Virtual Library

Abstract not provided

Abstract not provided

Abstract not provided

Abstract

Abstract
Epidemiology and Burden of Smoking Related Diseases in China Prevalence of Smoking in China Being the largest producer and consumer of tobacco across the globe, China produces one-third (2.66 million tons/year) of the global tobacco leaves [1] and consumes 30% of the world’s cigarettes [2]. According to the Global Adult Tobacco Survey (GATS) Collaborative Group, China had the highest number of tobacco users (300.8 million) and a low quit ratio compared to 16 countries [3]. The International Collaborative Study of Cardiovascular Disease in Asia showed that 147,358,000 Chinese male and 15,895,000 Chinese female aged 35–74 years had been current cigarette smokers [4]. Regardless of gender difference, such prevalence was higher in the rural population compared to the urban population (male 61.6% vs 54.5% P <0.001; female 7.8% vs. 3.4% P<0.001) [4]. A growing prevalence of smoking was also observed in women [5], adolescents and young adults [2,6-8]. Even among non-smokers, the threat of tobacco smoke remained because airborne nicotine had been detected in 91% of the 273 public locations sampled in rural and urban China [9]. Specifically, an estimated 50-72% of Chinese non-smokers had been exposed to secondhand tobacco smoke [10,11]. Considering active and passive smoking altogether, 72% of the Chinese population were tobacco exposed [12]. Such common exposure has aggravated tobacco-related morbidity and mortality which create a direct economic burden accounting for 42.31 billion yuan [13]. By increasing mortality from cancer, respiratory disease and cardiovascular disease [14-18], smoking currently costs over 1 million Chinese lives per year. If the trend continues, a predicted sum of 2 million Chinese may die of tobacco-related diseases in 2025 [19]. COPD and Smoking Chronic obstructive pulmonary disease (COPD) had an estimated prevalence of 8.2% (>43 million) in the Chinese population > 40 years old [20] and was ranked the fourth/third leading cause of death in urban/rural area respectively [21]. Prompted by the causative roles of active [22-24] and passive smoking [25], a yet increasing prevalence of COPD would be expected in the Chinese population. In the meantime, the expensive treatments and compromised productivity of COPD patients had already created an enormous economic burden equaling to 110% and 34% of the annual incomes in rural areas and urban areas respectively [26]. Even so, the situation might have been undermined due to premature mortality and impaired working capabilities within affected families. Anti-smoking measures could be the best solution since the absolute risks of COPD would fall by 56% in Chinese male and 63% in Chinese female 5 years after smoking cessation [27]. Lung Cancer and Smoking Smoking is the main risk factor for lung cancer regardless of smoking experience (ever, current and ex smoking), tobacco product variety (pipes, cigars and cigarettes) and histological subtypes [28].\\Lee et al. demonstrated the dose-response relationship between smoking and lung cancer pathogenesis [28]. Specifically, risk of lung cancer decreased with duration of smoking cessation but increased with an earlier age of smoking and elevations in (i) the amount and fraction of smoking; (ii) duration of smoking; and (iii) tar level. Analyzing data from10 cancer registries, the crude incidence rate of lung cancer in China was estimated to be 49.35 per 100,000 population (63.7 per 100,000 men and 35.0 per 100,000 women) in 2005 [29]. Compared to lifelong non-smokers, the mortality rate of lung cancer was found to be approximately 23 times and 13 times higher in current male smokers and current female smokers respectively [30]. As prevalence of smoking rose during the past 3 decades, lung cancer mortality also increased by 464.84% [31]. Since 2008, lung cancer has surpassed other malignant tumors to become the most common cause of death in Chinese cancer patients [32]. At present, the mortality rate of lung cancer is 600,000 per year [33]. If the current trend continues, it may reach 1 million by 2025 [33]. With an increased prevalence of lung cancer and more advanced technology, the total number of lung cancer inpatients increased from 174,066 to 364,484 while medical costs increased from 2.16 billion yuan to 6.33 billion yuan between 1999 to 2005 as illustrated in the China Statistical Yearbook. Nonetheless, such dedication did not effectively prove its worth since the 5-year survival rate of lung cancer remained relatively low (10% - 14%) [34]. To relieve the socioeconomic burden, measures should be taken to reduce the incidence of lung cancer and relevant medical costs. CAD and Smoking Smoking has been associated with increased risk of coronary artery disease (CAD). In China, the reported crude odd ratio varied between 1.37 - 5.19 in former and current smokers [35-38]. In a study about risk ratio for CAD mortality, former smokers and current smokers had a risk ratio of 0.68 and 1.81 respectively when compared to never smokers [37]. Nonetheless, such figures bore no significant difference if stratified by co-morbidity of diabetes. Perhaps not surprisingly, passive smoking was verified to independently increase the risk of cardiovascular heart disease (CHD) by 25% - 30% [39,40]. While the prevalence of coronary artery disease (CAD) have fallen in developed countries through control of preventable risk factors, China witnessed an opposite trend as CAD climbed from the fifth most common heart disease in 1948-1957 to the most common in 1980-1989 [41]. As reported, CAD caused 51.4% and 32.8% of mortality related to cardiovascular disease (CVD) in urban and rural areas respectively. Projected from 1990, 72.7 million Chinese male and 72.1 million Chinese female will have been diagnosed with CAD in 2020 [42]. Smoking, one of the modifiable risk factors of CAD, should be tightly controlled in China if the socioeconomic burden has to be alleviated. Conclusion COPD, lung cancer and CAD are common smoking related chronic diseases which occupy a large share of medical resources yet cost a massive number of lives in China. In order to improve the current situation, smoking cessation should be reinforced in China through introduction of effective measures supported by favorable policy. Reference 1. Wang H. Tobacco control in China: the dilemma between economic development and health improvement. Salud Publica Mex. 2006; 48(Suppl. 1): S140–7.

Abstract
Lung cancer (LC) is the leading cause of cancer deaths in the world. While smoking is universally accepted as the major cause of lung cancer in tobacco users, lung cancer in lifetime never smokers (LCNS) is among the 10 major causes of cancer deaths. LCNS is a very different disease than LC arising in ever smokers (LCES), and these differences are discussed in this Abstract. Because LCNS is highly influenced by gender and ethnicity, we put special emphasis on LCNS arising in East Asians. The reader is referred to several recent review articles on this subject [1-5] Etiology: Unlike LCES, the etiology of LCNS is not fully elucidated. The suspected factors include exposure to environmental tobacco smoke (ETS), exposure to industrial or domestic carcinogens including coal smoke and volatile cooking oils, radon exposure, viruses including HPV, and genetic factors. While these factors may individually or in combination contribute to the pathogenesis of LCNS, none of them is likely to be the major causative factor. Further investigation of causation is required. Clinico-patholgoical differences. While adenocarcinoma is the predominant form of NSCLC, the vast majority of LCNS are of adenocarcinoma histology, or large cell carcinomas (which may represent poorly differentiated adenocarcinomas). Squamous cell histology is rare and small cell carcinomas almost never occur. A retrospective study from Singapore identified significantly better performance status, younger age at diagnosis, and higher proportion of females (68.5% vs. 12-13%) and more advanced stage at diagnosis in never smokers compared with current and former smokers [6]. The disease stage variation at diagnosis might be explained by late presentation of symptoms and delayed diagnosis by physicians. The survival outcome of never smokers was significantly better than smokers, with the 5-year overall survival rate of LCES, respectively [6]. The differences in the treatment response and survival outcome between never smokers and smokers with lung cancer may be attributed to the differences in molecular pathogenesis and tumor biology (see below). Genetics: While lung cancer prone families have been well described, the risk of affected subjects is greatly increased after smoke exposure. Recently the interest has focused on single nucleotide polymorphisms (SNPs). Genome wide association studies (GWAS) identified a locus in chromosome region 15q25 that was strongly associated with lung cancer. The association region contains several genes, including three that encode nicotinic acetylcholine receptor subunits [7]. Such subunits are expressed in neurons and other tissues, including alveolar epithelial cells, pulmonary neuroendocrine cells and lung cancer cell lines, and they bind to potential lung carcinogens. Thus variants in this region undoubtedly code for increased susceptibility to smoke and are unlikely to be associated with LCNS. Not unexpectedly, GWAS studies indicate different patterns of susceptibility for Asians and never smokers and possibly related to gender [8, 9]. Molecular differences: The molecular differences between LCES and LCNS show marked differences and characteristic patterns. While TP53 mutations are common to all types of lung cancer, the mutational spectra are very different [10]. KRAS mutations are largely limited to LCES, and, along with TP53, show the typical smoking associated characteristic G to T transversions. In addition, the total numbers of non-synonymous and synonymous mutations in LCES tumors are much higher than that in LCNS, indicating that tobacco exposure results in in widespread genomic instability. Paradoxically, some of the most responsive currently available or potential molecular targets for precision medicine are more frequent in never smokers, including EGFR, BRAF and HER2 mutations and ALK translocations. Therapeutic options and precision medicine: While the overall treatment strategy is the same for LCES and LCNS, the differences in molecular profiles dictate differences in precision medicine and, response to targeted agents and overall survival. These factors are also influenced by gender and ethnicity. For instance, one study found that the frequency of driver mutations (EGFR, HER2, ALK, KRAS, or BRAF) in lung adenocarcinoma from female never-smokers in China was over 87% [11]. Summary: The differences between LCES and LCNS are major, and cover etiologic factors, clinic-pathological changes, genetic susceptibility genes, mutational and molecular changes and precision medicine. These differences are vast enough so that we can regard lung cancers arising in ever and never smokers as two different diseases. References: 1. Rudin CM, Avila-Tang E, Harris CC, et al. Lung cancer in never smokers: molecular profiles and therapeutic implications. Clin Cancer Res 2009;15(18):5646-61. 2. Sun S, Schiller JH, Gazdar AF. Lung cancer in never smokers - a different disease. Nat Rev Cancer 2007;7(10):778-90. 3. StatBite lung adenocarcinoma in smoker vs. never smokers. J Natl Cancer Inst 2010;102(10):674. 4. Lee YJ, Kim JH, Kim SK, et al. Lung cancer in never smokers: change of a mindset in the molecular era. Lung Cancer 2011;72(1):9-15. 5. Subramanian J, Govindan R. Lung cancer in never smokers: a review. J Clin Oncol 2007;25(5):561-70. 6. Toh CK, Gao F, Lim WT, et al. Never-smokers with lung cancer: epidemiologic evidence of a distinct disease entity. J Clin Oncol 2006;24(15):2245-51. 7. Hung RJ, McKay JD, Gaborieau V, et al. A susceptibility locus for lung cancer maps to nicotinic acetylcholine receptor subunit genes on 15q25. Nature 2008;452(7187):633-7. 8. Shiraishi K, Kunitoh H, Daigo Y, et al. A genome-wide association study identifies two new susceptibility loci for lung adenocarcinoma in the Japanese population. Nat Genet 2012;44(8):900-3. 9. Lan Q, Hsiung CA, Matsuo K, et al. Genome-wide association analysis identifies new lung cancer susceptibility loci in never-smoking women in Asia. Nat Genet 2012;44(12):1330-5. 10. Pfeifer GP, Besaratinia A. Mutational spectra of human cancer. Hum Genet 2009;125(5-6):493-506. 11. Zhang Y, Sun Y, Pan Y, et al. Frequency of driver mutations in lung adenocarcinoma from female never-smokers varies with histologic subtypes and age at diagnosis. Clin Cancer Res 2012;18(7):1947-53

Abstract
Approximately 20% of patients with NSCLC present with early stage diseases. While with the advances in imaging and the success in low-dose CT screening in high risk patients, the proportion of patients diagnosed of stage I disease may increase. Radical surgery has been well established as the primary treatment for localized disease. However, a substantial number are ineligible for resection because of comorbidities that are associated inoperable medical condition or advanced age. Conventional fractionated therapy has had disappointing outcomes for stage I NSCLC, with reported local failure rates as high as 60–70% in some series, likely due of inadequate doses. Prior dose escalation study suggested that 70 Gy in 2 Gy fractionation would predict a local-progression free survival of only 24% at 30 months, while dose of 80 to 90 Gy were needed to achieve a recurrence-free survival rate of 50%. Utilizing the advances in radiotherapy planning and tumor targeting techniques, stereotactic body radiation therapy (SBRT) using ablative-range daily doses of 7.5–30 Gy (1-8 fractions), has achieved a biologically effective dose above 100 Gy. This biological unique treatment is associated with notable increases in tumoricidal effect. Reported local control rates have been repeatedly around 90% at 3 years. There is some uncertainty equating SBRT doses and fractionations. In a recent systemic review involving 1076 patients with stage I NSCLC with a follow up of at least 30 months (15 studies), no positive dose–response relationship for tumor control was revealed within different schemes. Current dose to eradicate stage I disease might thus be overestimated. Treating central lesions with hypo-fractionated radiotherapy or SBRT at lower biologically effective doses may be justified. Survival after SBRT is, in general, worse than that after surgery in indirect comparisons, probably because of the frail nature of the patients who receive SBRT. In a population-based study, SEER data showed that even though lobectomy were associated with the best long term outcomes in fit patients with early-stage NSCLC, the survival after SBRT was similar to that after lobectomy in the propensity-score matched analysis, suggesting comparable efficacy with in select populations. Further, the introduction of SBRT reduced the proportion of stage I NSCLC patients who received no local therapy. In north Netherlands population, the application of SBRT corresponded to a 16% absolute increase in the proportion of patients receiving radiotherapy, and this shift was associated with a 6-month median survival improvement SBRT is characterized by both high conformality of the ablative dose delivered to the target, and a sharp dose gradient at the edge of the target volume. This enables possibility for the physician to minimize treatment toxicity. Rate of symptomatic pneumonitis is usually less than 20%. Common, self-limited toxicities were revealed in approximately up to 40% of patients including fatigue, cough, dyspnea and chest pain. Hemoptysis and rib fracture can occur, whereas life-threatening complications are rare. Dose constraints have been investigated for SBRT, though the basic data are now being accrued. Nevertheless, clinical factors like gender, smoking history, and larger gross PTV may equally important or even overweight dosimetric metrics. Further research is required to better understand the tolerance of normal tissues and the long term quality of life after SBRT.

Abstract
Lung cancer and COPD frequently occur together in smokers, and COPD increases the risk of developing lung cancer in at-risk individuals. Exposure to cigarette smoke is clearly the most important causative factor. Other biological mechanisms for susceptibility to both lung cancer and COPD may involve inflammation, abnormal repair, oxidative stress, cellular proliferation, and epithelial-mesenchymal transition. In addition, genomic and epigenomic changes - such as single nucleotide polymorphisms, copy number variation, promoter hypermethylation and microRNAs - could alter biological pathways and enhance susceptibility to lung cancer and COPD. Approaches of studying genomics, epigenomics and gene-environment interaction will yield greater insight into the shared pathogenesis of lung cancer and COPD, leading to new diagnostic and therapeutic modalities. In addition to smoking cessation and preventing smoking initiation, understanding shared mechanisms in these smoking-related lung diseases is critical, in order to develop new methods of prevention, diagnosis and treatment of lung cancer and COPD.

Abstract
CT-guided percutaneous needle biopsy(CT-guided PTNB) of the lung, with its high sensitivity, specificity, and accuracy, is an important diagnostic tool in the evaluation of pulmonary lesion, especially in malignant disease . And it’s specificity can reach 95 percent to 100 percent in malignant disease. Although PTNB of the lung is a mature technique, careful case selection is necessary to increase diagnostic yield and avoid unnecessary complications. It is indicated for indeterminate pulmonary nodules or masses, particularly those that will likely require chemotherapy or radiation rather than surgery. Pneumothorax and pulmonary hemorrhage are the most common complications of PTNB, whereas air embolism and tumor seeding are extremely rare. Attention to biopsy planning and technique and postprocedural care help to prevent or minimize most potential complications. A retrospective investigation of patients with CT-guided PTNB in Jinling Hospital between January 2000 to October 2010 was performed. The risk factors for complications were determined by multivariate analysis of variables related to patients’ demographics, lung lesions, biopsy procedures, and individual radiological features.1014 biopsy prcedures were enrolled. The total complication rate was 18.5 percent with pneumothorax 12.9 percent (131/1014), hemoptysis 5.6 percent (57/1014), and with no mortality. The diagnosis was cofirmed by PTNB in 961 patients (94.8 percent) with 639 patients as malignant disease (63 percent) and 322 patients as benign diease (31.8 percent). Taken into all the evidence, CT-guided percutaneous needle biopsy is a safe and effective means in the diagnosis of pulmonary occupying lesions.

Abstract
Until recently the oncologist was only interested to know whether a lung cancer was SCLC or NSCLC. However, recent changes, particularly during this century, require more precise classification of lung cancer, and, in some cases, for subclassification [1]. The different classes of lung cancer respond differently to conventional therapy and to precision medicine. The patterns of driver mutations are highly tumor type dependent, with very little overlap between classes. Thus mutation testing depends of accurate classification. Other reasons for accurate classification include: 1) Adenocarcinoma histology is a strong predictor of response to pemetrexed therapy in patients with advanced disease; and 2) Serious hemorrhagic complications after bevacizumab therapy have been reported in patients with squamous histologies. With the development and application of newer agents for precision medicine, the need for accurate classification will only increase. Complicating the increased need for accurate classification is the fact that currently 70% of lung cancers are diagnosed from small biopsies or cytological samples. Thus more accurate diagnoses are demanded from smaller amounts of materials [1, 2]. A further complication is that large international clinical trials often require that tumor materials be reserved for entry requirements or various tests. In routine pathology practice, immunostains are often used to classify poorly differentiated lung carcinomas. While many immunostains have been proposed, a simple algorithm utilizing TTF1 and Napsin A for adenocarcinoma and p63 (or its isoform p40) and high molecular weight keratins have is effective [3]. However, even with excellent pathology practices, over 10% of cases will be incorrectly classified or be unclassified (undifferentiated large cell carcinoma or NSCLC-not other wise specified (NSCLC-NOS). Pathology practices and quality may vary from institution to institution or country to country. The SEER data on cancer incidence indicates that over 20% of lung cancer cases in the USA are not further classified. For these reasons we developed highly specific and sensitive RNA expression signatures as an adjunct test for routine pathological classification. The signatures not only classify the smaples, but provide a numeric scor ranging from 0-1.0, indicating the degree of differentiation. We utilized expression arrays from multiple public and private sources including The Tumor Cell Genome Atlas (TCGA), which used several platforms including Illumina, Affymetrix and RNA-Seq. For complete identification, four signatures had to be developed and validated and can be utilized independently or in combination. These signatures are: 1) Adenocarcinoma-squamous cell carcinoma discrimination, 2) lung specific neuroendocrine (NE)-non neuroendocrine lung cancer discrimination, 3) Non-malignant lung- lung carcinoma discrimination and 4) lung respiratory cell-lung carcinoma cell discrimination. The adenocarcinoma signature includesTTF1, the squamous cell carcinoma signature includes p63 and several high molecular weight keratins, and the NE cell signature includes chromgranin A, synaptophysin and dopa decarboxyase, adding credence to the signatures. These signatures have <10% discrepancy rates with expert pathology review and have helped n the correct classification of NSCLC, large cell and NSCLC-NOS carcinomas, NE lung tumors and lung cancer cell lines. John Minna and Alex Augustyn, in collaboration with us, have utilized their modification of the NE cell signature, and have identified two potential major clinical applications. These include identification of the full NE expression signature in a subset (5-10%) of NSCLC. While some of these may represent misclassified large cell neuroendocrine carcinomas, others appear to be typical adenocarcinomas. In addition, they have identified that BCL2 is one of the downstream targets of ASCL1, the driving force for NE differentiation in the lung, and that inhibition of BCL2 results in apoptosis of SCLC and NSCLC-NE tumors. Practical application of our signatures requires modification to a more practical platform such as Nanostring technology, and application to formalin fixed paraffin embedded small biopsies. These are currently in development. We are grateful to Drs. William Travis and Natasha Rehktman, members of the TCGA pathology panel and Ignacio Wistuba, John Minna and Alex Augustyn for their invaluable assistance. References 1. Gazdar AF. The evolving role of the pathologist in the management of lung cancer. Lung Cancer Management 2012;1(4):1-9. 2. Travis WD, Brambilla E, Noguchi M, et al. Diagnosis of Lung Cancer in Small Biopsies and Cytology: Implications of the 2011 International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society Classification. Arch Pathol Lab Med 2012. 3. Travis WD, Rekhtman N. Pathological diagnosis and classification of lung cancer in small biopsies and cytology: strategic management of tissue for molecular testing. Semin Respir Crit Care Med 2011;32(1):22-31.

