Virtual Library

Abstract not provided

Abstract not provided

Abstract not provided

Abstract not provided

Background:
Evasion of immune system is a hallmark of cancer, which enables cancer cells to escape the attack from immune cells, by expression of immune inhibitory signalling proteins such as programmed death-ligand-1 (PD-L1); PD-L1 binds to programmed death-1 (PD-1) expressed on immune cells (T, B, dendritic and NK T-cells) to suppress anti-cancer immunity. Anti PD-L1antibodies (such as pembrolizumab) are now being used for the treatment of some cancers.

Methods:
We assessed the expression of PD-L1 on NSCLC by immunohistochemistry using the Dako IHC22C3 pharmDx® kit on the Dako Autostainer link48®. Slides were read and scored using the Dako guidelines based on a Tumour Proportion Score (TPS) (% of tumour cells expressing PD-L1, ≤1% (negative), 1–49% (low), ≥50% (positive)). Immune cells were not scored.

Results:
The 16 months-patient cohort was made up of 870 patients, from SVUH (43.9%) and Irish national hospitals (61.2%), 49.5% females and 51.5% males. Overall staining patterns were as follows: 31.5% positive (high TPS >50%), 23.1% low (low TPS 1–49%), 42.8% negative (TPS <1%). Specimens included cytology (22.9%, of which 57% were EBUS samples), biopsy (77.1%, 39% were lung/bronchial biopsies) and surgical (15.6%) specimens. Adenocarcinomas represented 59.3% of all NSCLC and 33.5% had a high TPS (≥50%) score. Squamous cell carcinomas (33.7%) were positive (≥50%) in 29.7%. Histology and cytology samples had similar distribution of high, low and negative TPS cases.

Conclusions:
This is the first comprehensive collection of PD-L1 testing data in NSCLC in Ireland. Our results broadly with the KEYNOTE-010 study validating our scoring. Some of these patients are now receiving pembrolizumab treatment. Heterogenous tumour populations and strong staining of inflammatory cells can make assessment difficult.

Clinical trial identification:


Legal entity responsible for the study:
St. Vincent's University Hospital Dublin

Funding:
MSD

Disclosure:
A. Fabre, K. Breen, J. McCormack: Financial funding received from MSD.

Background:
Programmed cell death ligand 1 (PD-L1) expression by immunohistochemistry (IHC) is an important predictive factor for patients with metastatic non-small cell lung cancer (NSCLC). Although PD-L1 IHC 22C3 pharmDx (Dako)® is the first FDA-approved companion diagnostic test for PD-L1 testing in NSCLC, it remains controversial which specimen is preferred from primary tumor or metastatic tissue.

Methods:
We analyzed formalin-fixed paraffin-embedded tissues of 24 paired primary tumor and metastatic lymph node (LN) from patients with pathological N1 or N2 NSCLC. All of them underwent surgical lung resection and LN dissection (or sampling) at Saitama Cardiovascular and Respiratory Center, and none of them received any chemotherapy or radiotherapy before surgery. According to PD-L1 IHC 22C3 pharmDx interpretation manual, all specimens were stained by using EnVision FLEX visualization system on Autostainer Link 48 in laboratory of LSI Medience Corporation in Japan. Next, we scored and divided each sample into three levels based on a Tumor Proportion Score (TPS); 1) Group 1 (TPS: <1%), 2) Group 2 (TPS: 1–49%) and 3) Group 3 (TPS: >=50%).

Results:
All patients were Asian (Japanese) with average age 67.3 years old (49–83). There were 8 females (33.3%), 8 never smoker (33.3%), 19 adenocarcinomas (79.2%) including 7 EGFR mutation and 1 ALK positive tumor. Number of Group 1, 2 and 3 were 5 (20.9%), 15 (62.5%), 4 (16.7%) in primary tumor, while that were 11 (45.9%), 9 (37.5%), 4 (16.7%) in metastatic LN, respectively. No primary tumor in Group 3 paired metastatic LN showing high PD-L1 expression.

