as containing a component of solid and/or micropapillary pattern. Cumulative incidences of local, nodal, regional and distant failure were compared between high risk vs. non-high risk adenocarcinoma subtypes with Gray’s test, and multivariable-adjusted hazard ratios were estimated from propensity score-weighted Cox regression models.

Results:
Median follow-up for the entire cohort was 17 months and 21 months for surviving patients. The 1-year cumulative incidence of local, nodal, regional and distant failure, respectively, in high risk and non-high risk lesions were 7.3%, 14.8%, 4.0%, 22.7% and 2.7%, 2.6%, 1.2%, 3.6%. Hazard ratios for local, nodal, regional and distant failure, respectively, of high risk lesions compared to non-high risk were 16.8 (95% CI 3.5-81.4), 3.8 (95% CI 0.95-15.0), 20.9 (95% CI 2.3-192.3), 6.9 (95% CI 2.2-21.1). No significant difference was seen with regard to overall survival.

Conclusion:
Outcomes following SBRT for early-stage adenocarcinoma of the lung are highly correlated with histologic subtype, with micropapillary and solid tumors portending significantly higher rates of locoregional and metastatic progression. In this context, histologic subtype based on core biopsies is a novel prognostic factor and may have important implications for patient selection, adjuvant treatment, biopsy methods and clinical trial design.

Background:
Stereotactic Body Radiation Therapy (SBRT) is the standard of care for medically inoperable patients with early-stage non-small cell lung cancer (NSCLC). However, NSCLC is comprised of several histological subtypes and the impact of this heterogeneity on SBRT treatments has yet to be established.

Methods:
We analyzed 740 early-stage NSCLC patients treated definitively with SBRT from 2003 through 2015. We calculated cumulative incidence curves using the competing risk method and identified predictors of local failure using Fine and Gray regression.

Results:
Overall, 72 patients had a local failure with a cumulative incidence of local failure at three years of 11.8%. On univariate analysis, squamous histology, younger age, fewer medical comorbidities, higher BMI, higher PET SUV, central tumors and lower radiation dose were associated with an increased risk of local failure. On multivariable analysis, squamous histology (HR 2.4 p = 0.008) was the strongest predictor of local failure. Patients with squamous cancers fail SBRT at a significantly higher rate than those with adenocarcinomas or NSCLC-not otherwise specified, with three-year cumulative incidences of local failure of 18.9% (95% CI= 12.7-25.1%), 8.7% (95% CI= 4.6-12.8%), 4.1% (95% CI= 0-9.6%), respectively.

Conclusion:
Our results demonstrate an increased rate of local failure after SBRT in patients with squamous cell carcinoma. Standard approaches for radiotherapy that demonstrate efficacy for a population may not achieve optimal results for individual patients. Establishing the differential dose-responses of SBRT across histological groups is likely to improve efficacy and inform ongoing and future studies that aim to expand indications for SBRT.

Abstract not provided