Abstract
Lung cancer remains as the most fatal disease world-wide.Non-small cell lung cancer (NSCLC) accounts for about 80% of all lung cancers. Incidence of pulmonary adenocarcinoma has been increasing in most countries and becomes a major histology. We had, up to the recent past, treated patients with chemotherapy without any clinical or biological selection. Unfortunately, the improvement in overall survival (OS) with platinum-based doublets is modest, although statistically significant when compared to best supportive care. We now, however, understand that adenocarcinoma could be divided into several subsets according to oncogenic drivers and each subset of adenocarcinoma has a different biology. So, targeted therapies against these drivers have been extensively studied and will play more and more important roles in treatment of advanced adenocaricnoma of the lung. Oncogenic drivers Adenocarcinoma is different in oncogenic drivers between East Asian and Caucasian patients. East Asian patients have more frequent epidermal growth factor receptor (EGFR) mutation but less frequent KRAS mutation. Incidence of EGFR mutation is about 50% - 78.8% but of KRAS mutation about 1.9% to 12%. Other oncogenic drivers include ALK or ROS1 rearrangement, BRAF mutation, HER2 amplification or mutation, c-MET amplification, etc, and arecomparable in their incidencesbetween Asian and Caucasian patients. These oncogenic drivers are mutually exclusive in majority cases. EGFR TKI Several phase II/III studies have investigated the efficacy of EGFR tyrosine kinase inhibitors (TKI) as front-line therapy of patients with advanced NSCLC. EGFR TKI is not appropriate for front-line therapy in unselected populations, in those without EGFR mutation, or those with unknown EGFR mutation status. Improvement in PFS with EGFR TKI is confined to those with EGFR mutation. In fact, first-line EGFR TKI seems to have a detrimental effect in those without an EGFR mutation. Clinical characteristics alone are not sufficient to correctly predict benefit from EGFR TKIs. Treatment with EGFR TKI in EGFR mutant NSCLC patients has also been found to be associated with improvement of progression-free survival (PFS) and quality of life and less toxicity profile. Both first-generation and second-generation EGFR TKIs are effective. Treatment of patients with acquired resistance to EGFR-TKI is wildly being studied. Switching to standard chemotherapy, continuation of an EGFR TKI beyond disease progression and/or plus local therapy, afatinib plus cetuximab are some options of treatment. ALK inhibitors Crizotinib proves effective in adenocarcinoma with ALKorRos1 rearrangement. Several studies (Profile 1001, 1005 and 1007) investigated crizotinib in advanced NSCLC with ALK rearrangement. Tumor response is about 51-61% and PFS 41.9-48.1 weeks. Second-line crizotinib was found more effective than chemotherapy in terms of tumor response rate and PFS. The compound was also found to be effective in those with ROS1 rearrangement. Among 35 patients, its tumor response rate was 60% and PFS was not reached. LDK 387 is a second-generation ALK inhibitor. Phase I study showed its promising efficacy in the patients with ALK rearrangement. It could overcome acquired resistance of NSCLC to crizotinib. Antiangiogenicagents Bevacizumab is approved to be combined with doublet chemotherapy as 1[st] line treatment of non-squamous NSCLC. The combination significantly improves tumor response, PFS and OS. But up to now, there is no biomarker for selection of non-squamous NSCLC patients to receive bevacizumab therapy. Many small molecular anti-angiogenicinhibitors plus standard chemotherapy have been investigated but failed in improvement of OS. Recently, LUME-Lung 1 trials suggested ninetedanib plus docetaxelsignificantly improved PFS and OS of patients with advanced adenocarcinoma of the lung in second line setting compared with docetaxel + placebo. KRAS inhibitors Some compounds are being investigated in those with KRAS mutation. Selumetinib, MKE1/2 inhibitor, combined with docetaxel significantly improved tumor response (37% vs 0%) and PFS (5.2 months vs 2.1 months, HR 0.58), compared with docetaxel alone.Trametinib plus second line chemotherapy produced about 12 to 28% of tumor response rate and 2.9 to 4.1 months of PFS. BRAF inhibitor Dabrafenib has been approved for treatment of melanoma harboringBRAF V600E mutation. Incidence of BRAF V600E mutation is about 1% in NSCLC. A phase II study investigated dabrafenib in adenocarcinoma of the lung withBRAF V600E mutation. Preliminary results in 20 patients showed 40% of tumor response rate and 60% of disease control rate with the compound. c-MET inhibitors c-METamplification is one of major mechanisms for acquire resistance of NSCLC to EGFR TKI. Several small molecular inhibitors of cMET and monoclonal antibodies against cMET are under clinical development. METmab plus erlotinib significantly improved PFS than erlotinib in those with MET high patients in the phase II trial. Crizotinib led to tumor shrinkage in a patient with MET amplification. HER2 inhibitors HER2 mutation and amplification are not frequently observed in adenocarcinoma of the lung. Mazieres and the colleagues reported that HER2-targeted therapies in additional lines of treatment produced 50% of overall response rate, 82% of disease control rate and 5.1 months of PFS. The disease control rate was 96% with trastuzumab-based therapies and 100% with afatinib monotherapy. The relative efficacy of these compounds deserves prospective evaluation in larger international clinical trials. Inhibitors of other oncogenic drivers Many inhibitors of other drivers including PDGFR, FGFR, RET rearrangement, PI3K, mTOR, MEK, AKT, STAT3, etc are under clinical development. We are just waiting for their results of clinical trials. In summary, EGFR TKI and ALK inhibitors are important agents for EGFR mutant and ALK or ROS1 rearranged adenocarcinoma of the lung, respectively. They become standard 1[st] line therapy for these patients. Bevacizumab plus doublet chemotherapy could be 1[st] line therapy for those with advanced adenocarcinoma harboring no oncogenic drivers. Many inhibitors of other oncogenic drivers are under clinical development and will become standard therapy for these patients in near future.

Abstract not provided

Abstract
Despite progressive advances in biomarker-driven personalised therapeutic approaches to non-small cell lung cancer (NSCLC) in recent years, the efficacy of first-line treatment remains suboptimal. Most chemotherapy-treated patients experience disease progression within 3–6 months[1,2] and even those who initially benefit from tyrosine kinase inhibitor (TKI) therapy inevitably progress after 10–14 months.[3–6] However, 40–50% of patients have a good performance status at progression and are suitable for subsequent therapy.[7,8] Thus, improving second-line treatment has the potential to significantly impact patient outcomes. The success of several molecularly targeted therapies in the first-line setting in clinical trials has stimulated research interest in similar applications in the second-line setting. Data from the DELTA[9] and CTONG0806[10] studies presented at ASCO 2013 corroborate findings from the TAILOR[11] study which suggest that chemotherapy may be a marginally better option than epidermal growth factor receptor (EGFR)-TKI for EGFR wild-type patients beyond the first-line setting. It is now clear that treatment response varies widely between patients with different biomarker profiles and this underscores the increasing importance of biomarker testing prior to second-line therapy. For patients with unknown mutation status in the first-line setting, biomarker analysis upon progression is essential to guide second-line treatment decisions to optimise treatment response, both for targeted therapies and chemotherapy. In the pivotal BR.21 trial of erlotinib versus placebo in the second-line setting, response to erlotinib increased from 8.9% in the unselected population to 27.0% in the EGFR mutation-positive sub-population. Similarly, overall survival (OS) increased from 6.7 months to 10.9 months when the EGFR genotype was known.[12,13] In patients with anaplastic lymphoma kinase (ALK)-positive tumours, crizotinib has demonstrated superiority to chemotherapy in the second-line setting with improved progression-free survival (PFS; 7.7 vs. 3.0 months; p<0.001) and quality of life, an important second-line outcome.[14] Although improvements in chemotherapy efficacy seem to have reached a plateau, the use of molecular testing to identify patients who will benefit most from chemotherapy is being actively investigated. A recent study exploring the predictive role of BRCA1 and ERRC1 genes in patients receiving second-line platinum-based chemotherapy showed that low mRNA levels of both genes correlated with increased OS (16.0 vs. 5.4 months; p<0.001) and PFS (4.1 vs. 2.0 months; p=0.002) compared with high levels.[15] Although clinically validated biomarkers have not been identified for most therapies, they remain a critical focus of research and currently available information offers clinicians new insights into second-line management. For patients with known mutation status who experience disease progression following first-line therapy, biomarker testing prior to therapy allows identification of mechanisms of acquired resistance to enable clinicians to tailor subsequent treatment strategies. The most common mechanism of acquired resistance to EGFR-TKIs is the T790M mutation, which has been reported in up to 60% of patients with acquired EGFR-TKI resistance.[16–19] Oxnard et al. demonstrated favourable prognosis and more indolent disease progression in patients with T790M-mediated acquired resistance compared with other mechanisms of acquired resistance, and customised subsequent treatment based on these findings. Over 80% of T790M-positive patients were maintained on TKI therapy, along with chemotherapy, to help maintain the indolent characteristics of T790M-associated progression.[17] A re-response phenomenon has also been described in T790M-positive patients in whom TKI-sensitive cells repopulate upon cessation of TKI therapy, allowing the tumour to regain sensitivity to EGFR-TKI. Thus, re-treatment with EGFR-TKI and chemotherapy may be well suited to target both sensitive and resistant cell populations.[20] Other mechanisms of acquired EGFR-TKI resistance include secondary c-MET overexpression/amplification via HER3/erbB3 or KRAS activation (5–19%), AXL upregulation (20–25%) and phosphatidylinositol-3-kinase mutations (5%).[21,22] Similarly, secondary genetic alterations have been demonstrated in crizotinib-resistant ALK-positive tumours.[23,24] For patients with known mutation status who are still on first-line treatment, biomarker testing provides real-time information to monitor for the development of mutations and to uncover additional targetable tumour characteristics that may impact treatment response and warrant a change in therapy. Tumour characteristics may evolve following first-line treatment as tumour heterogeneity may exist at both genomic and morphological levels. Bai et al. investigated the impact of chemotherapy on EGFR mutation in advanced NSCLC patients who received first-line chemotherapy and patients with stage IIb–IIIb disease who received neoadjuvant chemotherapy, and found that mutation-positive rates were lower post-chemotherapy in both cohorts (p<0.01 and p=0.13, respectively). Importantly, patients who lost EGFR mutation positivity post-chemotherapy had a better partial response than patients with a reverse change (p=0.037).[25] Morphological tumour heterogeneity following first-line therapy has been increasingly reported in the literature. EGFR mutation-positive adenocarcinomas have been reported to transform to small cell histology with maintained EGFR mutation following progression.[16,18] In a study by Sequist et al., these observations allowed investigators to switch patients to small cell lung cancer chemotherapy regimens, with 75% responding to treatment.[18] Epithelial-mesenchymal transitions have also been reported.[18,26] Biomarker testing in the second-line setting is important to detect any changes in tumour characteristics before significant clinical deterioration when alterations to regimens might be most effective. The growing number of biomarker-targeted treatment options may create a need for biopsy or re‑biopsy during treatment. Recent guidelines by the College of American Pathologists, the International Association for the Study of Lung Cancer and the Association for Molecular Pathology recommends re-biopsies for EGFR and ALK mutation analysis to guide treatment decisions beyond the first-line setting.[27] Although re-biopsy may be challenging due to patients’ and/or clinicians’ reluctance, it has shown to be feasible and provides sufficient material for mutation analysis in most patients. High-sensitivity sequencing methods can detect T790M mutation in up to 68% of re-biopsy samples from patients with acquired resistance.[16,17,28,29] Nevertheless, promising surrogates for tumour tissue DNA, such as circulating blood biomarkers, are being investigated and may represent a less invasive approach. The BATTLE-1 trial, which employed real-time biopsies to match patients to targeted therapies, proved that a biomarker-driven treatment approach is feasible.[30] BATTLE-2, which involves more drug combinations, and real-time selection and validation of predictive biomarkers, is currently ongoing;[31] the highly anticipated results hold promise for revolutionising NSCLC treatment.

Abstract
ABSTRACT Rationale: Effective treatment for lung cancer requires accuracy in sub-classification of carcinoma subtypes. Objectives: To identify microRNAs in bronchial brushing specimens for discriminating small cell lung cancer (SCLC) from non-small cell lung cancer (NSCLC) and for further differentiating squamous cell carcinoma (SQ) from adenocarcinoma (AC). Methods: Microarrays were used to screen 723 microRNAs in laser-captured, microdissected cancer cells from 82 snap-frozen surgical lung tissues. Quantitative reverse-transcriptase PCR was performed on 153 macrodissected formalin-fixed, paraffin-embedded (FFPE) surgical lung tissues to evaluate 7 microRNA candidates discovered from microarrays. Two microRNA panels were constructed based on a training cohort (n = 85) and validated using an independent cohort (n = 68). The microRNA panels were applied as differentiators of SCLC from NSCLC and SQ from AC in 207 bronchial brushing specimens. Measurements and Main Results: Two microRNA panels yielded high diagnostic accuracy in discriminating SCLC from NSCLC (miR-29a and miR-375, AUC 0.991 and 0.982 for training and validation dataset, respectively) and in differentiating SQ from AC (miR-205 and miR-34a, AUC 0.977 and 0.982 for training and validation dataset, respectively) in FFPE surgical lung tissues. Moreover, the microRNA panels accurately differentiated SCLC from NSCLC (AUC 0.947) and SQ from AC (AUC 0.962) in bronchial brushing specimens. Conclusion: We found 2 microRNA panels that accurately discriminated between the 3 subtypes of lung carcinoma in bronchial brushing specimens. The microRNA panels could have considerable clinical value in differential diagnosis and play an important role in determining optimal treatment strategies based on the lung carcinoma subtype.

Abstract
Drug-associated interstitial lung disease (ILD) is not uncommon, but it may developed to fatal acute respiratory distress syndrome, so an accurate diagnosis based on clinical, radiological and histological manifestations is important. As an EGFR-TKI, Gefitinib or Erlotinib has been widely used in advanced NSCLC, although it may prolong the patient’s survival, the possibility of ILD associated with EGFR-TKI remains a big problem that we need to confront especially in Asian NSCLC patient. Diagnosis For the assignation of ILD, patient usually need to accord with the following requirements: (1) progressive dyspnea with or without cough or fever, (2) radiographic findings(HRCT recommended) show bilateral, diffuse, or patchy interstitial and/or alveolar opacifications, (3) lack of evidence of infection and progression of underlying lung cancer, (4) consistent pathologic findings if available. Establishing a diagnosis on EGFR-TKI associated ILD is often difficult, and is particularly challenging in a patient having been given chemotherapy and/or radiotherapy, chemotherapy and radiotherapy, either alone or in combination, have been associated with the development of ILD. In addition, infections, and other environmental exposures can also mimic ILD. The characteristic images of EGFR-TKI associated ILD were of patchy diffuse ground-glass shadows; several other characteristic HRCT patterns can also been observed. In acute forms of ILD, ground-glass attenuation is usually seen bilaterally in the lung fields. In chronic forms of the disease, “honeycombing” is seen that results from extensive pulmonary fibrosis and loss of acinar architecture of the lungs. Although ILD can occur during the first 3 months of treatment, the median time to onset was actually 24 to 42 days, and ILD developed in most patients within the first 4 weeks of treatment, with possibly rapid progression.On the other hand, ILD can develop in patients who are retreated with EGFR-TKI after a period of interruption. Therefore, all patients receiving EGFR-TKI who present with an acute onset of dyspnea, regardless of the presence of cough or low-grade fever, should be promptly evaluated, especially during the first month of treatment. Epidemiology There are more frequent reports of EGFR TKI-associated ILD in Japan than elsewhere in the world. The causes for this worldwide differences are unknown and require further scientific investigation. Several reasons have been suggested for this difference, including differences in follow-up period, the clinical characteristics of the study population, and the applied diagnostic criteria for ILD. Pre-existing ILD, including usual interstitial pneumonia, has been found in the reported EGFR-TKI induced ILD patients，the presence of IPF seems to be an important risk factor. Alternatively, there may be a specific increased genetic susceptibility to ILD among the Japanese population. However, this ethnic difference in reporting rates does not extend to other Asian countries, where the frequency of ILD is comparable with the rest of the world Mechanism of ILD The molecular mechanisms leading to ILD are also unclear. The distribution of EGF and EGFR in normal adult human lung has been demonstrated by immunohistochemistry, with expression observed in the basal cell layer of the bronchial epithelium . EGF signaling probably represents an important mechanism that helps coordinate the process of recovery from lung injury by stimulating epithelial repopulation and restoration of barrier integrity. Some investigator have suggested that EGFR-TKI therapy may augment any underlying pulmonary fibrosis via a decrease in EGFR phosphorylation with a coincident decrease in regenerative epithelial proliferation. Therefore, it is possible that EGFR inhibition will at least in part reduce the ability of pneumocytes to respond to lung injury. Compared with other EGFR inhibitors, the largest amount of information regarding the association with ILD is available for gefitinib, as this agent has been given to more patients than any other EGFR-TKIs. Treatment Treatment of EGFR TKI–induced ILD include supplemental oxygen, empirical antibiotics, and mechanical ventilation depending on the severity of the situation. Immediate discontinuation of the TKI drug is recommended . Acute pneumonitis commonly resolves on discontinuation of therapy, although in severe cases patients , systemic corticosteroids are usually prescribed, Prognosis with treatment is good if the diagnosis is made early; however, once fibrosis has occurred, the damage may be permanent with irreversible loss of lung function.

Abstract
The plasma protein complexes level was measured by electrophoresis analyses in 31 patients with advanced NSCLC treated with 125 or 150 mg/day icotinib hydrochloride until disease progression or unacceptable toxic effects or the patient refused further treatment. Eligibility criteria include performance status≤2, age≥18 years, and stage ⅢB-Ⅳ disease. Herein we found more than 87 % of the change in plasma IIRPCs appears at earlier time than histopathology occurs during the treatment with icotinib hydrochloride: (1) having a crest; (2) having a trough. The increasing or discreasing point always appears at earlier time in the treatment before histopathology occurs. There are no significant differences of the median PFS among the other clinical information groups, including: ages, gender, smoking history and EGFR mutation. Therefore, we showed that measurement of plasma protein complexes level during the treatment in patients with NSCLC may be a new surrogate marker for monitoring the therapeutic efficacy of icotinib and predicting the progression of the disease.