Conclusions:
We found apparent discrepancy of TPS between primary tumor and metastatic LN of NSCLC, and there are concerns that will cause serious problem when we decide chemotherapeutic agents. It is future subject to explore which site should be biopsied for PD-L1 IHC.

Clinical trial identification:


Legal entity responsible for the study:
N/A

Funding:
Saitama Cardiovascular and Respiratory Center Research Grant, Eiken Chemical Co., Ltd

Disclosure:
Y. Saito: This work was supported by the Saitama Cardiovascular and Respiratory Center Research Grant (Grant No. TE17, for Yuichi Saito) and Eiken Chemical Co., Ltd. These funding bodies had no rule in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript. All other authors have declared no conflicts of interest.

Background:
Non-small cell lung cancer (NSCLC) is one of the most severe malignant tumors in the world. Recent studies have reported the important role of PD-L1 in immune escape of tumor microenvironment.

Methods:
In this study, we explored the molecular mechanisms in regulating the PD-L1 expression during the epithelial-to-mesenchymal transition (EMT) process treated with transforming growth factor β-1 (TGFβ-1) and -2 (FGF-2) in NSCLC. The phenotypic alteration of EMT was evaluated by wound healing assay and western blot. And the protein expression was evaluated by Western Blot and Flow Cytometry Analysis. Furthermore, the expression of PD-L1 was increased significantly treated with Gefitinib in tumor xenograft model.

Results:
The results showed that EMT promoted the expression of PD-L1 remarkably in A549 cell line while have no obvious influence on H1650 and H1975 cell lines. Furthermore, AKT pathway inhibitor Ly294002, Erk pathway inhibitor PD98059 and TAK1 pathway inhibitor 5Z-7 inhibited the expression of PD-L1 in A549 and H1650, but not H1975 in EMT process. Besides, our study indicated that AKT, Erk and TAK1 pathways regulated the expression of PD-L1 by mediating transportation of the transcription factor Stat3 and the subunit p65 of NF-κB from cytoplasm to nucleus.

Conclusions:
Take together, our study supports the role of ERK, AKT and TAK1 in mediating the expression of PD-L1 during EMT process and represents a promising strategy for treatment NSCLC in clinic.

Clinical trial identification:
none

Legal entity responsible for the study:
Peking University Third Hospital

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
Later numerous publications have demonstrated that lymphocytic FOXP3 is significantly associated with immune suppression. However, there are conflict data concerning its function among malignant cells. In colorectal cancer cells the inhibition of FOXP3 expression can result in increased cancer stemness. However whether this is the case in lung CSC or whether it is related to GLI-1 remains unclear.

Methods:
In this study, a series of in vivo and in vitro experiments will be conducted to clarify the regulation of FOXP3 expression in non-small-cell lung cancer cells, and its influence upon lung cancer cell stemness.

Results:
The cells with FOXP3 over expression and negative controls were applied for mRNA expression microarray experiments, and the results showed that when the expression of FOXP3 was up regulated, the expression of GLI-1 was oppositely regulated. Three NSCLC cell lines were treated with NNK for different periods. The results show that with the treat time progressing, the expression of FOXP3 was up regulated with the expression of GLI-1 down regulated. When the FOXP3 expression was up regulated, the expression of GLI-1 was suppressed, while the expression of cancer stem cell markers includes SOX2, Nanog and CD133 were also up regulated, which meant the cancer stemness increased. When the GLI-1 expression was up regulated, the expression of FOXP3 was increased, and the expression of cancer stem cell markers include SOX2 and Nanog were also up regulated, which meant the cancer stemness increased. For tumors with FOXP3 over expressed, the expression of GLI-1 was up regulated and the cancer stemness increased. GLI-1 and FOXP3 might bind with each other inside cells. It was easier for H460-FOXP3 cells to form tumor sphere, and the diameter is much larger.

Conclusions:
GLI-1 might influence lung cancer stem cells by regulating the expression of FOXP3.

Clinical trial identification:


Legal entity responsible for the study:
Chinese University of Hong Kong

Funding:
General Research Fund from Chinese University of Hong Kong

Disclosure:
All authors have declared no conflicts of interest.

Background:
Most studies focused on the role of canonical Wnt signaling pathway, an increasing field of research, however, is concerning about the noncanonical Wnt pathways. The role of Wnt11, a noncanonical Wnt family member, has not been established in lung cancer. Epigenetic inactivation of tumor suppressive genes through promoter CpG methylation is a fundamental regulatory process during tumorigenesis.

Methods:
The expression levels of Wnt11 were assessed in human normal tissues and lung cancer cell lines panel by semi-quantitative reverse transcription-PCR(RT-PCR). The promoter CpG methylation of Wnt11 were tested in bisulfite treated DNA by methylation-specific PCR (MSP). Western blots assay, colony formation assay, cell proliferation assay, wound-healing assay, dual-luciferase reporter assay and apoptosis assay were used to characterize the changes induced by overexpression of Wnt11.

Results:
In our study, analysis of Wnt11 expression revealed it was broadly expressed in human normal adult and fetal tissues, while it's frequently downregulated or silenced in multiple lung cancer cell lines. By performing methylation-specific PCR (MSP), promoter CpG methylation of Wnt11 were frequently detected in multiple lung cancer cell lines. Functional assays show that ectopic expression of Wnt11 could suppress tumor cell growth, possibly through inducing apoptosis. Moreover, Wnt11 represses canonical Wnt/β-catenin signaling and AKT signaling pathway. Wnt11 overexpression also reversed EMT and downregulated stem cell markers.

Conclusions:
Together our data suggest that in lung cancer, Wnt11 is lost by methylation and represents a tumor suppressor by antagonizing canonical Wnt/β-catenin signaling and AKT signaling pathway. Restoration of Wnt11 expression through demethylation could be an important therapeutic approach in the treatment of lung cancer.

Legal entity responsible for the study:
The Chinese University of Hong Kong

Funding:
RGC (TBRS #T12-401/13R), China Natural Science Foundation (NSFC #81572327), Johns Hopkins Singapore, and VC special research fund from The Chinese University of Hong Kong

Disclosure:
The author has declared no conflicts of interest.

Background:
Novel therapeutic approaches are urgently needed in lung cancer, particularly ones that address the malignant cells in their stroma microenvironment critical to drug resistance and disease relapse. The stroma constituents, mesenchymal stem cells (MSCs), interact with cancer cells by various methods including transfer of microvesicles (MVs) that vehicle protein, mRNA and microRNAs thereby altering recipient cells’ phenotype. Here, we examined the effect of MSCs’ MVs from primary (lung) and metastatic (bone marrow (BM)) niches on NSCLC cells with emphasis on translation initiation's (TI) role in the process.

Methods:
Lung and BM MSCs’ MVs were isolated and applied to NSCLC cell lines (H1299, H460). MVs uptake was confirmed and NSCLC cells were assayed for: viability (WST-1); cell count/death (trypan); proliferation (PCNA); migration (scratch); autophagy; TI status (factors, regulators, targets); MAPKs activation (immunoblotting).

Results:
We observed increased viability, proliferation and migration of Lung-MSCs’ MVs treated NSCLC cells whereas, BM-MSCs’ MVs treated cells showed reductions (50–90% and −40%, respectively p < 0.05). Correspondingly, Lung MSCs’ MVs elevated TI status whereas BM-MSCs’ MVs diminished it (60–120% and −30–70%, respectively p < 0.05). The opposite trend was also evident in MAPK activation and autophagy induction.

Conclusions:
Our observations not only depict a role for MSCs’ MVs in NSCLC phenotype but also display distinct differences between the primary and metastatic niches and may emphasize specific factors that shape disease progression. Further studies into the mechanism underlying the MVs-NSCLC cells’ contact and cargo transfer may promote the design of a therapeutic approach that will sabotage the dialogue between NSCLC cells and MSCs.