Abstract not provided

Abstract

Abstract
Introduction Lung cancer is a major health problem with no improvement in survival over the last decades. At time of diagnosis, lung cancer is often already in advanced stage, with 5-year survival of no more than 15%. Currently, several lung cancer screening trials investigating whether early detection of lung cancer in high-risk individuals will reduce lung cancer mortality are ongoing. In 2011, the National Lung Screening Trial (NLST), was the first and to date only reporting a 20% decrease in lung cancer mortality when three rounds of annual low-dose computed tomography (CT) were compared with three annual rounds of chest X-ray screening. A major challenge, however, is the high rate of positive test results reported by the NLST (24.2%). No less than 96.2% of these comprised false-positive test results, causing unnecessary patient anxiety, radiation exposure and cost. The Dutch-Belgian lung cancer screening trial (Dutch acronym: NELSON study) was launched in September 2003. The NELSON study is an ongoing multicentre randomized controlled multi-detector low-dose CT lung cancer screening trial. The primary object is to investigate whether chest CT screening in year 1, 2, 4 and 6.5 will decrease lung cancer mortality by at least 25% in high-risk (ex-)smokers between 50 and 75 years of age compared to a control group receiving no screening. The NELSON study is the first lung cancer screening trial in which nodule management is based on nodule volume, instead of transverse cross-sectional nodule diameter for new nodules, and nodule growth in terms of volume doubling time (VDT) for existing ones. In this presentation, different aspects of nodule management in the NELSON study will be discussed. Volume detection thresholds Sensitive pulmonary nodule detection is crucial not to miss any lung cancer in a screening setting. The sensitivity of nodule detection was investigated by scanning a Lungman phantom according to the standard NELSON protocol. Nodules of five different volumes (range 14–905mm[3]) were randomly positioned in the phantom. A sensitivity of 100% was found for nodules with a volume equal to or larger than 65mm[3] (5mm), and a sensitivity of 60–80% was found for solid nodules with a volume of 14mm[3] (3mm). Since the lung cancer probability of lung nodules smaller than 50mm[3] or 4mm is neglectable, the sensitivity of nodule detection using the NELSON protocol is sufficient for accurate detection of malignant lung nodules. Measurement reproducibility For accurate decision making in serial CT studies, nodule measurement reproducibility is essential. A sub-study of the NELSON trial showed a difference in repeatability among three reconstruction settings, demonstrating that the use of consistent reconstruction parameters is important. Volume measurements of pulmonary nodules obtained at 1mm section thickness combined with a soft kernel were found to be most repeatable. Another sub-study showed that variability on volume measurements is related to nodule size, morphology and location. Besides image reproducibility, interobserver variability in performing semi-automated volume measurements is of major importance in the classification of lung nodules. Gietema et al. found that interobserver correlation was very high (r=0.99) in small-to-intermediate size (15-500mm[3]) nodules. Volume criteria for nodule stratification For solid nodules, and solid components of part-solid nodules, volume was calculated by 3-dimensional volumetric computer assessment, using LungCare software (version Somaris/5:VA70C-W; Siemens Medical Solutions). The final screen result was based on the nodule with largest volume or fasted growth. In the NELSON study, nodules were classified as negative if volume was <50mm[3] (4.6mm diameter if the nodule would have been perfectly spherical), leading to an invitation for the regular next-round CT, as positive if nodule volume was >500mm[3] (>9.8mm diameter), leading to direct referral to a pulmonologist for further workup, and as indeterminate in case of volume of 50-500mm[3]. Indeterminate nodules underwent a 6-week to 3-month follow-up low-dose CT for growth assessment. Volumetric growth assessment of pulmonary nodules After a nodule has been selected by a radiologist, the LungCare software automatically calculates nodule volume. Information is saved in the NELSON Management System (NMS), which calculates the growth in case of a pre-existing nodule. Growth is defined as a change in volume of ≥25% between two subsequent scans according to the formula: Percentage volume change (%) = (V2-V1)/V1)*100 V2 = volume at last CT, and V1 = volume at previous examination. Determination of the volume-doubling time For solid nodules, or solid components of partial-solid nodules with PVC≥25%, the VDT is semi-automatically calculated by the NMS according to the formula: VDT (days) = (ln(2)*Δt)/(ln(V2/V1)) The VDT is used to distinguish between positive screens (VDT<400days), requiring additional diagnostic procedures, indeterminate screens (VDT 400-600days), requiring an extra follow-up CT 12 months after the regular round CT and negative screens (VDT>600days). Using this two-step approach of volume and growth assessment, 2.6% of NELSON baseline screens were positive, and compared to other screening trials, a higher proportion (34.6% at baseline) were true-positive. The NELSON study reported a baseline screen sensitivity of 94.6% and a negative predictive value of 99.9%. Comparison between volumetric and diameter assessment of pulmonary nodules For determining pulmonary nodule size, the use of volume measurements has been found to be more reliable than diameter measurements. In the previously mentioned phantom study, measurements of the manually measured maximal transverse diameter and semi-automated measurements of diameter and nodule volume were compared with actual properties. In both methods, diameter and volume of the spherical nodules were significantly underestimated. In diameter evaluation, the overall underestimation for solid nodules was about 10% using the manual method, compared with less than 4% using the semi-automated method. In volumetry, the overall underestimation for solid nodules was about 25% (translates into 8% diameter underestimation) using the manual method, compared with less than 8% (translates into 2.5% diameter underestimation) using the semi-automated method. It is important to keep in mind that a small change in diameter already corresponds to a considerably higher change in volume. Thus, in lung cancer screening we suggest nodule measurements by semi-automated volumetry should be used. Differences between volume and diameter based nodule management protocol in terms of early lung cancer detection, morbidity, mortality, radiation exposure and costs remain to be demonstrated.

Abstract not provided

Abstract not provided

Abstract
Biological function of RAS An activity that transforms mouse NH 3T3 cells in DNA from human cancers turned out to be present in human homologues of retroviral oncogenes found earlier. These genes were named as HRAS or KRAS according to the names of corresponding viruses; Harvey- or Kirsten- ratsarcoma viruses. The difference between RAS gene present in normal tissue and that in cancer tissue was a single missense point mutation either at codon 12 , and less frequently at codons 13 or 61. The third member of the RAS family gene, NRAS was identified one year later from a human neuroblastoma cell line, although its viral homologue was not identified. There is a tendency that a certain type of cancer uses a particular type of RAS gene; e.g. most RAS mutations in lung or pancreas cancer occur in KRAS gene, whereas most RAS mutations in bladder cancer occur in HRAS gene . RAS gene encodes for a 21kDa protein that toggles guanosine diphosphate (GDP)-bound inactive form to and from guanosine triphosphate (GTP)-bound active form because RAS has a GTPase activity. Guanine nucleotide-exchange factors (GNEFs) and RAS GTPase activating proteins (RAS-GAPs) positively and negatively regulate the amount of GTP bound RAS, respectively. Oncogenic point mutations either at codon 12,or less frequently at codons 13 or 61 make RAS impair its intrinsic GTPase activity and confer resistance to GAPs, thereby causing RAS to accumulate in its active GTP-bound state and sustained activation of RAS signaling. It is known that GTP-bound, active RAS interacts with more than 20 effector proteins and stimulates downstream signaling cascades. These effectors and corresponding functional outcomes include RAF (proliferation), RIN1 (endocytosis), PI3K (survival), PLCe (second messenger signaling), RalGEF (endocytosis). Rather paradoxically, oncogenic RAS has been shown to cause senescence in primary cell culture through the activation of the WAFp21-p53 or p16-Rb pathways. It is also known that, to acquire its biological and transforming activities, RAS proteins should be bound to inner surface of the plasma membranes by appropriate post-translational modification. This process includes farnesyltation, proteolytic cleavage of AAX motif, carboxymethylation of the terminal Cys and palmitoylation. This process was initially thought to be a target of therapeutic intervention. However, inhibition of farnesyl transferase results in alternative geranylgeranylation of RAS which supports membrane binding. RAS gene activation in lung cancer Frequent somatic mutation of the RAS gene in lung cancer was first identified in 1987. RAS mutation in lung cancer usually occurs in KRAS, although rare instances of HRAS or NRAS mutations are reported. Mutation of the KRAS gene usually occurs in adenocarcinoma, rarely in squamous cell carcinoma and almost never occurs in small cell lung cancer. KRAS mutations predominantly occur in Caucasian patients (~30%) rather than East Asians (~10%). Association between KRAS mutation and smoking exposure has been reported back in 1991. KRAS mutation at codon 12 in lung cancer is characterized by the frequent a G to a T transversion in contrast to the frequent a G to a A transitions found in colorectal cancer. Even within lung cancer, more than half of KRAS mutations in smokers are either G12C (GGT-TGT) or G12V (GGT-GTT), while those in never smokers are G12D (GGT-GAT). It is thought that not all the KRAS mutations are created equal. There is a report that G12V has a weaker GTPase activity than G12D, suggesting stronger oncogenic activity of G12D. It is also generally believed that KRAS codon 13 mutation is weaker oncogene than codon 12 mutation. In terms of effect of cetuximab in colon cancer, tumors with G13D behaves like those with WT KRAS. Prognostic impact of KRAS mutations in lung cancer are variably reported, but in general it is thought to be a weak negative prognostic factor. Whether there is a difference in prognostic impact among different KRAS mutations remains to be elucidated. In terms of histologic types, KRAS mutations are associated with lung adenocarcinoma with mucus production / goblet cell morphology. Lung cancer with KRAS mutations often accompanies with CK20 and CDX2. These phenotypes are commonly observed in colorectal, pancreato-biliary, and ovarian mucinous carcinomas. How to cope with KRAS mutated lung cancer Although KRAS mutations occur in mutually exclusionary fashion with activation of other driver oncogenes such as EGFR, ALK, ROS1, RET, etc, it appears that not all cancers with KRAS mutations are dependent on mutant KRAS. Upon treatment of shRNAs to deplete KRAS in lung cancer cell lines harboring KRAS mutations, half of the cell lines maintained viability without expressing KRAS. This makes it difficult to develop treatment strategy against KRAS mutated tumors.. Although MEK-ERK signaling is an essential downstream of mutant KRAS, single treatment of MEK inhibitor exhibits variable responses and PI3K pathway activation strongly influences its sensitivity. Therefore, simultaneous downregulation of MEK-ERK and PI3K-AKT may have potential therapeutic value. Recent approach is to identify synthetic lethal interactions in cancer cells harboring KRAS mutation. In other words, it is to find which genes, when silenced, kill cells harboring mutant RAS gene but not cells without this mutation. However, the list of genes with synthetic lethal activity against RAS mutated tumors are expandingand includes THOC1, eNOS, Myc, Survivin, STK33, PLK1, SYK, RON, integrin b6, TBK1, NFkB, WT1, PKC delta, CDK4, JNK, ATR, GATA2. However, a subsequent and comprehensive study could not reproduce the synthetic lethal activity of STK33, throwing out the caveat that one should be cautious to interpret the RNAi data because individual shRNA can downregulate tens or hundreds of off-target genes . Above-mentioned experimental evidence suggests that RAS collaborate with many different molecules depending on cellular contexts to have oncogenic activity. This is why the development of RAS-targeted therapy is difficult and suggests that it would be necessary to develop combination therapy depending on different cellular context.

Abstract
KRAS mutations are found in ~30% of adenocarcinomas and ~5% of squamous NSCLC. They are more common in current or former smokers. Most KRAS mutations in NSCLC occur on codon 12 and less frequently codons 13 and 61. Prognostic Value of KRAS The prognostic significance of KRAS has been investigated extensively. Results have been inconsistent with heterogeneity among studies including differing endpoints and patient populations studied. A large meta-analysis of 28 studies reported that KRAS mutation was a negative prognostic factor for OS (p=0.01) when all cancers were considered, in adenocarcinoma (HR 1.52, CI 1.30-1.78, p=0.02) but not squamous histology (HR 1.49, CI 95%: 0.88–2.52; p=0.48). The International Agency for Research on Cancer assessed KRAS in 762 patients with resected NSCLC. Mutations were detected in 18.5%; KRAS was not prognostic for PFS (p=0.26). The LACE-Bio group performed a pooled analysis of 1,543 patients from four randomized trials of adjuvant chemotherapy vs observation. KRAS mutations were present in tumors of 300 patients (codon 12 275, codon 13 24, and 1 codon-14). This was the first study to assess the prognostic effect of different KRAS mutations. In observation patients, there was no prognostic difference for OS for codon-12 (HR=1.04) or codon-13 (HR=1.01) mutations, nor for specific codon-12 amino acid substitutions. KRAS was not prognostic in the adenocarcinoma subgroup (HR=1.0, p=0.97). This group was the first to report that OBS patients with KRAS-mutated tumors were more likely to develop second primary cancers (HR=2.76, p=0.005). This observation requires validation. Predictive Value of KRAS Mutation for Chemotherapy Several studies have assessed the predictive value of KRAS in NSCLC patients treated with chemotherapy, but few have had untreated control arms to be able to isolate the predictive from the prognostic effects of mutation status. Rodenhuis et al. assessed KRAS in 83 patients with advanced adenocarcinoma treated with ifosfamide/carboplatin/etoposide; 26% had mutations.[10 ]The presence of KRAS mutation was not significantly associated with response rate, PFS or OS (p=0.486, p=0.22 and p=0.29, respectively). The TRIBUTE trial in advanced NSCLC compared first-line carboplatin/paclitaxel +/- erlotinib. KRAS mutations were present in 21% of samples tested. Response rates in the chemotherapy-alone arm were 26% and 23% for patients with wild-type and mutated KRAS, respectively, with no significant survival difference (median OS 13.5 and 11.3 months, respectively). In a neo-adjuvant chemotherapy study, Boermann et al[12] reported ORRs of 80% and 77% in patients with KRAS wild-type and mutated tumors, respectively. PFS was longer in patients with wild-type tumors compared to those with mutations (PFS 21 vs 9 mo, p=0.003) although there was no difference in OS (p=0.07). The LACE-BIO pooled analysis revealed no significant effect of KRAS mutation on benefit from adjuvant chemotherapy with respect to OS or DFS, even in adenocarcinoma (interaction p=0.99). Analysis by KRAS subtype revealed a non-significant benefit from ACT in patients with wild-type KRAS (HR=0.89, p=0.15) but not codon-12 mutations (HR=0.95, p=0.77); with codon-13 mutations, ACT was deleterious (HR=5.78, p=0.001, interaction p=0.002). There was a trend towards benefit from ACT for codon-12 G12A or G12R (HR=0.66 p=0.48) but not G12C or G12V (HR=0.94 p=0.77) or G12D or G12S (HR=1.39 p=0.48), (comparison of 4 HRs, including WT p=0.76). Predictive Value of KRAS Mutation for Epidermal Growth Factor Receptor Inhibitors In TRIBUTE, patients with KRAS mutant tumors who received chemotherapy+erlotinib had shorter median TTP than those treated with chemotherapy+placebo (3.4 vs 6 months, p=0.03). OS also was significantly shorter in the KRAS mutant subgroup treated with chemotherapy+erlotinib than those treated with chemotherapy+placebo (4.4 vs 13.5 months, p=0.019). In the NCIC CTG BR.21 trial of erlotinib vs placebo in advanced NSCLC, KRAS mutations were found in 15% of response-evaluable patients in the erlotinib arm. Response rates were 10% and 5% for patients with wild-type and mutated KRAS, respectively (p=0.69). There was no significant difference in survival benefit from erlotinib based on KRAS status (interaction p=0.09) on multivariable analysis (p=0.13), despite a trend in univariate analyses (KRAS mutant HR 1.67, p=0.31; KRAS wild-type HR 0.69, p=0.03). In the ATLAS trial that compared maintenance bevacizumab+placebo to bevacizumab+erlotinib, 93 patients had tumors with KRAS mutations. There was no significant PFS benefit for bevacizumab+erlotinib (HR 0.93, p=0.7697), while in wild-type KRAS, there appeared to be some benefit for the combination (HR 0.67, p=0.01).[14] In the SATURN trial, stable and responding patients were randomized to receive maintenance erlotinib or placebo. KRAS mutation was detected in 18%. Modest PFS benefit from erlotinib was seen both in patients with mutant KRAS and wild-type tumors (interaction p=0.95). Data are limited regarding KRAS mutation subtype and response to EGFR-TKIs in NSCLC. One recent investigation of KRAS mutation status and response to EGFR-TKI in EGFR wild-type advanced NSCLC demonstrated that patients with codon 13 KRAS mutations had worse PFS (p=0.04) and OS (p=0.005) than patients with codon 12 mutations. However, there were only 14 and four patients having mutations in codons 12 and 13, respectively. Two meta-analyses have evaluated the association between KRAS and EGFR TKIs in NSCLC. Linardou et al. assessed 17 trials (1008 patients, 165 with KRAS mutation). Mutation was significantly associated with lack of response to TKIs. Mao et al. included 22 studies; 16% (231/1470) had KRAS mutations. ORRs were higher for KRAS wild-type compared to mutation (26% and 3%, respectively). The pooled relative risk for response was 0.29 (p<0.01). In Asians, relative risk was 0.22 (p=0.01), and 0.31 (p<0.01) in Caucasians. In BMS-099, advanced NSCLC patients were randomized to receive taxane/carboplatin +/- cetuximab. KRAS mutations were found in 17% of assessable samples. There was no significant association between KRAS status and response, PFS or OS. The FLEX study compared cisplatin/vinorelbine +/- cetuximab in EGFR-expressing NSCLC. KRAS mutations were detected in 19% of assessable samples. The addition of cetuximab to chemotherapy did not significantly affect survival, PFS or response in patients with KRAS wild-type or mutated tumors. Summary KRAS is at most, a weak prognostic marker in NSCLC. It should not be considered a tool to select patients for treatment at this time.