Clinical trial identification:


Legal entity responsible for the study:
Meir Medical Center

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
Mast cells (MCs) are key effectors in allergic reactions, but are also involved in tissue remodeling, wound healing and protection against pathogens. MCs infiltrate tumors and their number within the tumor microenvironment in certain cancer types, such as lung cancer, has been correlated with poor prognosis. The nature of crosstalk between lung cancer and MCs remains poorly resolved. In this study, we investigated the activation patterns within the MCs following cell-to-cell contact with lung cancer cells.

Methods:
Human MCs (HMC-1 and LAD-2) were exposed to Human lung cancer cell (H1299) derived membranes to recapitulate cell contact mediated activation. Lysates of MCs were tested for protein expression and posttranslational modifications (i.e. phosphorylation) by targeted western blotting. We unraveled the intracellular signaling molecules that are necessary for this signaling pathway by a pharmacological approach using several inhibitors. Each treatment was repeated at least 3 times.

Results:
H1299 membrane exposure activated the ERK1/2 MAP kinases in HMC-1 and in LAD-2 cells. AKT signaling was also activated in LAD-2 cells as a result of this contact. Furthermore, we discovered that inhibition of protein kinase C (PKC) augments the activation of ERK1/2 in LAD-2 cells, while it inhibits ERK1/2 activation in HMC-1 cells. Activation of AKT is inhibited by PI3K and PKC inhibitors.

Conclusions:
Our results suggest that H1299 membranes activate ERK1/2 in MCs. In addition, we discovered that there is an important difference between ERK1/2 MAP kinase signal transduction in HMC-1 and LAD-2 cells, whereby PKC is an inhibitor of the H1299 stimulated activation of ERK1/2 in LAD-2 cells, while it mediates ERK 1/2 activation in HMC-1 cells. Furthermore, we can conclude that H1299 membranes activate AKT and that the activation is mediated by PI3K and PKC. Rachel Shemesh and Yaara Gorzalczany contributed equally to this work. Correspondence Authors: Nir Peled, Ronit Sagi-Eisenberg.

Clinical trial identification:


Legal entity responsible for the study:
Prof. Nir Peled, Prof. Ronit Sagi-Eisenberg

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
In recent years, cancer metastasis remains a serious issue for drug development and target therapy. Although the metabolic reprogramming including glycolysis appears to promote cancer metastasis, the molecular mechanism by which this occurs remains unclear.

Methods:
From high throughput screening of glycolytic enzymes, we investigated aldolase A (ALDOA) as the most significant enzyme promoting cell metastasis in vitro and in vivo. Furthermore, we recruited the enzyme inhibitors and enzyme-dead constructs to compromised function of aldolase A.

Results:
We established a His-tagged ALDOA construct model and found ALDOA directed protein-protein interaction (PPI) with g-actin and the status correlated with malignant cancer cells, whereas in normal cell it did not. Meta-analysis of intergraded RNA and protein levels suggested ALDOA could be a prognostic marker in several cancer types. Moreover, compared with non-tumor tissues increased levels of ALDOA and g-actin are commonly detected in malignancies and strongly predict a worse prognosis in cancer patients. Therefore, we designed a specific peptide to block the interaction between ALDOA and g-actin to decrease the metastatic ability of cancer cells in vitro and prolong survival rate in vivo.

Conclusions:
These findings suggest a new therapeutic strategy for targeting the cancer-associated PPI between ALDOA and g-actin to combat metastatic cancers.

Clinical trial identification:


Legal entity responsible for the study:
Genomics Research Center, Academia Sinica, Taiwan

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
Cigarette smoking has been demonstrated as an important risk factor for lung cancer and causes poor prognosis. The critical roles of aerobic glycolysis and Warburg effect in supplying building blocks and energy for proliferation of lung cancer cells have also been well documented. However, it still remains unclear whether and how cigarette smoke alters the glucose uptake and glucose metabolism to promote the proliferation of NSCLC.

Methods:
Glycolysis and mitochondrial respiration rate were quantified by Seahorse XF analyzer. The gene expressions were assessed by quantitative RT-PCR and immunoblot. The cell lines were manipulated to inhibit or knockdown glucose transporters by glucose transporter competitive inhibitors and si-RNA. Fluorescence–labeled glucose analogue was employed to measure the glucose uptake ability. Cell viability and proliferation rate were analyzed by MTT assay and IncuCyte live cell analysis system respectively. Biochemical assays were used to evaluate the levels of glycolytic products.

Results:
NSCLC A549 and NCI-H292 cell lines were treated with cigarette smoke extract (CSE) or its carcinogenic ingredient Benzo[α]pyrene (B[α]P) as the cigarette smoke exposure models. Cigarette smoke promoted glucose uptake and glucose metabolism in NSCLC by increasing glucose transporter 3 (GLUT3) and sodium glucose transporter 1 (SGLT1) expression. The enhancing glycolysis activity was demonstrated in [13]C labelling LC/MS detection and further confirmed in biochemical assays of endogenous lactate and NADH production. Inhibiting glucose transporters were related to promoting survival in cigarette smoke treated cancer cells.

Conclusions:
The results suggest that targeting glucose transporters or glucose metabolism related enzymes in combination with the standard treatment are potential therapeutic strategies in treating smoker lung cancer patients.

Clinical trial identification:
NA

Legal entity responsible for the study:
China Medical University, Taiwan

Funding:
Ministry of Science and Technology, Taiwan

Disclosure:
All authors have declared no conflicts of interest.

Background:
We previously identified nucleolar protein interacting with the FHA domain of pKi-67 (NIFK) as a poor prognostic marker in lung cancer. Furthermore, NIFK overexpression promotes cancer metastasis via decreasing casein kinase 1α (CK1α) expression, a suppressor of pro-metastatic TCF4/β-catenin signaling. We further observe the axis is induced by the downregulation of a novel transcription factor RUNX1. However, the interplay between NIFK, CK1α and RUNX1 remains largely unknown. In this study, we aim to unravel the interactive mechanism of the signaling axis NIFK/RUNX1/CK1α, and to characterize its potential clinical value in cancer patient cohort.

Methods:
NIFK is pointed out to possess RNA binding function via the RNA Recognition Motif (RRM). RNA immunoprecipitation assay was performed using specific NIFK antibody in lung cancer PC13 and A549 cells after NIFK overexpression. RNA targets were analyzed by RT-PCR and Next Generation Sequencing (NGS). In addition, relative NIFK, RUNX1 and CK1α expression and its association with patient survival outcome were investigated in lung cancer cohorts.

Results:
We observe the increase in amount of RNA binding targets after NIFK overexpression respectively in PC13 and A549 cells as comparing with the control. Moreover, NIFK appears to bind with RUNX1 RNA but not CK1α suggesting it is the initial step of NIFK-mediated TCF4/β-catenin signaling regulation. NIFK also leads to RUNX1 RNA instability of which mechanism remains to be explored. RUNX1 is observed to associate with good prognosis in lung cancer datasets (jacob-00182-CANDF and GSE13213). In addition, relative expression of the axis is further revealed in lung cancer cohort.

Conclusions:
We first show the interactive mechanism of pro-metastatic molecule NIFK in regulating TCF4/β-catenin signaling, which might contribute to therapeutic target design for lung cancer patients.

Clinical trial identification:


Legal entity responsible for the study:
Chang Gung Memorial Hospital

Funding:
Ministry of Science and Technology, Taiwan

Disclosure:
All authors have declared no conflicts of interest.