Abstract not provided

Abstract
Staging is an objective measurement of the extent of cancer to allow logical grouping of patients with similar prognosis and pathobiological characteristics. Actually, the stage is expressed as combination of three factors: the size and invasion of the primary tumor (T), metastasis to the locoregional lymph nodes (N), and distant disease (M). Nowadays, any planning of the treatment is not possible without accurate staging. Moutain, who took the great leadership in the revision of TNM staging system, described staging as “assigning a simple coded designation to be a patient in accordance with an established set of rules”. Traditionally, UICC and AJCC have taken an initiative for the revision of the classification rules of TNM system. Since 7[th] edition which was published in 2009, IASLC was principally involved in the creation of proposals for revision to UICC and AJCC based upon the world-wide database. This process was known as “IASLC Lung Cancer Staging Project” lead by Goldstraw, and it is still underway for 8[th] edition. Although TNM staging system covers the malignant tumors of most organs, such aggressive intervention of international academic societies has been rarely seen except IASLC. The advent of mediastinoscopy, PET, and EBUS technique contrubuted to better staging. The IASLC Staging Project is now extended to cover not only lung cancer but also mesothelioma, thymic tumors, and esophageal cancer. As of 2013, surgery is still playing a principal role in the treatment of lung cancer especially for the relatively early stages of the disease with curative intent. Surgery is respected as the integration of two different parts: "art (surgical skill)" and "science". Therefore, we should realize that the evolution of lung cancer surgery has been achieved by the refinement of surgeons’ skills and advent of new technique (technology) as well as the accumulation of novel scientific evidence given by the well planned clinical trials. Surgery for lung cancer began as pneumonectomy as early as in 1930. However, the present-day gold standard surgery for lung cancer is defined as at least lobectomy and lymph node sampling/dissection. Series of clinical trials in 1980’s, mainly focusing upon the prognostic evaluation of adjuvant chemotherapy, were performed by Lung Cancer Study Group. The technically challenging surgery, such as those for superior sulcus tumor, has been also improved greatly. Even tumors located at the difficult potion of the thoracic inlet could be resected by refined method as shown by Grunenwald. How to manage the metastasis to the locoregional lymph nodes is also an important issue. Owing to the lymph node map originally drawn by Naruke and colleagues in 1970’s, the precise location of the metastatic nodes could be documented, and further analyses and comparison of the resected lung cancer with node metastasis became possible. The prognostic impact of the lymph node dissection was evaluated by the recent ACOSG study. In 1990’s, the minimally invasive technique (video-assisted thoracic surgery) was introduced in the surgery for lung cancer, and the comparison between open and VATS procedures were being performed. The trend toward the minimally invasive surgery is now generalized in the thoracic surgical community. The future directions in lung cancer surgery include the development of less invasive technique such as robotics, the improvement of the adjuvant treatment with new active drugs, the definition of the role of surgery in the multimodality treatment for advanced lung cancer, and the comparison between surgery and other local modalities (SBRT, ablation) as the treatment for pathologically early lung cancer. References 1970’s Pearson FG et al. The role of mediastinoscopy in the selection of treatment for bronchial carcinoma with involvement of superior mediastinal lymph nodes. J Thorac Cardiovasc Surg 1972;64:382-90. Naruke T et al. Lymph node mapping and curability at various levels of metastasis in resected lung cancer. J Thorac Cardiovasc Surg 1978;76:832-9. 1980’s Holmes EC, et al. THE LUNG CANCER STUDY GROUP. A randomized comparison of the effects of adjuvant therapy on resected stages II and III non-small cell carcinoma of the lung. Ann Surg 1985;202:335-41 Mountain CF. A new international staging system for lung cancer. Chest 1986;89:225S-33S 1990-1995 Valk PE, et al. Staging of non-small-cell lung cancer by whole-body positron emission tomographic imaging. Ann Thorac Surg 1995;60:1573-82. Lung Cancer Study Group. Randomized trial of lobectomy versus limited resection for T12 N0 non-small cell lung cancer. Ann Thorac Surg 1995;60:615-23. 1995-2000 TNM Classification of Malignant Tumours. 5[th] Ed. Lung. International Union Against Cancer. Wiley-Liss, New York, pp93-97, 1997. Grunenwald D et al. Transmanubrial osteomuscular sparing approach for apical chest tumors. Ann Thorac Surg 1997;63:563-6. 2001-2005 Goya T et al. Prognosis of 6,644 resected non-small cell lung cancers in Japan: a Japanese lung cancer registry study. Lung Cancer 2005;50:227-34. Mateu-Navarro M et al. Remediastinoscopy after induction chemotherapy in non-small cell lung cancer. Ann Thorac Surg 2000;70:391-395. Van Schil PE et al. Remediastinoscopy after neoadjuvant therapy for non-small cell lung cancer. Lung Cancer 2002;37:281-285. Stamatis G et al. Repeat mediastinoscopy as a restaging procedure. Pneumologie 2005;59:862-866. De Leyn P et al. Prospective comparative study of integrated PET-CT scan versus re-mediastinoscopy in the assessment of residual mediastinal lymph node disease after induction chemotherapy for mediastinoscopy proven IIIA-N2 non-small cell lung cancer. A Leuven Lung Cancer Group study. J Clin Oncol 2006;24:3333-9. 2005-2010 The IASLC Staging Manual in Thoracic Oncology, Editorial Rx, Florida, 2009. Falcoz et al. The Thoracic Surgery Scoring System (Thoracoscore): Risk model for in-hospital death in 15,183 patients requiring thoracic surgery., J Thorac Cardiovasc Surg 2007;133:325-32. 2010- Yasufuku K et al. A prospective controlled trial of endobronchial ultrasound-guided transbronchial needle aspiration compared with mediastinoscopy for mediatinal lymph node staging of lung cancer. J Thorac Cardiovasc Surg 2011;142:1393-400. Darling GE et al. Randomized trial of mediastinal lymph node sampling versus complete lymphadenectomy during pulmonary resection in the patient with N0 or N1 (less than hilar) non-small cell carcinoma: Results of the American College of Surgery Oncology Group Z0030 Trial. J Thorac Cardiovasc Surg 2011;141:662-70. Swanson SJ et al. Video-Assisted Thoracoscopic Lobectomy Is Less Costly and Morbid Than Open Lobectomy: A Retrospective Multiinstitutional Database Analysis., Ann Thorac Surg 2012;93:1027-32

Abstract
Etiology and epidemiology Awareness that lung cancer is for many patients a self-inflicted disease has become common knowledge and its incidence can only be reduced by an active fight against smoking . The IASLC has always considered this as very important (1). The last decade much attention was given the non-smokers who developed lung cancer. These patients have specific characteristics, of which EGFR mutation is one (2). What is responsible for this class of lung cancer is unknown. With an estimated number of 300,000/year, it is far from an orphan disease (3). Early detection Lung cancer cure rates are far from impressive (4). For those diagnosed with symptoms the outcome is grim, cure is extremely rare, palliative needs are common (5). The 5 year survival rates in patients with resectable tumors is decreasing with increasing stage (6). Finding early stage lung cancer with state-of -the-art CT technology resulted in an impressive 10 yr survival rate of 88% (7). This modern CT technologywas evaluated in the largest lung cancer screening study ever performed (8). For the first time it was demonstrated that screening is effective and results in a relative reduction in mortality from lung cancer of 20.0%, and death from any cause by 6.7% (95% CI, 1.2 to 13.6; P = 0.02). Still many questions remain unanswered and confirmation is needed (9)? How to treat these lesions with minimal invasive surgery (10) or stereotactic radiotherapy (11). Pulmonology Autofluorescence bronchoscopy improves the detection of mucosal abnormalities (12) such as pre-invasive lesions (13), carcinoma in situ (14) and radiologically occult lung cancer (15). Through the EBUS (endobronchialultrasound) scope virtually every lymph node adjacent to the bronchial tree can be reached (16). In combination with the ultrasound from inside the oesophagus (17) this results in a sensitivity of > 90% (18). In a RCT it was demonstrated that combining these techniques should be done before thinking of a mediastinoscopy as their yield is comparable to mediastinoscopy (19). Bronchoscopy became important for treatment as well, ranging from palliative to really curative. Stenting the airway but should be used with great caution as migration is common, it seriously affects mucus clearance and narrowing of the airways through granulation tissue might develop (20). A desobstruction technique such as Nd-YAG laser, electrocautery or argon plasma coagulation can be used if intraluminal tumor gives obstruction (20). In specific situations with very limited cancer within the bronchial wall endobronchial treatment might even lead to cure, an example of this is photodynamic therapy (21). Radiology Within the last 40 years imaging techniques have improved considerably. With the introduction of computed tomography, it became possible to visualize the primary tumor as well as mediastinal lymphnodes in a much better way. A further technical improvement, the Positron Emission Tomography (PET) and the use of 18-fluorodeoxyglucose (18-FDG) improved this (22). Further developments of imaging may lead to decision making on treatment (23). References 1 Tobacco policy recommendations of the International Association for the Study of Lung Cancer (IASLC): a ten point program. Lung Cancer 1994; 11: 405-407 2 Ren JH, et al. EGFR mutations in non-small-cell lung cancer among smokers and non-smokers: a meta-analysis. Environ Mol Mutagen. 2012 Jan;53(1):78-82 3 Sun S, et al. Lung cancer in never smokers—a different disease. Nat Rev Cancer. 2007;7(10):778-790. 4 Goldstraw P, et al. The International Association for the study of lung cancer. The International staging project on lung cancer. J ThoracOncol 2006; 1: 281-286. 5 Ferrell B, et al. Palliative care in lung cancer. SurgClin North Am 2011; 91: 403-418. 6 Goldstraw P, et al. The IASLC Lung Cancer Staging Project: Proposals for the revision of the TNM stage groupings in the forthcoming (seventh) edition of the TNM classification for Lung Cancer. J Thor Oncol 2007; 2: 706-714. 7 The International Early Lung Cancer Action Program Investigators. Survival of Patients with Stage I Lung Cancer Detected on CT Screening. N Engl J Med 2006; 355:1763-1771. 8 National lung screening trial research team, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 2011; 365: 395-409. 9 Field JK, et al. Prospects for population screening and diagnosis of lung cancer. Lancet 2013; 382: 732-741. 10 Nakamura K, et al. A phase III randomized trial of lobectomy versus limited resection for small sized peripheral non-small cell lung cancer. Jpn J ClinOncol 2010; 40: 271-274. 11 Senan S, et al. Treatment of early-stage lung cancer detected by screening: surgery or stereotactic ablative radiotherapy? Lancet Oncol 2013; 14: 270-274. 12 Venmans BJW, et al. Clinically relevant information obtained by performing autofluorescence bronchoscopy. J Bronchol 2000; 7: 118-121. 13 Breuer RHJ, et al. The natural course of preneoplastic lesions in bronchial epithelium - A longitudinal study. Clin Cancer Res 2005; 11: 537-543. 14 Venmans BJW, et al. Outcome of bronchial carcinoma in situ. Chest 2000; 117: 1572-1576. 15 Vonk-Noordegraaf A, et al.Bronchoscopic treatment of patients with intraluminal microinvasiveradiographically occult lung cancer not eligible for surgical resection: a follow-up study. Lung Cancer 2003; 39: 49-53. 16 Herth FJ, et al. Transbronchial and transoesophageal (ultrasound-guided) needle aspiration for the analysis of mediastinal lesions. EurRespir J 2006; 28: 1264-1275. 17 Silvestri GA, et al. Endoscopic ultrasound with fine-needle aspiration in the diagnosis and staging of lung cancer. Ann ThoracSurg 1996; 61: 1441-1445. 18 Wallace MB, et al. Minimally invasive endoscopic staging of suspected lung cancer. JAMA 2008; 299: 540-546. 19 Annema JT, et al. Mediastinoscopyvsendosongraphy for mediastinal nodal staging of lung cancer: a randomized trial. JAMA 2010; 304: 2245-2252. 20 Bolliger CT, et al. Therapeutic bronchoscopy with immediate effect: laser electrocautery, argon plasma coalgulation and stents. EurRespir J 2006; 27: 1258-1271. 21 Cortese DA, et al. Photodynamic therapy for early stage squamous cel carcinoma of the lung. Mayo ClinProc 1997; 72: 595-602. 22 Silvestri GA, et al Methods for staging lung cancer. Chest 2013; 143: 211S-250S. 23 Bahce I, et al. Development of [(11)C]erlotinib positron emission tomography for in vivo evaluation of EGF receptor mutational status. Clin Cancer Res. 2013; 19: 183-193.

Abstract not provided

Abstract
Systemic Therapy of Early Stage NSCLC The addition of chemotherapy to surgery before or after surgery was studied because trials in the 1970’s demonstrated that cure rates were lower than in other cancers and because the majority of relapses were in distant sites (1). Initial adjuvant studies showed no survival advantage for single agent chemotherapy. Subsequent trials in the 1980’s and 1990’s established that cisplatin based 2-drug combinations produced a modest (4-5%) improvement in 5 year survival rates but only in stages II and IIIa (2). Adjuvant therapy has not been shown to improve outcomes in Stage I with the possible exception of Stage IB tumors larger than 4 cm (3). Neoadjuvant chemotherapy produces similar improvement compared to adjuvant therapy as demonstrated by randomized trials and metaanalyses (4,5). Post-operative radiotherapy has not shown benefits in stage I and II where it may be harmful and it role in stage IIIa after surgery is under evaluation as there are conflicting data on its role in this setting (6,7).Systemic Therapy of Stage III NSCLC Combinations of radiotherapy with chemotherapy were shown to produce superior survival compared to either alone based on randomized trials conducted in the 1990’s (8). Subsequent studies indicated that concurrent chemo-radiotherapy was superior to sequential therapy (9,10). There are conflicting data on whether two or four cycles of chemotherapy is best (11). There are also conflicting data on whether triple modality therapy is superior to two modalities for Stage IIIA N2 disease (12).Systemic Therapy of Stage IV NSCLC Chemotherapeutic agents and chemotherapy combinations were tested in the 1970’s and early 1980’s but failed to show any survival advantage. Two drug combinations combining cisplatin with vindesine or vinorelbine were shown to prolong survival compared to best supportive care in the 1980’s and 1990’s (13,14). Subsequent studies showed that 2-drug platinum based combinations were superior to a single active drugs (13,15,16). The survival advantage increased median survival times from 4-5 months to 8-12 months. Two-drug combinations with a platinum combined with gemcitabine, paclitaxel, docetaxel or pemetrexed were shown to produce equivalent survival in randomized trials conducted in the 1990’s and in the 2000’s (17,18). An exception to the equivalence was the finding that the pemetrexed/cisplatin combination was superior to gemcitabine/cisplatin in non-squamous cancer but inferior in squamous cancers (19). Three and 4 drug combinations were not superior to 2 drug combinations. These 2 drug combinations were superior in patients with PS 0-1 but benefitted elderly as well as younger patients (20). There is evidence that the paclitaxel/carboplatin combination may benefit PS2 patients (21). Thus, histology and performance status are key factors in therapy selection. Since the 1990’s, docetaxel, erlotinib, and pemetrexed have been shown to prolong survival when used in the 2[nd] line setting (22-24). For pemetrexed this improvement was limited to non-squamous histology (24). Since 2000 the use of targeted therapy began with the studies of inhibitors of VEGFR and EGFR signaling. Angiogenesis inhibitors were widely studied. Bevacizumab, a monoclonal antibody to VEGF, was shown to produce promising results in a randomized phase II trial (25). However, patients with squamous cell carcinoma had excess bleeding on this study and were excluded from all further trials. An ECOG randomized trial (4599) showed that bevacizumab improved survival in non-squamous histologies when combined with platinum doublets (26). However, the survival advantage is small and is less striking in elderly patients. The survival advantage was not observed in a randomized trial from Europe using gemcitabine/cisplatin as the chemotherapy backbone (27). As noted above, the EGFR TKI erlotinib was shown to prolong survival in unselected patients failing 1 or 2 chemotherapy regimens (23). In 2004 an association between mutations in the EGFR and response to EGFR TKIs was established (28,29). Subsequent randomized trials showed that EGFR TKIs were superior to chemotherapy in 1[st] line therapy of EGFR mutant patients but chemotherapy was preferred for those without mutations (30-35). In 2007, it was shown that EML4/ALK fusions could serve as driver molecular changes in up to 5% of NSCLC’s (36). Crizotinib, an ALK TKI was shown to produce high response rates and long PFS and was superior to chemotherapy in the second line setting (37-39). Patients with ALK fusions nearly always have adenocarcinoma histology, more often are younger and female sex and are light or never smokers (40) but clinical features should not be used to determine who should be tested (41). These and other molecular drivers may be present in more than 50% of lung adenocarcinomas (42). Molecular analyses of squamous and small cell cancers have recently been described (43-46). Checkpoint inhibitors such as PD1 and PDL1 were shown to be therapeutic targets since 2010. Antibodies to PD1 and PDL1 have produced responses in about 20% of patients who had failed multiple lines of chemotherapy and many of these were durable (46,47). PDL1 expression is being evaluated as a biomarker and many trials are in progress. Maintenance therapy with continuation of the original platinum doublet was shown in many trials to be associated with an increase in the PFS, an increase in toxicity but no increase in survival and therefore this approach was not adopted (48) . In 2009, Fidias et al reported that maintenance docetaxel could increase survival as well as PFS (49). This trial was followed by a trial showing that erlotinib could improve PFS and survival as maintenance after a platinum doublet (50). PFS and survival were improved in all histologies but the improvement in PFS and OS was most striking in patients with EGFR mutations. Pemetrexed was shown to improve PFS and survival as switch maintenance after a platinum doublet that did not contain pemetrexed (51). A subsequent trial showed that pemetrexed continuation maintenance also improved PFS and OS after induction therapy with a pemetrexed/platinum doublet induction (52). An unpublished trial, (POINTBREAK), comparing pemetrexed/carboplatin/bevacizumab with pemetrexed/bevacizumab maintenance compared to paclitaxel/carboplatin/bevacizumab followed by bevacizumab, showed no difference in survival. Thus, there is no evidence at presence that maintenance should contain two drugs although the ECOG is comparing pemetrexed with bevacizumab or the combination after induction therapy with paclitaxel/carboplatin/bevacizumab.Systemic Therapy of Early Stage SCLC Patients with Stage I and IIA SCLC, although infrequent, benefit from resection and adjuvant chemotherapy and the IASLC TNM classification is more accurate than the old VA classification (53). SCLC patients with stage IIB and III (limited stage SCLC) were shown to have prolonged survival when treated with chemotherapy and radiotherapy compared to either alone (54,55). An ECOG randomized trial showed that chest RT with BID radiation to 45 Gy was superior to once daily chest RT to the same dose when combined with etoposide/cisplatin (56). However, similar results were obtained with higher total doses of once daily RT and both once daily and twice daily are in routine practice. Concurrent chemoradiotherapy is superior to sequential therapy but results with radiotherapy starting at either cycle 1 or cycle 3 are similar. The combination of etoposide/cisplatin is the most frequent chemotherapy regimen because of reduced toxicities compared to Adriamycin or other combinations. Prophylactic cranial irradiation in good responders reduces brain relapse and prolongs survival (57). 25 Gy is the preferred dose (58).Systemic Therapy for Stage IV SCLC Both cisplatin and etoposide were first tested and shown to be active in the 1970’s. Studies in the 1980’s showed that the combination of etoposide and cisplatin produced high response rates (80%) with some complete responses (10-15% (59, 60). These results lead to randomized trials comparing etoposide/cisplatin to CAV, CAE or alternating combinations. Etoposide/cisplatin (EP) produced equivalent efficacy with less toxicity (60,61) and thus became the standard combination in the 1990’s. Pemetrexed/carboplatin was compared to etoposide/carboplatin and was inferior (62). Several trials have shown that irinotecan combined with cisplatin or carboplatin is equivalent to etoposide with cisplatin or carboplatin (63, 64). Thus EP remains the standard today. Topotecan is approved for used in the second line setting albeit at a dose and schedule rarely used due to toxicity (65,66). Both oral and intravenous topotecan produce similar results. Topotecan improved PFS as maintenance but did not improve survival and increased toxicity (67). Thus, use in the maintenance setting was not widely adopted. Retreatment with EP for those with late relapse has been the most successful retreatment approach and is standard in this setting (68). After 2000, randomized trials showed that PCI after induction response could prolong survival in extensive stage as well as limited stage SCLC and as now used routinely in this setting (69). There has been little change in chemotherapy options for SCLC over the past 20 years but there is some hope that the immune checkpoint inhibitors could improve outcomes (70).

Background
Many studies in the literature have suggested that gene expression biomarkers may guide patient classification and clinical management in NSCLC. Despite minimal external validation and no clinical trial evidence, gene expression biomarker panels have been proposed as tools for making treatment decisions. Recent controversy surrounding the validity of such data and its potential applicability to clinical practice led us to perform an external validation study of published gene expression biomarker panels.

Methods
We performed gene expression profiling for a total of 209 patients with both Affymetrix whole transcriptome U133Plus2 arrays in addition to a NSCLC-specific array constructed by our group for assessment of mRNA expression in frozen tumor specimens of NSCLC. Clinical outcome data were collected and analyzed for correlations of gene expression with disease-free and overall survival. Cox proportional hazard models were used to test significance of individual genes and for gene sets defined by each panel. Panels tested included those previously published from Michigan, Mayo Clinic, Taiwan, Toronto, and UCSF.

Results
Expression profiling data were generated for a total of 209 patients with NSCLC. This included U133Plus2 arrays of 242 tumor samples and 105 matched surrounding normal lung tissue, as well as 111 tumor profiles using the NSCLC-specific array. There were 98 women and 111 men in the study cohort, with 120 patients having Stage I NSCLC (57.4%), 38 with Stage II (18.2%), 50 with Stage III (23.9%), and one patient with Stage IV disease (0.5%). Mean follow-up time after surgical resection was 62.4 ± 48 months. Seventy-four patients (35.1%) developed post-resection recurrence after a mean of 53.3 ± 49.3 months, of which 62 patients died (83.8%). Known clinical predictors such as TNM stage, histology, and tumor grade were predictive of survival. Although many genes within the published biomarker panels were significantly correlated with disease-free and overall survival, none provided additive prognostic value beyond standard clinical predictors.

Conclusion
Although a number of individual gene expression biomarkers have prognostic significance in univariate models, published biomarker panels perform poorly in external validation studies such as this. The additive prognostic value beyond standard, known clinical predictors in the TNM staging system casts doubt as to whether such information will be useful in clinical practice. Despite the success of gene expression biomarkers for molecular subtyping in other cancers, our data suggests that this information has a low likelihood of clinical translation in NSCLC for unselected patients.

Background
Somatic mutations and gene fusions have been identified as oncogenic drivers in lung cancer, however, a number of lung cancers have no apparent molecular aberration driving oncogenesis. It appears that gene/protein overexpression may sustain these “pan-negative” cancers. Fibroblast growth factors (FGFs) and their receptors (FGFRs) regulate cell proliferation, differentiation, migration and survival and dysregulation of this signaling pathway is observed in a proportion of lung cancers. A number of compounds targeting FGF/FGFR are in clinical development but clinically applicable biomarker assays and companion diagnostics that accurately identify patients with tumors sensitive to these agents are needed. We previously presented cell line data demonstrating that FGFR1 mRNA (ME) or protein expression (PE) better identified FGFR1 inhibitor sensitive tumors compared to gene copy number (GCN). The goal of this study was to examine FGFR1 ME, PE and GCN in a surgically treated NSCLC clinical cohort and explore possible associations with clinical features and prognosis.

Methods
Immunohistochemistry, brightfield in situ hybridization, and silver in situ hybridization were used to investigate ME, PE and GCN, respectively, in a cohort of 189 NSCLC surgically-treated patients. PE was scored by the H-score method (0-300) and ME on a semiquantative integer scale (0-4+), both evaluating the entire tumor specimen. GCN was scored on continuous scale by counting the individual signals in 50 cells and determining the average GCN per tumor cell.

Results
Amplification (GCN >=4) was present in 8% of the entire cohort and in 11% of the squamous cell carcinoma (SCC) or mixed histology subgroup. No amplifications were found in the adenocarcinomas (ADC) or tumors from never smokers. In contrast, 29% of SCC and ADC patients had high ME (= 4+). Elevated PE (>= 100) was observed in 20% of the cohort, with the highest expression observed in SCC/mixed histology, but 6% of ADCs also showed elevated PE. There was no elevated FGFR1 PE in the never smokers. There was significant correlation but incomplete overlap between biomarkers. There were no prognostic associations, either with overall or disease-free survival, for FGFR1 GCN, ME, or PE. There was excellent inter-observer agreement among the readers of all 3 biomarker assays.

Conclusion
Overexpression of FGFR1 mRNA and protein are more frequent than FGFR1 gene amplification in NSCLC patients. Although GCN amplification was restricted to SCC, elevated ME and PE were found in both ADC and SCC. There was no prognostic association with FGFR1 GCN, ME, or PE. These data are consistent with our previous cell line data that showed elevated PE and ME in non-amplified cells and suggests that GCN may not identify all the potential patients who could benefit from FGF/FGFR pathway inhibitors.

Background
To date, no personalized decision-making tool exists for adjuvant radiation after resection of non-small cell lung cancer (NSCLC). Our objective was to retrospectively determine if our previously developed 10-gene expression signature, called radiosensitivity index (RSI), would classify patients into radioresistant (RSI-poor) or radiosensitive (RSI-good) using disease-free survival (DFS).

Methods
Inclusion criteria: pathologic AJCC v6 stage III NSCLC at time of resection, negative margins, at a single institution between 2000 and 2012. Neo or adjuvant chemotherapy was required. For radiation group (RT), at least 45 Gy of conformal or intensity-modulated radiation was required. An identical stage group (control) did not receive radiation. Gene expression profiling was conducted on primary lung tumor mRNA. DFS was defined as time-to-recurrence or death from any cause. Predefined cut-point was lowest quartile of calculated RSI. Two-sided log-rank and Cox regression were used.

Results
Of 144 screened, 95 were eligible (53 RT and 42 control). Demographics: median age 67 yrs, 54% female, 96% white, and 91% current / former smokers. Operations consisted of 56% lobectomy, 26% pneumonectomy, and 18% segmentectomy/wedge. Adjuvant doublet consisted of 48% taxane, 32% gemcitabine, or 20% other. Mean RT dose 54.8 Gy, median follow-up 3.5 yrs. Histology: 64% adenoca, 25% squamous, 10% large-cell. Mean tumor volume 58 cm[3], 77% were pN2, 58% had angiolymphatic invasion and 51% were poorly-differentiated. Mean preoperative PET SUV~max~ was 9.5. No imbalance in clinical factors were observed between RSI-good vs. RSI-poor. On univariate analysis, for RT group, median DFS for RSI-good vs RSI-poor was 5.8 yrs vs. 1.4 yrs, HR 4.2 (95% CI 1.9 – 9.5), p = 0.017. 5-year DFS was 63% vs 22%, p = 0.01. No significant difference was observed for the chemo-only control group, with median DFS for RSI-good vs. RSI-poor: 2.3 vs 2.7 yrs, HR 0.7 (95% CI 0.3 – 1.6), p = 0.98. A test for interaction confirmed that the effect was restricted to the RT group and not the control, with p = 0.04. On multivariate analysis, for the RT group, the RSI was more strongly associated with DFS than any other variable (age, gender, tumor volume, nodal status, baseline SUV~max~, histology, grade, LVI, and operation). After inclusion of covariates, it remained an independent predictive variable with HR 3.8 (95% CI 1.6 – 9.2) p = 0.003. Figure 1

Conclusion
RSI appears to be predictive for benefit from adjuvant radiation. Additional independent prospective validation is required.

Background
Therapies targeting tumor angiogenesis, such as anti-VEGF antibodies (bevacizumab), are a major step in the treatment of non small cell lung cancer (NSCLC) but are costly drugs and may be responsible for significant toxicities. The goal of our study was to assess the value of non-invasive tools evaluating early the response to bevacizumab in NSCLC.

Methods
56 consecutive patients with stage IIIB-IV non-squamous NSCLC were prospectively recruited. According to multidisciplinary committee advice, one group of patients (bevacizumab group, n =24) had a chemotherapy combined with bevacizumab, the second one (control group, n = 32) had a similar chemotherapy but without bevacizumab. Quantitative tumor perfusion was sequentially evaluated with CT-scan before (T0) and after 1 cycle (T1) and 3 cycles (T2) of chemotherapy. CT-scan parameters included: (a) tumor height and diameter; (b) tumoral blood volume (BV) and capillary permeability (CP). Blood biomarkers (Endocan, VEGF, Angiopoïetin-2, VEGFR-2, VE-cadherin) were measured at the same time points.

Results
We observed an early and quite specific decrease of BV, CP and blood levels of VEGF, Angiopoïetin-2 and VE-cadherin in the bevacizumab group compared to control group. In the bevacizumab group, the decrease of BV between T0 and T1 was more important in patients responding to treatment than in subjects with progression on clinical (ΔBVT0-1 =-2.72ml vs 0.32ml, p=0.004) or RECIST criteria (ΔBVT0-1 =-3.35ml vs 0.04ml, p=0.011). An initial high Endocan level appeared as a marker of bad prognosis (overall survival) (HR=1.469 [1.120-1.925]; p=0.005) using a cut-off value of 0.72ng/ml (HR=2.276 [1.074-4.82]; p=0.032). Moreover, in the bevacizumab group, a significant decrease of Endocan level between T0 and T1 was a marker of good prognosis (HR=0.141 [0.022-0.889]; p=0.037).

Conclusion
Whole tumor perfusion analysis by CT-scan exhibited a promising predictive value for patients treated by chemotherapy combined with anti-angiogenic drug, whereas blood Endocan appeared as the most interesting blood marker, having a significant prognostic value in the same patients. These two exciting non-invasive tools deserve further and larger studies to confirm their value in monitoring NSCLC patients with therapies targeting tumor angiogenesis.

Background
Lung cancer is the leading cause of death from cancer for both men and women in the United States with a 5-year survival rate of approximately 15%. Many gene expression microarray datasets have been collected through different studies, while a single genomics study usually contains no more than 500 microarrays due to the high cost. We collected and manually curated mRNA expression microarrays together with clinical information for 5,218 lung cancer patients from 40 studies. The wealth of these large-scale datasets provides us great opportunities to generate significant scientific findings, while also posing great challenges for data integration.

Methods
To facilitate clinicians and researchers to access and use the resource, we developed an open web portal, The Lung Cancer Explorer, to explore gene expression and clinical associations in lung cancer. This database aggregates over 40 public clinically-annotated lung cancer gene expression studies, along with some private data from the University of Texas Southwestern Medical Center, and presents a user-friendly, web-based interface to explore and analyze this data. The database stores various information about patients including demographics, histology, stage classifications, clinical outcomes, and also stores the probe-level genome-wide mRNA expression information, allowing users to perform very rich analysis on the data.

Results
From the user’s perspective, usage is as easy as logging in and clicking a button to perform any of our current analysis functions: · Survival Analysis: Test the association between the gene expression level and patients’ overall survival time in one study. · Meta-Survival Analysis: Summarize the association between the gene expression level and patients’ overall survival time across multiple studies. · Comparative Analysis: Test the association between the gene expression level and patients’ characteristics, such as gender, age, histology types, disease stages, etc. · Tumor vs. Normal: Test whether the gene expression levels different significantly between tumor samples and normal samples. · Co-expression analysis: Calculate the correlations among a list of user-specified genes based on the gene expression levels. The web application is now online and available for usage: http://qbrc.swmed.edu/lce/ . I will talk about the data curation, quality control, database development and the usage of this resource.

Conclusion
The Lung Cancer Explorer is a highly interactive open resource for lung cancer research and it can greatly facilitate the translational lung cancer research.

Abstract not provided

Background
Nomogram is a recognized method for individually predicting prognosis of cancer patients through combining various significant prognostic factors. Although the prognostic value of molecular biomarkers has been well studied, previous published nomograms are basically built based on only clinical factors. We sought to combine the clinicopathologic variables with the molecular markers to develop a more precise nomogram for predicting survival for early stage NSCLC patient who underwent surgery.

Methods
Based on data from the China Clinical Trials Consortium (CCTC) that included 1038 patients with resected NSCLC for whom the 14-gene molecular assay (BAG1, BRCA1, CDC6, CDK2AP1, ERBB3, FUT3, iL11, LCK, RND3, SH3BGR, WNT3A with ESD, TBP and YAP as internal reference) was tested, we conducted multivariate stepwise Cox regression analyses to identify significant factors which were then integrated to establish the nomogram. Nomogram based on clinicopathologic variables only (c-nomogram) or both clinical and molecular factors (cm-nomogram) were established respectively. Eighty percents of randomly sampled data were used to build the nomogram while the remaining data were used to validate it. The predictive accuracy and discriminative ability of the nomogram was determined by concordance index (C-index). Risk group stratification within a certain stage was proposed for the nomograms.

Results
We identified 15 independent prognostic factors, including 7 clinicopathologic variables (age, sex, histology, differentiation, tumor location, T and N stage) and 8 genes (with only CDK2AP1, FUT3, iL11, BAG1, CDC6, and RND3 were selected), then incorporated them to build the nomogram (Figure 1). The calibration curves for probability of 1, 3, 5-year overall survival (OS) showed good concordance between prediction by nomograms and actual observation in the validation set. The C-index of the cm-nomogram was statistically higher than that of the 7[th] edition TNM stage for predicting survival (0.72 vs 0.66, P=0.02) whereas the c-nomgram did not show superior performance than TNM stage system (0.69 vs 0.66, P=0.463). The stratification into three risk groups according to cm-nomogram allows significant distinction between Kaplan-Meier curves in each TNM stage respectively (P<0.01 for all stages, Figure 2).Figure 1

Conclusion
We developed a novel and validated nomogram that combines clinicopathologic factors and molecular markers, which provided more accurate predictions for OS of resected NSCLC patients compared with the TNM staging system and nomogram considering only clinical variables. This prognostic model lent support to clinicians and patients in decision making. In addition, it indicated that it is feasible and essential to incorporate molecular markers when building a nomogram to obtain more accurate prediction.

Background
Approximately 35%-40% of NSCLC have locally advanced disease. The average survival time of these patients only have 6-8 months with chemotherapy and radiotherapy. The aim of this study is to explore and summarize the probability of molecular biomarker detection in cancer tissues, mediastinal lymph nodes and peripheral blood for molecular stages and types of lung cancer, and for individual surgical treatment and postoperative adjuvant therapy and for prediction of postoperative recurrence of lung cancer in stage III disease; to summarize the long-time survival result of personalized surgical treatment of 1036 patients with LANSCLC based on molecular biomarker detection.

Methods
CK19 and Muc-1 mRNA expression of peripheral blood was detected in 1036 patients by RT-PCR before and after operation for individual molecular staging and personalized surgical treatment and postoperative adjuvant therapy. micro-RNA and gene chips were used to detect the differential micro-RNAs and gene profiles between the primary cancer tissues and metastatic mediastianl lymph nodes for individual postoperative adjuvant therapy and prediction of prognosis of the patients with LANSCLC. The long-term survival of personalized surgical treatment was retrospectively analyzed in the 1036 patients based on molecular staging and typing.

Results
There were 678 squamous cell carcinoma and 358 adenocarcinoma. 212 patients had IIIA disease and 824 had IIIB disease according to P-TNM staging. 126 patients had M-IIIA disease, 603 had M-IIIB disease and 307 had M-IV disease according to molecular staging. Of the 1036 patients, bronchoplastic procedures and pulmonary artery reconstruction was carried out in 356 cases; double sleeve lobectomy combined with resection and reconstruction of partial left atrium, superior vena cava, carina, aorta and postcava was performed in 680 cases in this series. Thirteen patients died of operative complications and the operative mortality was 1.16%. CK19 and Muc-1 mRNA positive expression in peripheral blood was found in 265(25.6%) patients. The differential micro-RNAs and gene profiles between the primary cancer and metastatic mediastinal lymph nodes divide the 1036 patients into high and low recurrence risk groups. The median survival time was 51.74 months. The 1, 3, 5 and 10 year survival rates of the 1036 cases was 81.1%, 49.3%, 30.8% and 21.4%, respectively.The postoperative survival rate was remarkably correlated with individual molecular staging and typing, micrometastasis, histological classification and size of primary cancer and LN metastasis (P<0.05). Multivariable Cox model analysis showed that “personalized molecular staging”, micrometastasis, the differential micro-RNAs and gene profiles and mediastinal lymph node metastasis were the most significant factors for predicting prognosis in the patients with LANSCLC.

Conclusion
Detection of micrometastasis in peripheral blood will be helpful for individual surgical treatment and postoperative adjuvant therapy in LANSCLC patients. The differential micro-RNAs and gene profiles can predict the recurrence and prognosis of the cancer. Individualized surgical treatment can significantly improve prognosis and increase curative rate and long-term survival rate of LANSCLC based on personalized molecular staging and typing.

Background
Numerous diagnostic and prognostic molecular markers have been proposed for lung cancer. However, genetic heterogeneity has limited the success of these initiatives. This limitation may be overcome by the use of biomarkers related to the host response to cancer. In this study we tested the capacity of lung cancer cells to activate the complement system and evaluated the diagnostic performance of complement-activation fragments. We demonstrate for the first time that lung cancer cells efficiently activate the classical complement pathway and that fragments of complement activation are of value for detection and prognosis of lung cancer at a very early stage.

Methods
We first assessed complement activation in bronchial epithelial and lung cancer cell lines. C4d, a degradation product of complement activation, was determined in 90 primary lung tumors; in bronchoalveolar lavage supernatants from 50 patients with lung cancer and 22 non-malignant respiratory diseases; and in plasma samples from different cohorts, including: advanced (n=133) and early (n=84) non-small cell lung cancer patients, subjects with inflammatory lung diseases (n=133) and asymptomatic individuals enrolled in a lung cancer CT-screening program (n=190; 32 of them with lung cancer).

Results
Lung cancer cells treated with normal human serum activated complement and deposited C3 more efficiently than non-malignant bronchial epithelial cells. Incubation of cells with different buffer conditions, complement depleted sera and complement inhibitors showed that lung cancer cells bind C1q and activate complement through the classical complement pathway. In a set of lung cancer cell lines, a significant correlation was found between C1q binding and C4 or C3 deposition. The presence of phosphatidylserine inhibited C1q binding and diminished complement activation. Based on these results, C4d, a classical pathway-derived split product, was evaluated as a possible diagnostic or prognostic biomarker in lung cancer. Many lung primary tumors (adenocarcinomas and squamous cell carcinomas) deposited C4d. More importantly, survival was decreased in patients with high C4d deposition in their tumors (HR=3.06; 95% CI=1.18-7.91). Moreover, C4d levels were increased in bronchoalveolar lavage fluid from lung cancer patients as compared to patients with non-malignant respiratory diseases (0.61 ± 0.87 vs. 0.16 ± 0.11 µg/ml, respectively; P<0.001). C4d levels in plasma samples from lung cancer patients at both advanced (III and IV) and early (I and II) stages were also increased compared with control subjects (4.13 ± 2.02 vs. 1.86 ± 0.95 µg/ml, P<0.001; and 3.18 ± 3.20 vs. 1.13 ± 0.69 µg/ml, P<0.001, respectively). In addition, C4d plasma levels were associated with shorter survival in patients at advanced (HR=1.59; 95% CI=0.97-2.60) and early stages (HR=5.57; 95% CI=1.60-19.39). Plasma C4d levels were dramatically reduced after surgical removal of lung tumors. Finally, plasma C4d levels were associated with increased lung cancer risk in asymptomatic individuals: OR=4.38; 95% CI=1.61-11.93.

Conclusion
Lung tumors activate the classical complement pathway and generate C4d, a stable complement split product. Moreover, C4d is increased in biological samples from lung cancer patients, is associated with poor prognosis, and may be of clinical value for the early detection of lung cancer.

Background
In vitro data and early clinical results suggest that metformin, an agent commonly used in diabetes therapy, has direct cancer growth inhibition potential via mammalian target of rapamycin (mTOR) pathway suppression. Furthermore, a number of observational studies have associated lower cancer incidence and a lower risk of nonspecific cancer-related mortality with metformin use. Our first objective is to determine whether the use of metformin is associated with improved local recurrence (LRR) and overall survival (OS) rates in diabetic patients with non-small cell lung cancer (NSCLC) treated with definitive chemoradiation. Based on encouraging retrospective clinical results, we moved on to establish an in-vivo murine model of lung cancer and to evaluate the tumor growth delay from using metformin as a radiosensitizing agent.

Methods
Data from 760 consecutive patient treatment courses from our institution for patients with NSCLC and small cell lung cancer treated with radiation therapy between 6/2008 and 6/2013 were analyzed. All patients with diabetes and stage IIIA and IIIB NSCLC who received metformin during definitive radiotherapy were analyzed to determine clinical outcomes. For the in-vivo murine study, H1299 adenocarcinoma cells were injected in the flanks of nude mice for the subcutaneous tumor model. On day 2, mice began receiving daily intraperitoneal injection of metformin or vehicle for 5 days, after which they underwent irradiation to the flanks of 3Gy X 3 fractions. Tumor measurements were taken every other day and tumor growth delay was plotted. In order to assess the effect of metformin in the lungs as well as in-situ tumor effects, an orthotopic mouse model using bioluminiscence imaging (BLI) will be developed to allow serial lung tumor measurements as well as assessment of metformin effects on the normal lung when combined with irradiation.

Results
Of 760 patient treatment courses analyzed, 16 distinct patients with stage III NSCLC were identified that received metformin for diabetes while undergoing definitive chemoradiation. Patients were predominantly female (63%) and had stage IIIA disease (69%). They were treated to a median of 66.6/1.8 Gy with concurrent (81%) or sequential (19%) chemotherapy.A dramatic improvement in LLR in patients receiving metformin was seen compared to historical controls. With a median follow-up time of 10.4 months, only 2 local recurrences (9.6 and 14.9 months post-radiotherapy) have occurred. The median disease-free survival and OS have not been reached. From our in vivo murine data, early data supports the use of metformin as a radiosensitizing agent in the treatment of locally advanced NSCLC.

Conclusion
Our clinical experience demonstrates patients receiving definitive chemoradiation for stage III NSCLC who took metformin for diabetes had improved local control and OS compared with our patients not taking metformin and compared with historical controls. Additional evidence is needed to supporting radiation potentiation effects of metformin in the setting of definitive chemoradiation for locally advanced NSCLC patients. Such findings, along with our clinical retrospective data, will lead to institutional prospective clinical trials, for the first-time, using metformin as a radiosensitizing agent in combination with radiation therapy and chemotherapy in the treatment of lung and potentially other cancers.

Background
BRM, an ATPase subunit of the SWI/SNF chromatin remodeling complex, is a putative tumor susceptibility gene in lung cancer. Loss of BRM expression occurs in 15% of lung cancers. Two BRM promoter insertion polymorphisms (BRM-741 and BRM-1321) lead to epigenetic silencing of BRM and highly correlate with loss of BRM expression and function in lung tumors. Pharmacologic reversal of the epigenetic changes of BRM is feasible. We previously demonstrated a strong risk association between these two polymorphisms and susceptibility to early stage NSCLC. Here, we evaluate the association between the two BRM polymorphisms and risk of developing: 1) advanced NSCLC, and 2) SCLC among smokers.

Methods
Genotyping for BRM promoter polymorphisms was performed using TaqMan. The cohorts analyzed were: 1) 417 stage III-IV NSCLC cases and 2) 111 SCLC cases treated at the Princess Margaret Cancer Centre (PMCC), Toronto; and 3) 43 SCLC cases from the University of Florida (U of F), all with a smoking history of ≥1 pack-year. Cases were matched to healthy controls by frequency distribution (1:2 for PMCC cases; 1:1 for U of F cases) based on age, gender, pack-year smoking history, and either current smoking status (PMCC) or ethnicity (U of F). Adjusted odds ratios (aORs) with their 95% confidence intervals (CI) of the association between polymorphisms and lung cancer risk were estimated by multiple logistic regression models.

Results
Of the 417 NSCLC cases, 59% were male; 41%, current smokers; 63%, adenocarcinoma; 51%, stage IV; median age, 63 years. The frequency of homozygosity was BRM-741, 21%; BRM-1321, 20%; both, 11%. The homozygous variants of BRM-741 and BRM-1321 were associated with an increased risk of advanced NSCLC compared to the wild types, with aOR’s of 1.6 (95% CI: 1.1-2.2; p=0.008) and 1.4 (95% CI: 1.0-2.0; p=0.04), respectively. Being homozygous for both BRM promoter variants carried an even greater risk (aOR 2.4 [95% CI: 1.4-4.0; p=0.0009]), with the strongest effect observed among current smokers (aOR 3.4; p=0.0005), and those with a histological diagnosis other than adenocarcinoma (aOR 3.2; p=0.0005). Among the 111 PMCC SCLC cases, 62% were male; 56%, current smokers; median age 65 years; of the 43 U of F SCLC cases, 35% were male; median age, 63 years. The presence of double homozygous variants of BRM-741 and BRM-1321 had no effect on the risk of developing SCLC in either of the two cohorts analyzed, with aOR’s of 1.1 (95% CI: 0.3-3.5; p=0.94) and 0.3 [95% CI: 0.04-2.41; p=0.27), respectively.

Conclusion
The presence of double homozygous variants of the BRM promoter polymorphisms, BRM-741 and BRM-1321, significantly increases the risk of advanced NSCLC among individuals with a smoking history greater than one year, with the strongest effect observed among current smokers. In contrast, the same two polymorphisms had no effect on the risk of developing SCLC in either of the two cohorts analyzed. Thus, this study offers further insight into potential mechanisms underlying the genetic susceptibility to developing advanced NSCLC among smokers. Validation in larger populations is warranted.

Abstract not provided

Background
Oncogenic driver alterations identify several types of lung adenocarcinoma with different prognosis and sensitivity to targeted agents. MicroRNAs (miRNAs) are a new class of non-coding RNAs involved in gene expression regulation. How miRNAs are dysregulated in lung cancer with ALK translocation, EGFR or KRAS mutation is largely unknown. In the present analysis we aimed to investigate miRNAs expression according to a specific molecular driver and to correlate miRNAs deregulation with patient outcome.

Methods
The study was conducted in a cohort of 67 lung adenocarcinoma patients (pts) including 17 ALK+ tumors, 11 ALK-/EGFR mutation+, 15 ALK-/KRAS mutation+, 24 ALK-/EGFR and KRAS wild-type and defined as triple negative cases. Matched normal lung tissues from 18 cases representative of the entire cohort were also included onto the analysis. RNA was isolated from formalin-fixed paraffin-embedded tissue (FFPE), using the Recover ALL kit (Ambion). NanoString nCounter system platform was used to generate the miRNA profile. We used Limma to test for differential expression analysis of data. Among the miRNAs evaluated, the miR-515 family expression between tissues was validated by RT-qPCRs, analyzed using the parametric t-test (unpaired, 2-tailed for validation).

Results
miRNA expression profile clusters distinctly ALK+ pts from ALK- and normal lung tissue. Within the ALK- group we found specific miRNAs subsets able to sub-stratify KRAS versus EGFR careers clustering sharply triple negative versus EGFR mutation+ and triple negative versus KRAS mutation+. miRNAs belonging to the miR-515 family seems to be the most deregulated in the ALK+ versus ALK-. Although their expression is stably high in normal tissues and ALK+ class, they are highly downregulated in KRAS mutated versus EGFR mutated and versus triple negative (p-value <0.001 for all comparisons).

Conclusion
miRNAs profile significantly differs in lung cancer pts with ALK translocation, EGFR mutations and KRAS mutations. Putative targets of deregulated miRNAs are under investigation to better define differences in driver-dependent pathway activation.

Background
Immunosuppressive regulatory T lymphocytes (Tregs) have been proved to play a critical role in immune tolerance to tumor. In this study we have analyzed several markers related to Tregs, in both tumor and stroma areas in patients with resectable NSCLC.

Methods
Tumor FFPE samples from 135 early-stage NSCLC patients were used in this retrospective study. The most representative areas of tumor cells and tumor stroma of each sample were carefully micro-dissected. RTqPCR using hydrolysis probes was performed to determine the expression of Treg markers such as: CD127, CD25, FOXP3, CTLA-4, IL-10, TGFB-1, LAG-3, GITR and TNF-a as well as CD4 and CD8. Relative gene expression was assessed using GAPDH and CDKN1B as endogenous controls and results were normalized against a human cDNA as a reference. FOXP3 protein expression was assessed by immunohistochemistry, in 80 of the 135 patients included in this study. The absolute number of FOXP3-positive lymphocytes was determined in both tumor and stroma areas by averaging the cell counts in 10 fields (400X). All statistical analyses were considered significant at p< 0.05.

Results
Gene expression analyses revealed an over-expression of CD25 (5.40X and 7.95X, respectively) and down-expression of CD127 (0.28X and 0.37X, respectively) in both, tumor and stroma. There was a tendency toward higher expression of FOXP3 (1.67X and 2.01X, respectively) and CTLA-4 (1.92X and 1.76X, respectively) as well. Paired Wilcoxon test showed significant gene expression differences between tumor and stroma in FOXP3 (p=0.006), CD25 (p<0.0001), CD4 (p<0.0001), CD8 (p=0.028), IL-10 (p<0.0001) and TGFB-1 (p<0.0001). Survival analyses revealed that patients with a “Treg profile” (↑CD25/↓CD127) had a reduced overall survival (OS), whilst those patients with higher levels of the ratio FOXP3 stroma/tumor had worse time to progression (TTP) (Table 1). Spearman test revealed a significant association between stromal FOXP3 expression levels and the number of FOXP3-positive lymphocytes (by IHC) in stroma, p=0.006. Moreover, chi-square test showed that patients with squamous cell carcinoma histology presented a higher number of FOXP3-positive lymphocytes than those patients with adenocarcinoma, p= 0.035. Table 1: OS for “Treg profile” and TTP for Ratio FOXP3 Stroma/Tumor

	OS
	Median (months)	95% CI	p
Others	74.33	65.96 - 82.69	0.003
"Treg profile"	29.90	4.91 - 6.54
	TTP
	Median (months)	95% CI	p
↓ Ratio FOXP3 Stroma/Tumor	NR	--	0.040
↑ Ratio FOXP3 Stroma/Tumor	32.50	16.25- 48.74

Conclusion
Gene expression of Treg markers in tumor microenvironment seem to play an important prognostic role in early-stage NSCLC patients. Furthermore, preliminary IHC analysis indicated a correlation between mRNA and protein levels for FOXP3 in NSCLC patients. Supported in part, by grants PS09/01149, RD06/0020/1024 and RD12/0036/0025 from Red Temática de Investigación Cooperativa en Cáncer, Instituto de Salud Carlos III (ISCIII).

Background
Estrogen receptor pathway has been reported to be interacted with epidermal growth factor receptor (EGFR) signal pathway. This study focused on the impact of intracellular ERβ localization (cytoplasmic or nuclear) on the efficacy of EGFR-TKI.

Methods
Tumor tissue specimens from 149 stage IV NSCLC patients treated with EGFR-TKI were analyzed using immunohistochemistry (IHC) for ER expression (ERαorβ) and their associations with clinicopathological variables and clinical outcomes. Significance of cyto-ERβ expression was further examined in NSCLC cell lines.

Results
The expression of ERα and ERβ was detected in 15% and 28.9% of the patients, respectively. Cyto-ERβ positive cases showed shortened progression free survival (PFS) compared with cyto- ERβ negative ones (3.1 months vs. 7.3 months, p=0.061). In the subgroup with concurrent EGFR mutation, the differences of PFS were enlarged with significant statistics (4.7 months vs. 10.9 months, p=0.042). COX’s proportional hazard model showed that female, EGFR mutation and c- ERβ negative expression were independent predictive factors for PFS. PC-9 cells present ERβ in cytoplasma as well as nucleus. Estrodial (E2) induced PC-9 cells moderately resistant to erlotinib with a 3-fold increase of IC50, and the resistance can be reversed by ER blocker (fulvestrant) or siRNA directed to ESR2. The function of E2 was accomplished by nongenomic activation (MAPK phosphorylation) caused by E2 via cyto- ERβ. Combination therapy with erlotinib and fulvestrant turned out to be far more effective than either treatment alone in PC-9 cells. Furthermore, 2 patients harboring both EGFR mutation and cyto-ERβ expression underwent PD of EGFR-TKIs, and re-obtained disease control after receiving combined EGFR-TKIs with fulvestrant.

Conclusion
Cyto-ERβ expression may predict relatively poor efficacy to EGFR-TKI compared with non- cyto-ERβ expression in NSCLC patients harboring EGFR mutation.

Background
Recent studies have demonstrated the feasibility of rebiopsy in patients (pts) with EGFR mutant NSCLC at the time of AR to the EGFR tyrosine kinase inhibitors (TKIs) erlotinib or gefitinib, and provide estimates of the prevalence of well described mechanisms of AR including the EGFR T790M mutation, MET amplification and small cell lung cancer (SCLC) transformation. HER2 amplification has also been described in cases of AR to EGFR TKIs, however, its exact frequency is still unclear. Moreover, comprehensive analysis of paired pre- and post-treatment samples to establish whether HER2 amplification is acquired during treatment with TKIs have not been performed. This prompted us to further investigate HER2 amplification in EGFR mutant NSCLC cases.

Methods
Pts with metastatic or recurrent NSCLC who developed AR while on a molecularly targeted agent were enrolled on an IRB approved repeat biopsy protocol. Tumor biopsies were obtained at the time of AR, and histopathological and molecular analyses of the tumors were performed. Known mechanisms of AR to EGFR TKIs were analyzed (T790M mutation, MET amplification and SCLC transformation) as well as amplification of HER2. The presence of T790M was assessed either by Taqman or pyro-sequencing (unless T790M status was available from an outside institution). HER2 and MET amplification were determined using fluorescence in situ hybridization (FISH).

Results
41 pts with AR to EGFR TKIs (erlotinib or gefitinib) were enrolled at YCC between Jan 2012 and May 2013. Histological analysis of all specimens revealed transformation of adenocarcinoma to SCLC in 3 cases (7%). Depending on the availability of tissue, samples were prioritized for T790M analysis followed by MET and HER2 amplification. T790M was identified in 36% of pts; MET and HER2 amplification were found in 11% and 10% of samples respectively. In the two cases with HER2 amplification, analysis of the pre-treatment specimen revealed that amplification of this receptor tyrosine kinase preceded treatment with EGFR-TKIs, however, the amplification level was lower pre-treatment in both cases. Specifically the ratio of HER2 to CEP17 probes was 2.8 pre-treatment in both cases and increased to 4.3 and 8 following TKI treatment. HER2 amplification was mutually exclusive with the other tested mechanisms of resistance.

Conclusion
T790M was the most commonly identified mechanism of AR to EGFR TKIs in the YCC cohort consistent with other studies. MET amplification, HER2 amplification and SCLC transformation were also observed. The observation that HER2 was amplified pre-treatment warrants further investigation of HER2 amplification in AR and pre-treatment specimens. Whole exome sequencing of specimens without known resistance mechanisms is ongoing.

Abstract not provided

Background
Epidermal growth factor receptor (EGFR) exon 20 insertion mutations account for ~10% of EGFR-mutated non-small-cell lung cancer (NSCLC), for the most part occur at the N-lobe of EGFR after its C-helix (after amino-acid M766) and have unsolved patterns of response to ATP-mimetic EGFR tyrosine kinase inhibitors (TKIs).

Methods
To understand the patterns of resistance or response to EGFR TKIs of EGFR exon 20 insertion mutations, we decided to study representative mutations using in vitro systems, structural models and also NSCLCs with these specific EGFR mutations.

Results
We selected three mutations located within the C-helix (A763_Y764insFQEA [identical to D761_E762insEAFQ], Y764_V765insHH and M766_A767insAI) and four mutations following the C-helix (A767_V769dupASV [identical to V769_D770insASV], D770_N771insNPG, D770_N771insSVD [identical to S768_D770dupSVD] and H773_V774insH [identical to P772_H773insH]) mutations. Our data indicates almost all EGFR exon 20 insertions are resistant to submicromolar concentrations of gefitinib or erlotinib; data that mirrors the lack of clinical response of NSCLCs with these mutations. The crystal structural and enzyme kinetic studies of a prototypical post C-helix EGFR TKI-resistant insertion, between residues D770_N771 (D770_N771insNPG), highlight that these mutations favor the active conformation (i.e., are activating), don’t alter EGFR’s ATP-binding pocket and are less sensitive than TKI-sensitive mutations. D770_N771insNPG is predicted to be 7.66 fold less sensitive than the TKI-sensitive EGFR-L858R. Unexpectedly, we identified the atypical EGFR-A763_Y764insFQEA as the only EGFR exon 20 insertion hypersensitive to EGFR TKIs using enzyme kinetic and cell line models. In patients with EGFR exon 20 mutated NSCLCs, the response rates to gefitinib or erlotinib were significantly higher for A763_Y764insFQEA (2/3; 66.6%) when compared to all other mutations within or following the C-helix (0/17, 0%; p=0.0158). The unorthodox homology model of A763_Y764insFQEA suggests a mechanism of activation (by shifting the register of the C-helix N-terminal) related to TKI-sensitive mutations (such as L858R or L861Q).

Conclusion
Our findings not only explain the intricate interplay between different EGFR mutations and their response to EGFR TKIs, but also have clinical implications for the treatment of EGFR exon 20 insertion mutated NSCLCs. Therefore, based on our data and previously published reports the aforementioned mutations affecting amino acids V765 to V774 should be classified as non-sensitizing to the reversible EGFR TKIs gefitinib and erlotinib. Our models may usher the development of EGFR TKIs specific for EGFR exon 20 insertion mutations.

Background
Genetic subtyping is increasingly being clinically relevant in NSCLC, and the search for novel targetable driver mutations is warranted. We intended to study the frequency and types of a vast number of potential druggable genetic aberrations in a large cohort of non-small cell lung cancers of all major histological subtypes. Herein we report the first findings.

Methods
Blood samples and tumor tissue was obtained from 96 operated early stage lung cancer patients admitted to Oslo University Hospital-Rikshospitalet in the period 2006-2011. Tissue was taken from the excised tumours, snap frozen in liquid nitrogen in the operation room, and stored at -80[o]C until DNA isolation. The tumor cell content in the specimens was found to be more than 70% in most samples. DNA was isolated from both tumor and corresponding blood sample according to standard procedures. High-throughput sequencing was performed using the SureSelect Human Kinome kit (Agilent Technologies), with capture probes that target 3.2 Mb of the human genome and include exons for all known kinases, select cancer-specific genes and their associated UTRs, in total 612 genes. The derived sequence reads were analyzed based on a pipeline including calling variations, somatic mutations, DNA copy number changes, indels and genomic rearrangements, as well as functional annotations.

Results
Tissues from 48 females and 48 males were analyzed; 73 adenocarcinomas, 21 squamous cell carcinomas and 2 large cell carcinomas. 55 patients were in stage I, 27 in II and 14 in stage III. 13 patients were never-smokers. 25 samples harbored a KRAS-mutation and 10 an EGFR mutation. The number of mutated genes per sample varied from 1 to 81. The median number of mutated genes was 14 in the overall cohort, 15 in the EGFR wildtype/KRAS wildtype tumors, 17 in KRAS- mutated patients, 5 in the EGFR-mutated group and 6 in the never-smoking patients (of whom 4 patients were EGFR-mutated).Figure 1

Conclusion
KRAS-mutated tumors contain the same amount of genetic aberrations as in wild-type tumors, whereas EGFR-mutated tumors show a much lower number of mutations per tumor. Never-smokers harbor a low number of mutations independent of EGFR-mutation status. Novel driver mutations are probably found in samples with low numbers of mutations.

Background
Recent advances in targeted therapy in NSCLC have achieved impressive results in advanced disease. For molecular testing,cytology samples are not commonly used since is less likely to be adequate. At ICO Badalona- Germans Trias i Pujol Hospital we have used cytology specimens when biopsy was not available. We describe the general results when using cytology specimens in NSCLC to detect EGFR mutation, KRAS mutations and ALK translocations.

Methods
From February 2007 to May 2012, 227 cytology samples from patients with NSCLC were collected at the Department of Pathology as cell block or fresh specimen over an apropiate slide. After that, tumor cells were(8-150) captured by laser microdissection. DNA sequencing for EGFR exons 18, 19, 20, 21, KRAS codons 12 and 13 was performed at Molecular Biology Laboratory( ICO-Badalona) and ALK translocation were analyzed at Pathology Department by FISH

Results
EGFR mutations were tested in 227 samples.The overall output was 86.3% (not evaluable in 15 , insufficient tissue in 8, no tumor cells in 4, not done in 4). EGFR mutation was detected in 8.81% (20/227). KRAS mutation were tested in 41 samples with results in 33, 80.5% (2 not evaluable, insufficient tumor cells 3, no tumor 1 and not done 2 samples). KRAS mutation was positive 6 (14.6%). ALk translocation were tested in 9 p with results in 6 p ( 1 not evaluable and 2 insufficient tumor cells) Both cell-block and fresh specimen over an apropiate slide were used to perform molecular testing. The output for cell-block was 83.3%(124/148) and testing was not possible in 23(11 not evaluable, 6 insufficient tumor cells, 4 not tumor and 3 not done). The output for membrane was 91.1% (72/79) and was not possible in 7(4 were not evaluable, 2 insufficient tumor cells and not done in 1). 54.7% of samples were obtained from endobronquial ultrasound guided transbronquial needle aspiration of mediastinal adenopathies, 11.3% lung mass needle aspiration and 11.7% from pleural effusion.

Conclusion
Our results support the potential use of cytology samples for molecular testing in NSCLC when biopsy specimens are not available. Both membrane preparations and cytology blocks have been used and are equally suitable for molecular testing.

Background
The majority of actionable drivers in SQCLCs occur in the PI3K (30%) and FGFR1 (20%) pathways. The biologic behaviors and natural histories of these subtypes are not well characterized. Characterization of these data may help to elucidate the biologic relevance of these putative oncogenic events.

Methods
As of October 2011, all patients with SQCLCs at MSK have undergone prospective, multiplex testing of their FFPE tumors for FGFR1 amplification (FISH, FGFR1:CEP8 ≥ 2.2), PIK3CA mutations (Sequenom and exon sequencing), PTEN loss (IHC, Cell Signaling), and PTEN mutations (exon sequencing), among others. The PI3K abberant group was defined as PIK3CA mutant, PTEN complete loss, or PTEN mutant. Patient characteristics, outcomes, and metastatic sites were identified. Survival probabilities were estimated using the Kaplan-Meier method. Group comparisons were performed with log-rank tests and Cox proportional hazards methods.

Results
77 stage IV SQCLC patients were analyzed. Genotypes were: FGFR1 amplified (23%); PTEN loss (22%), PIK3CA mutant (8%), PTEN mutant (7%). Events were non-overlapping save for 2 cases with PTEN nonsense mutations and PTEN loss. The sole significant clinical difference (KPS, age, sex, lines of tx, smoking status) was sex (women in PI3K group 52% vs. in others 23%, p=0.02). Metastatic patterns for PI3K and FGFR1 vs. all others were:

Site	PI3K	p	FGFR1	p	Other	Total
Brain	6 (22%)	0.002	0 (0%)	0.6	0 (0%)	6 (7%)
Pleura	5 (19%)	0.4	5 (28%)	0.7	9 (28%)	19 (25%)
Liver	5 (19%)	0.4	1 (6%)	1	1 (3%)	7 (9%)
Bone	8 (30%)	0.8	3 (17%)	0.7	10 (31%)	21 (27%)
Lung	12 (44%)	0.8	10 (56%)	0.2	12 (38%)	34 (44%)
Adrenal	3 (11%)	1	3 (17%)	1	4 (13%)	10 (13%)
Pericardium	1 (4%)	1	1 (6%)	0.3	0	2 (3%)

Median OS for PI3K vs. all others: 9mo (95%CI:8-NR) vs. 16mo (95%CI:11-NR), p=0.004. Median OS for FGFR1 vs. all others: 20mo (95%CI:11-NR) vs. 10mo (95%CI:9-16), p=0.06. Multivariate analysis for risk of death: PI3K HR=3.3 (95%CI:1.5-7, p=0.003); FGFR1 HR=0.5 (95%CI:0.2-1.1, p=0.06); Age ≥65, HR=1.3 (95%CI:0.6-2.8, p=0.5); KPS≤70, HR=3.2 (95%CI:1.6-.6.4, p<0.001); Lines of therapy ≥ 2, HR=2.3 (95%CI=0.8-5.7, p=0.08), male gender, HR=0.7 (95%CI:0.3-1.4, p=0.3).

Conclusion
Patients with stage IV PI3K-aberrant SQCLCs have poorer survival compared to other patients with SQCLCs while patients with FGFR1 amplified SQCLCs have a trend towards better survival. Brain metastases in SQCLC are rare, and occurred exclusively in patients with PI3K-aberrant tumors. These data suggest that PI3K pathway activation confers a distinct biology, and that targeting this in SQCLC patients with brain metastases may be an effective therapeutic strategy. Whole exome and RNA-sequencing data from 8 resected SQCLC brain metastases (4 paired with lung primaries) will be presented.

Abstract not provided

Background
The benefits of concurrent chemoradiotherapy in locally advanced non-small cell lung cancer (NSCLC) are tempered by treatment toxicity. Germline genetic variants have been associated with intrinsic radiosensitivity and radiotoxicity in various cancer settings. We investigated whether variants in genes involved in inflammation response and DNA repair pathways independently influence radiation-induced phenotypes of esophagitis and pneumonitis. From 19 candidate genes, 52 polymorphisms, directed by literature and by tagging procedures, were systematically selected for assessment. The candidate genes were involved in DNA repair (double-strand breaks, homology directed, nucleotide excision) and pro/anti-inflammatory signaling. The this investigation sought to evaluate the association of genetic sequence markers for two clinically significant radiation-induced toxicities - esophagitis and pneumonitis – seen in NSCLC patients treated with a curative intent.

Methods
From 312 patients treated at PMCC between 2005-12, a training cohort was defined consisting of 92 definitive concurrent chemoradiation/radiation-treated NSCLC patients with genotype information on the 52 polymorphisms. A second, validation cohort consisted of 209 patients. Multivariate logistic regression was performed for each polymorphism of interest, adjusting for known clinical and dosimetric prognostic factors on the dichotomized outcomes of radiation esophagitis (Grades 0-2 vs 3-5) and pneumonitis (Grades 0-1 vs 2-5). The CTCAEv4.03 grading criteria were used. Additive genetic models were used for genetic association analysis. In the training set, genetic variants, genotyped by IlluminaGoldenGate, with p<=0.05 were identified for validation; HWE was set at p>0.01, a criteria met by all polymorphisms with statistical significance.

Results
In the combined training and validation datasets, 63% were males, with median age of 65 years. Specifically in the training dataset, 65% were male, with median age of 62, median mean lung doses of 15.9, median max esophageal dose of 67.1 and median V20 of 27.6. For esophagitis, the final models were adjusted for concurrent chemotherapy, V20 and max esophageal dose. Five genetic variants linked to TNF and IL6 were significantly associated with outcome (each using wild-type genotype as reference) (Table 1). For pneumonitis, the final models adjusted for V20 and smoking status. Eight genetic variants found within four genes (ATM, BRCA2, IL1alpha, IL1RN) were associated with significant pneumonitis (Table 1).

ESOPHAGITIS
Function / Pathway	Gene	refSNP	OR	95% CI	P value
pro-inflammatory cytokine	TNF	rs3093662	3.54	1.9-10.6	0.02
pro-inflammatory cytokine	TNF	rs3093664	3.42	1.2-10.2	0.03
pro-inflammatory cytokine	TNF	rs3093665	4.95	1.2-21.1	0.03
anti-inflammatory cytokine	IL6	rs1800797	2.53	1.0-6.2	0.04
anti-inflammatory cytokine	IL6	rs1800795	2.45	1.0-5.9	0.046
PNEUMONITIS
Function / Pathway	Gene	refSNP	OR	95% CI	P value
double-strand break repair	ATM	rs664143	2.67	1.3-5.6	0.01
double-strand break repair	ATM	rs664677	2.37	1.2-4.7	0.01
homology-directed repair	BRCA2	rs1799955	2.59	1.3-5.3	0.01
homology-directed repair	BRCA2	rs1801406	2.42	1.2-4.8	0.01
homology-directed repair	BRCA2	rs1799943	2.09	1.0-4.2	0.04
anti-inflammatory cytokine	IL1alpha	rs17561	2.63	1.2-5.7	0.01
anti-inflammatory cytokine	IL1alpha	rs2856863	2.60	1.1-5.9	0.02
anti-inflammatory cytokine	IL1RN	rs3087263	0.17	0.04-0.8	0.04

Conclusion
In our 92 patient training set, genetic variations in TNF and IL6 are associated with radiation esophagitis, while genetic variations in ATM, BRCA2, IL1alpha and IL1RN are associated with pneumonitis. Results from the 209 patients in the validation dataset will be presented at the meeting (A.H. and G. L are co-senior authors).

Background
Small-cell lung cancer (SCLC) is one of the most aggressive types of cancer, yet the molecular mechanisms underlying its devastating clinic outcome remain elusive. In this study, we investigated whether microRNA (miRNA) expression profiles can predict clinical outcomes of SCLC patients.

Methods
A total of 82 patients with very limited SCLC, who received surgical resection followed by adjuvant chemotherapy according to the standard of care, were enrolled in this study. All the tumor samples used for miRNA profiling were required to contain at least 60% tumor cells and RNA was isolated from formalin-fixed paraffin-embedded specimens. First, we surveyed 924 miRNAs for their expressions from 42 SCLC patients to discover survival relevant miRNAs and develop prognostic models, which were then validated in an independent cohort of 40 cases. A risk score of miRNA signature for survival prediction was calculated according to a combination of expression level of the miRNA weighted by the regression coefficient derived by univariate Cox regression analysis. Kaplan-Meier overall survival curves were compared using the log-rank test and multivariate Cox regression model was used to test if the miRNA signature was an independent prognostic factor.

Results
For all the patients, the median follow up time was 57.2 months. Forty-four patients (53.7%) are still alive. Forty-two patients (51.2%) had recurrent disease and the median time to diagnosis of relapse was 12.3 months. In the training set, we identified that two miRNAs, miR-150 and miR-886-3p, were significantly associated with poor OS. The results compared between NL and SCLC tissues also verified that the miR-150 and miR-886-3p expression levels in SCLC were much lower than in normal lung samples (884±126 vs 2954±1652 for miR-150 and 1873±256 vs 3154±448 for miR-150 ). We then derived a miRNA signature 0.545×miR-150 + 0.617 ×miR-886-3p. Compared with patients with low-risk miRNA signature, patients with high-risk signature had significantly shorter median OS (12.6 months versus not reached, P=0.02). This signature was also demonstrated to be a significant predictor of survival in the validation set. Patients with high risk miRNA signatures had poor overall survival (P=0.005) and progression-free survival (P=0.017) compared to those with low-risk scores. It retained statistical significance in a model adjusting for age, gender and smoking status (HR 0.27, 95% CI 0.10-0.72, P=0.008), which suggesting that the miRNA signature may be an independent predictor of survival.

Conclusion
In this study, we developed a prognostic miR-150/miR-886-3p signature and validated in an independent dataset for resectable SCLC. Our results indicated that microRNAs may serve as promising molecular prognostic markers as well as new therapeutic targets for SCLC. Larger sample size studies are needed to further validate our findings.

Background
BRM, an ATPase subunit of the SWI/SNF chromatin remodeling complex, is a putative tumor susceptibility gene in NSCLC. Loss of BRM expression occurs in 15% of NSCLC, and has been linked to adverse outcome. Two BRM promoter insertion variants (BRM-741 and BRM-1321) result in epigenetic silencing of BRM through recruitment of histone deacetylases. The presence of double homozygous BRM variants is linked to loss of BRM expression and function in lung tumors, and double the risk of lung cancer. Pharmacological reversal of the epigenetic changes of BRM is feasible. In this study we evaluated the association between the BRM promoter variants and survival outcomes of advanced NSCLC patients.

Methods
The training cohort consisted of 564 stage III-IV NSCLC patients treated at the Princess Margaret Cancer Centre, Toronto 2006-2010. The validation cohort comprised 219 stage IIIb-IV NSCLC patients from the NCIC-CTG BR24 clinical trial, a phase II/III double-blind randomized trial of cediranib versus placebo in patients receiving carboplatin/paclitaxel for the treatment of advanced or metastatic NSCLC. Genotyping for the BRM promoter variants was performed using Taqman. Associations of BRM promoter variants and overall (OS) and progression free survival (PFS) were assessed using Cox proportional hazard models adjusted for clinically relevant variables, and in the case of the BR24 population, stratified by treatment arm.

Results
Among the training cohort, 73% were Caucasian, 52% male, median age 63 yrs, 55% stage IV disease, and 67% adenocarcinoma. Median OS was 1.6yrs; median follow up, 3.6yrs. The frequency of homozygosity was BRM-741, 23%; BRM-1321, 21%; both 12%. Homozygous variants of BRM-741 were strongly associated with worse OS (adjusted HR [aHR] 2.5 [95% CI: 1.9-3.3; p=6x10E-10]) and PFS (aHR 2.0 [95% CI: 1.6-2.6; p=9x10E-8]) compared to the wild types. Similar findings were observed for the BRM-1321 homozygous variants (aHR for OS of 2.0 [95% CI: 1.5-2.6; p=2x10E-6]; aHR for PFS of 1.8 [95% CI: 1.4-2.4; p=3x10E-6]). The presence of double homozygous BRM-741 and BRM-1321 variants was strongly associated with worse OS (aHR 2.8 [95% CI: 1.9-4.0; p=7x10E-8]) and PFS (aHR 2.7 [95% CI: 1.9-3.8; p=1x10E-8]). Genotyping was possible for 219/296 BR24 participants. Of these, 59% were male, median age 59 yrs, 83% stage IV, 46% adenocarcinoma, with 50% receiving cediranib. Individuals carrying the homozygous variants of both BRM-741 and BRM-1321 (13% of cases) had a substantially worse OS (aHR 9.0 [95% CI: 4.3-18.5; p=1x10E-9]) and PFS (aHR 3.8 [95% CI: 1.9-7.3; p=3x10E-5]) compared to the wild types, irrespective of whether they were treated with cediranib (aHR for OS of 6.4; p=1x10E-4; aHR for PFS of 2.1; p=0.02) or placebo (aHR for OS of 16.8; p=2x10E-7; aHR for PFS of 8.3; p=1x10E-4).

Conclusion
The same two homozygous BRM promoter variants that are associated with increased risk of NSCLC are also strongly associated with adverse OS and PFS in this study of advanced NSCLC patients. We are completing additional studies focusing on the relationship between the BRM promoter variants and BRM protein expression; results will be presented at the meeting.

Abstract not provided

Background
EGFR mutation is a strong positive predictive factor of EGFR-TKIs therapy. However, at least 10% of patients with wild-type EGFR are responsive to TKIs, suggesting that other determinants of outcome besides mutant EGFR might exist. miR-200c is an important regulator of epithelial-to-mesenchymal transition and might be associated with drug-resistance. Our objective was to characterize miR-200c expression in NSCLC and its role in TKI sensitivity in EGFR wild-type NSCLC.

Methods
miR-200c levels in 7 NSCLC cell lines were measured by real-time quantitative reverse transcription-PCR (qRT-PCR). Direct target of miR-200c was identified through the TargetScan database and was validated through qRT-PCR and Western blot analysis. The precursor of miR-200c was up-expressed in H1975 and A549 cells using a lentivirus construct, and miRNA inhibitor was used to down-regulate the expression of miR-200c in PC9 cell line. Effects of miR-200c on cell proliferation and sensitivity to EGFR-TKIs were evaluated by MTT assay in vitro. The expression of proteins correlating with signaling pathway was determined by western blot analysis. 141 FFPE samples of advanced NSCLC patients were enrolled in this study, and miR-200c expression and EGFR mutations were detected by qRT-PCR and amplification refractory mutation system (ARMS), respectively.

Results
We identified a tight association between the expression of miR-200c, epithelial phenotype, and sensitivity to TKIs in NSCLC cell lines. Up-expression of miR-200c in A549 and H1975 cells up-regulated E-cadherin levels, down-regulated expression of ZEB1, vimentin, pERK and pAKT. Up-regulated miR-200c increased sensitivity to gefitinib in the primary resistant cell line A549. Analysis of 141 NSCLC specimens indicated that median PFS of EGFR wild-type (n=57) and EGFR mutant NSCLC patients (n=73) treated with second/third line targeted therapy was 1.8m vs. 12.0m respectively (P<0.0001). Patients with high expression level of miR-200c had a positive association towards a longer PFS in NSCLC harboring EGFR wild-type when considering 2[-ΔCt]=0.01128 (median level) as cut-off value (3.95m vs. 1.60m, P=0.015). The objective response rate (ORR) was 7% in the EGFR wild-type cohort, and patients with high miR-200c expression level had better ORR than those with low level (12.5% and 3.0%, P=0.3). In Cox regression analysis, miR-200c expression also present the same trend for benefit from EGFR-TKIs in EGFR-negative NSCLC (HR= 0.375, 95%CI: 0.198-0.712, P= 0.003).

Conclusion
miR-200c appears to act as a critical role in EGFR-TKIs sensitivity in NSCLC patients with wild-type EGFR. Up-expression of miR-200c can trigger MET and suppress PI3K/AKT, MEK/ERK pathway, which can also partially overcome EGFR-TKIs resistance. miR-200c might be a predictive biomarker of clinical response to EGFR-TKIs and assist in selecting the subpopulation in patients with wild-type EGFR to benefit from targeted therapy.

Background
Diagnostic utility study of EGFR mutation analysis of tumor and plasma from FASTACT 2 confirmed that the plasma EGFR mutation DNA (pEGFRmut) is a sensitive and specific biomarker. (Wu et al, Lancet Oncology 2013; T. Mok, ASCO 2013). Primary objective of this study is to investigate the dynamic change in pEGFRmut during course of treatment. Secondary objective is to study the diagnostic utility of pEGFRmut in patients with distant organ metastasis whom we assumed to have higher level of plasma DNA.

Methods
Retrospective EGFR mutation testing of FFPET and plasma from FASTACT 2 were performed with two allele-specific assays, cobas® 4800 EGFR_FFPET test and cobas® EGFR_blood test (in Development). Both tests are designed to detect one or more of the 42 known EGFR mut. One FFPET section was used for tissue test and 2-ml plasma was used for blood test. We studied the plasma samples collected at baseline, post cycle 3 (C3) and at tumor progression according to RECIST criteria (PD).

Results
Complete analysis of plasma samples at baseline, C3 and PD was available in 305 of 451 pts(67.6%). Incidence of pEGFRmut positive at baseline, C3 and PD was 35% (106/305),15% (47/305)and 27% (81/305), respectively. 98 of 106 pEGFRmut patients harbor the Exon 19 deletion or L858R at baseline. (C arm 51; CE arm 47). At C3, 21 (41%) pts lose pEGFRmut positivity in C arm comparing to 39 (83%) in CE arm. At PD, 8 of the 21pts in C arm and 18 of the 39 in CE arm regained pEGFRmut positivity. Table 1 summarized the median pEGFRmut copies/PCR. There was a considerable decline at C3 in both C and CE arm. However, pEGFRmut copies/PCR rebounded to high level at PD in C arm only and remained low in CE arm. Correlation of dynamic change in pEGFRmut copies/PCR with clinical tumor response and PFS will be presented at the meeting. We have also identified 93 (out of 224 matched tissue and plasma samples) patients with known distant organ metastasis. Sensitivity of pEGFRmut in this patient subgroup is 91% (41/45), specificity at 98% (47/48) and overall concordance at 95% (88/93). Table 1

Median pEGFRmut copies/PCR	Baseline	C3	PD
C (Exon 19)	27.6	2.3	35.8
CE (Exon 19)	43.2	0	2.7
C(Exon 21)	40.9	2.6	63.9
CE (Exon 21)	87.1	0	3.5

Conclusion
This is the first study demonstrating the quantitative dynamic change in pEGFRmut in pts who received C or CE for advanced NSCLC. At RECIST progression, pEGFRmut remained low in patients who received erlotinib but not in patients who received chemotherapy only. pEGFRmut is a potential biomarker for monitoring tumor response.

Background
EGFR-TKis are more effective in NSCLC patients with EGFR activating mutations. However, about 90% of non-Asian patients are EGFR wild type, and a test for optimizing treatment in pts with wild-type or in patients with undetectable EGFR mutation status or squamous histology is of clinical value. VeriStrat (VS) is a serum protein test that assigns "good" (VSG) or "poor" (VSP) classification and has demonstrated prognostic and predictive utility in retrospective studies. PROSE is the first completed multicenter prospective randomized biomarker validation trial, designed to evaluate the ability of VS to predict survival in 2[nd]- line NSCLC pts treated with E or CT. As reported at 2013 ASCO[1], VSG pts derived similar overall survival (OS) benefit from both agents (hazard ratio (HR) for E=1.06; p=0.71) whereas CT was the superior option for VSP pts (HR for E=1.72; p=0.02). PROSE met its primary endpoint of demonstrating significant treatment*VS interaction with a p-value of 0.031. The present report discusses the results for the secondary endpoints, PFS.

Methods
285 pts, stratified by ECOG-PS, smoking, and blinded pre-treatment VS classification, were randomized 1:1 to receive E or CT at standard doses. Primary endpoint was overall survival (OS) and the primary hypothesis was a significant interaction between VS status and treatment. Sample size was calculated based on an estimated 65%/35% VSG:VSP ratio and hazard ratio (HR) for interaction of 2.35, with a 2-sided α=0.05 and 90% power.

Results
263 pts (129 CT, 134 E) were included in the per protocol primary analysis. 68% of pts in CT arm and 72% in E arm were classified as VSG, and analysis was performed at 226 survival events.VSP classification was significantly correlated with worse PFS as compared to VSG, in overall comparison (HR=1.75, 95%CI: 1.34-2.95, P <0.001) , in the CT (HR = 1.69, 95%CI: 1.15-2.48, P <0.007) and the E (HR = 1.91, 95%CI: 1.340-2.80, P<0.001) arms, demonstrating its prognostic value also in PFS. In VSG median PFS was 4.8 months (m) on CT, and 2.5 m on E (HR = 1.26, 95% CI: 0.94-1.69, P =0.129); in VSP median PFS was 2.8 m on CT and 1.7 m on E (HR=1.51, 95% CI: 0.96-2.38, P =0.078). No statistical significant interaction was detected (p=0.44)

Conclusion
The analysis of PFS and OS indicates that the differential treatment benefit in OS related to VS classification is determined by the combination of prognostic and predictive properties of the test.

Abstract not provided

Background
Nintedanib is an orally available potent anti-angiogenic agent inhibiting the isoforms of VEGFR, PDGFR and FGFR. LUME-Lung 1 is a placebo-controlled phase 3 trial of nintedanib + docetaxel in second-line NSCLC patients.

Methods
Patients with stage IIIB/IV or recurrent NSCLC after failure of first-line chemotherapy were stratified by histology, ECOG PS, prior bevacizumab and brain metastases, and were randomised to nintedanib 200 mg bid + docetaxel 75 mg/m[2] q21d (n=655), or placebo + docetaxel (n=659). The primary endpoint was centrally reviewed PFS after 714 events. The key secondary endpoint was OS after 1,121 events. Predefined sensitivity analyses used baseline sum of longest diameters of target lesions (SLD) and stratification factors, as covariates in the Cox model.

Results
The study met its primary endpoint demonstrating a statistically significant improvement in PFS that translated into a 21% reduction in the risk of progression in patients treated with the combination of nintedanib + docetaxel vs placebo + docetaxel (HR 0.79; CI: 0.68, 0.92; p=0.0019; median 3.4 vs 2.7 months), regardless of histology (adenocarcinoma HR 0.77, CI: 0.62, 0.96; p=0.0193; squamous HR 0.77, CI: 0.62, 0.96; p=0.0200). OS was significantly prolonged in adenocarcinoma patients treated with the combination of nintedanib + docetaxel vs placebo + docetaxel (HR 0.83; CI: 0.70, 0.99; p=0.0359; median 12.6 vs 10.3 months) but not in squamous cell carcinoma patients (HR 1.01; CI: 0.85, 1.21; p=0.8908; median 8.6 vs 8.7 months). The intent-to-treat (ITT) analysis of OS in all study patients showed a 1-month improvement that did not reach statistical significance (HR 0.94; CI 0.83, 1.05; p=0.272; median 10.1 vs 9.1 months). When adjusted for SLD, however, a significant OS benefit was seen for the ITT population (HR 0.88; CI: 0.78, 0.99; p=0.0365). Further analyses showed that the impact of SLD was reflected in the squamous cell carcinoma population (HR 0.92; CI: 0.77, 1.10; p=0.3649), with the greatest impact observed for squamous cell carcinoma patients with a large SLD. An impact of SLD was also seen in adenocarcinoma patients but to a lesser extent (HR 0.81; CI:0.69, 0.97; p=0.0186), as compared with the squamous cell carcinoma population. The most common AEs reported for the ITT population were diarrhea (any: 42.3 vs 21.8%; Gr ≥3: 6.6 vs 2.6%) and ALT elevations (any: 28.5 vs 8.4%; Gr ≥3: 7.8 vs 0.9%). Incidence of CTCAE Gr ≥3 AEs was 71.3 vs 64.3%. Withdrawals due to AEs (22.7 vs 21.7%) were similar in both arms, as were Gr ≥3 hypertension, bleeding or thrombosis.

Conclusion
Nintedanib + docetaxel significantly reduced the risk of progression in NSCLC patients independent of histology. Adjustment for tumor burden, as represented by the SLD, led to a significant reduction in the risk of death. AEs were generally manageable with dose reductions and symptomatic treatment.

Background
KRAS mutations that activate the MEK/ERK pathway are found in 20–30% of NSCLC. Response to second-line therapies for advanced NSCLC may be different in the presence or absence of a KRAS mutation. MEK inhibitors are being developed in combination with cytotoxic chemotherapy for NSCLC, based on preclinical findings that MEK inhibition increases pro-apoptotic BIM levels, enhancing cytotoxic therapy, and that MEK inhibition reduces KRAS mutation-induced oncogenic drive. We reviewed available information from KRAS mutation-positive (KRAS+) and KRAS wild-type subsets in AstraZeneca clinical studies in second-line NSCLC and published data on MEK inhibitors. Our objective was to determine whether differential therapeutic activity is present in KRAS+ and KRAS wild-type populations and whether preclinical findings translate into enhanced tumour response.

Methods
We reviewed data on objective clinical response in second-line NSCLC according to KRAS status in five randomised double-blind Phase II or III studies of gefitinib, vandetanib or selumetinib and three published studies of trametinib. Ninety-five percent confidence intervals (CI) around point estimates of objective response were calculated using exact (Clopper-Pearson) methods for a single proportion.

Results
The studies involved 4466 patients receiving second- or later line treatment for advanced NSCLC. In total, 1286 patients received singlet chemotherapy (docetaxel or pemetrexed), including 429 with known tumour KRAS mutation status: 138 had KRAS+ and 291 had KRAS wild-type NSCLC. Additionally, 132 patients with known KRAS status received singlet chemotherapy plus a MEK inhibitor (selumetinib or trametinib): 91 with KRAS+ and 41 with KRAS wild-type NSCLC. Figure 1

Conclusion
Our retrospective comparison suggests that second-line singlet chemotherapy response rates may be greater in KRAS wild-type than in KRAS+ NSCLC, and that MEK inhibition may enhance second-line chemotherapy activity in both KRAS+ and KRAS wild-type NSCLC. These observations support prospective validation of these results and further evaluation of MEK inhibitors plus chemotherapy in second-line KRAS unselected NSCLC.

Background
The impact of tyrosine kinase inhibitors (TKIs) in EGFR-mutant advanced NSCLC is poorly documented. Two studies (Jacob et al, ISPOR2010, Brown et al, Health Technol Assess, 2010) are based on modelisation and indirect comparisons. The present study reports a cost-utility analysis of a phase III randomized trial (EURTAC).

Methods
A three state Markov model (first line PFS, second line PD and death) was built. Clinical data and resource assessment (drugs, drug administration, adverse events, second-line treatment) were collected from the trial. Utility values were derived from Nafees et al, as previously published (Vergnenegre et al. JTO 2011). Incremental cost-utility ratios (ICUR) were calculated for the first-line treatment and the overall strategy until death from the perspective of different countries (2013 actualized euros). Sensitivity analyses researched the main cost drivers.

Results
The quality-adjusted life-years gained was 0.124 with erlotinib, which showed an improvement in the quality of life for these patients. Despite the extra treatment costs of second-line erlotinib in the chemotherapy arm, there was a cost benefit for erlotinib first, resulting in fewer patients receiving second-line pemetrexed along with other therapy. Cost gain in favor of first-line erlotinib was 8,918 Euros. The main results are depicted in Table1.

	First-line erlotinib	First-line chemotherapy
Average cost of first-line (euros 2013)
Drugs	21,679	1030
Administration	329	4,455
Adverse events	546	2,686
Cost of post-first progression care	40,467	67,281
ICUR (erlotinib versus chemotherapy)
ICUR France		negative
ICUR Spain		negative
ICUR Italy		negative

Sensitivity analyses will be presented at the meeting.

Conclusion
ICUR favored first-line erlotinib in EGFR-mutant patients with advanced NSCLC, which is the widely accepted treatment compared to chemotherapy. The cost-utility of the overall strategy remained beneficial in three different European countries. On behalf GFCP,GEPC and AIOT groups

Abstract not provided

Background
Crizotinib is a potent selective ATP-competitive ALK inhibitor demonstrating a high ORR in patients with advanced ALK-positive NSCLC. The main objective of the present post hoc analyses was to compare the impact of crizotinib on efficacy, safety, and PROs with that of standard second-line chemotherapy in a subgroup of patients of Asian ethnicity from the ongoing phase III study PROFILE 1007.

Methods
Patients with stage IIIB/IV ALK-positive NSCLC who had received one prior platinum-based regimen were randomized to open-label crizotinib (250 mg PO BID) or chemotherapy (pemetrexed 500 mg/m[2] or docetaxel 75 mg/m[2], IV q3w). In these subgroup analyses, PFS and ORR based on independent radiologic review, OS, safety, and PROs were evaluated. PROs were assessed at baseline, on day 1 of each cycle, and at end of treatment using the validated cancer-specific questionnaire EORTC QLQ-C30 and its LC module QLQ-LC13. Time to deterioration (TTD) was defined as the time from randomization to the earliest time with a ≥10-point increase from baseline (worsening) in pain in chest, dyspnea, or cough. Repeated measures mixed-effects analyses were performed to compare change from baseline scores between the treatment arms.

Results
Of 347 patients randomized, 45% were of Asian ethnicity (crizotinib, n=79; chemotherapy, n=78 [pemetrexed, 50; docetaxel, 27; no treatment, 1]). At data cutoff (March 2012), 52 Asian patients (crizotinib, 41; chemotherapy, 11) were continuing on treatment. PFS was significantly longer with crizotinib than with chemotherapy (median 8.1 vs. 2.8 months; HR, 0.53; P=0003). The ORR on crizotinib (75%) was significantly higher than on chemotherapy (22%; P<0.0001). In an interim analysis, median OS had not yet been reached in the crizotinib arm and was 22.8 months in the chemotherapy arm (HR, 0.89; P=0.347, noting that in the overall study population, only 40% of planned events had occurred and 64% of patients in the chemotherapy arm subsequently received crizotinib in another study). The most common all-causality AEs with crizotinib were diarrhea (70%), vision disorder (68%), and nausea (66%) and with chemotherapy were decreased appetite (40%), nausea (39%), and fatigue (35%). Crizotinib treatment was associated with a significantly longer TTD in LC symptoms compared with chemotherapy (median 4.2 vs. 1.6 months; HR, 0.66; 95% CI, 0.44−0.98; P=0.037). A significantly greater improvement from baseline was observed with crizotinib for global QOL (P<0.05), cough (P<0.001), dyspnea (P<0.001), pain in arm or shoulder (P<0.001), pain in chest (P<0.001), pain in other parts (P<0.05), fatigue (P<0.05), insomnia (P<0.05), and pain (P<0.001). A significantly greater improvement was observed with crizotinib compared with chemotherapy for emotional functioning (P<0.05), physical functioning (P<0.05), hair loss (P<0.001), and sore mouth (P<0.05). A significantly greater deterioration was observed in the crizotinib arm for constipation (P<0.05) and diarrhea (P<0.001) compared with chemotherapy.

Conclusion
Consistent with previously reported results in the overall study population, crizotinib treatment showed significantly greater improvement in PFS, ORR, patient-reported LC symptoms, and global QOL compared with chemotherapy in a subgroup of patients of Asian ethnicity with previously treated advanced ALK-positive NSCLC, confirming the utility of crizotinib in this patient population.

Background
Anaplastic lymphoma kinase (ALK) is a tyrosine kinase constitutively activated following chromosomal translocation in 3-7% of non-small cell lung cancer (NSCLC). These patients usually respond to the ALK inhibitor crizotinib with a median duration of response around 10 months. CH5424802 is a more potent and specific ALK inhibitor that is being studied as a treatment for NSCLC patients with ALK gene rearrangement.

Methods
A phase 1 dose escalation study of CH5424802 was performed using 3+3 study design in NSCLC patients who failed crizotinib. The primary endpoint was dose limiting toxicity, and the secondary endpoints were efficacy, safety and pharmacokinetic (PK) analyses. Key eligibility criteria include prior progression on crizotinib, ECOG 0-2, adequate organ functions, confirmed ALK-rearrangement by an FDA approved test. Patients with symptomatic CNS metastases required treatment before participating. CH5424802 was administered orally at doses of 300, 460, 600, 760 and 900 mg BID until lack of clinical benefits. Intensive PK sampling was performed. Efficacy was assessed by RECIST criteria v1.1. Toxicities were evaluated by CTCAE v4.0.

Results
37 NSCLC patients who have failed crizotinib and chemotherapy were enrolled in the study from 6 US sites from May 2012 to May 2013. No DLTs were observed up to the highest dose tested (900 mg BID). Only 1 patient required dose modification due to grade 2 fatigue. The most common AEs were fatigue, CPK increase, myalgia, cough, ALT increased, peripheral edema and rash. Grade 3/4 AEs include GGT increase (n=3), neutrophil decrease (n=2), hypophosphatemia, hyperglycemia, syncope, renal failure and pericardial effusion (n=1 each), but no grade 3 nausea, vomit, diarrhea, edema were reported. Preliminary efficacy was observed with PR 48% and SD 34% by investigator assessment amongst the 30 evaluable patients (See Figure of Waterfall plot). Median progression-free survival has not been reached with 27 patients (73%) remaining on study as of June 10, 2013 (median duration 85 days, range 39-347+ days). CNS activity was observed and described in the companion abstract by Ou et al. CH5424802 single dose half-life was approximately 22 hr, AUC was dose-dependent from 300 to 600 mg BID following multiple doses with a potential plateau at doses higher than 600 mg BID based on available data.Figure 1

Conclusion
CH5424802 is a well-tolerated ALK inhibitor with no DLTs observed up to the highest dose tested in this study. Promising anti-tumor activity was observed in patients who have failed crizotinib.

Background
Disease progression in brain occurs in ~50% ALK-rearranged NSCLC patients treated with crizotinib. This is likely due in part to low penetration of crizotinib into CNS. CH5424802 is a new ALK inhibitor that is effective in patients who have ALK re-arrangement. Preclinical studies in CNS implantation models suggest a promising anti-tumor activity of CH5424802 against CNS lesions. This report describes CNS activity observed in an ongoing phase I/II clinical trial.

Methods
A phase I dose escalation study of CH5424802 was performed in ALK-rearranged NSCLC who have failed crizotinib. Patients received oral CH5424802 doses ranging from 300 to 900 mg BID. All patients had head CT/MRI and body CT scans at baseline, and every 6 weeks after initiation of treatment if baseline scans are positive for brain metastasis. Brain lesions without prior radiation were used to assess CNS response based on modified RECIST criteria. Simultaneous collection of cerebrospinal fluid (CSF) and plasma PK samples in selective patients is ongoing to evaluate CSF/plasma CH5424802 ratios to correlate with clinical activity in brain metastasis.

Results
As of June 6, 2013, 37 patients were enrolled in the phase I study, and 31 of them were evaluable for efficacy. Preliminary overall response rate (ORR) is ~48% (15/31) in evaluable patients. 16 had brain metastases at baseline, and 2 had no prior brain irradiation but all had documented CNS progression prior to study treatment. These 16 patients received CH5424802 at 300mg (n=2), 460mg (n=2), 600mg (n=5), 760mg (n=3), and 900mg (n=4) BID. The median duration of follow-up of these 16 patients was 130+ days, with the longest being 347+ days. Activity against CNS lesions was observed as early as the first scan (3[rd] week). The preliminary CNS response is highly promising as shown in the representative scans below. Enrollment is still ongoing and CNS progression-free survival (PFS) will be presented. Currently 2 patients had simultaneous CSF and plasma levels of CH5424802, and the CSF/plasma ratios will be reported to evaluate any correlation between CSF/plasma ratios and the observed clinical activity of CH5424802 in brain metastasis.Figure 1

Conclusion
CH5424802 demonstrates consistent and rapid clinical activity in brain metastases in ALK+ NSCLC patients who progressed on crizitinib. Within 3-6 weeks of treatment, CH5424802 dramatically shrinks brain lesions that progressed on crizotinib. CH5424802 could potentially replace or delay the need of brain radiation in ALK-positive NSCLC patients.

Abstract not provided