Background:
Lung cancer is the leading cause of cancer death in both gender accounting for 15% of deaths among young people (0–49 years), 30% among adults (50–69 years) and 27% among those over seventy. Matrix metalloproteases (MMPs) are a large family of proteins consisting of at least 26 human MMPs. They are zinc-dependent endopeptidases that cleave components of the extracellular matrix (ECM) and basement membrane and has been reported that play an important role in several steps of cancer development. Many studies have shown that a nucleotide polymorphism (–1306C3T) in the MMP2 promoter in addition to smoking and age are major risk factors for the onset of lung cancer. The aim of this study was to examine the association of MMP-2 polymorphism and smoke as a risk for cancer in 71 Italians lung cancer patients.

Methods:
Seventy-one patients (56 men and 15 women) aged between 44 and 84 years with adeno or squamous carcinoma in inoperable stage IIIA/IIIB/IV were enrolled in this study; information about clinical and histopathological data and smoking habits were collected through the clinical charts; genotyping was performed using direct DNA sequencing.

Results:
44/71 patients (62%) had the CC genotype, 15/71 (21%) patients had CT genotype and 12/71 (16%) had TT genotype. About smoking 47/71 (66%) patients were smokers, 5/71 (7%) patients had never smoked and 19/71 (26%) of them were ex-smokers and had stopped for at least 3 years. In subgroup of smokers patients, the overall average number of years of smoke was 44, the average number of smoked cigarettes was 25 and the number of pack- year 48; the smoker group was divided into heavy smokers smoking from 50 to 60 cigarettes/day, a group of heavy smokers smoking from 11 to 49 cigarettes/day and light smokers smoking from 2 to 10 cigarettes/day. A higher allelic frequency of CC genotype and stage IV disease in the heavy and mean smoking group were observed compared to light smokers (p < 0.001 and p < 0.0001 respectively) while the TT genotype was much more frequent in stage III and in subgroup of light smokers (p < 0.05).

Conclusions:
These preliminary results suggest a significant association between the mmp2-1306c/t polymorphism and smoke that could represent a significant risk factors of developing lung cancer.

Clinical trial identification:


Legal entity responsible for the study:
IRCCS Istituto Tumori Giovanni Paolo II

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
Long intergenic non-coding RNA (lincRNA) is a family of gene transcripts whose functions are largely unknown in disease process. Although cigarette smoking is the main cause of lung cancer, lung cancer in never smokers is a separate entity and its underlying cause is little known. Growing evidence suggests lincRNAs play a significant role in cancer development and progression; however, such data is lacking for lung cancer in never-smokers.

Methods:
This study conducted comprehensive profiling of lincRNAs from RNA-seq data in 27 pairs of lung adenocarcinoma and its normal tissues of never smokers. Both known and novel lincRNAs segregated tumors from normal tissues clearly. About a third of lincRNAs were differentially expressed between tumors and normal samples and most of them were coordinated with their putative protein gene targets. More interestingly, lincRNAs defined two clusters of tumors that were associated with tumor aggressiveness and patient survival.

Results:
We identified a subset of lincRNAs that were differentially expressed but also associated with patient survival. Almost perfect concordance was observed for differentially expressed lincRNAs and lincRNAs associated with survival from the discovery set were also predictive for survival in the validation set of 85 transcriptomes.

Conclusions:
With further validation, these lincRNAs could serve as potential diagnostic and prognostic markers.

Clinical trial identification:


Legal entity responsible for the study:
Mayo Clinic

Funding:
The National Natural Science Foundation of China (No.81472835)

Disclosure:
All authors have declared no conflicts of interest.

Background:
Numerous studies have shown that long non-coding RNAs (lncRNAs) behave as a novel class of transcript during multiple cancer processes, such as cell proliferation, apoptosis, migration, and invasion. LINC00152 is located on chromosome 2p11.2, and has a transcript length of 828 nucleotides. The biological role of LINC00152 in LAD (lung adenocarcinoma) remains unknown.

Methods:
Quantitative reverse transcription PCR (qRT-PCR) was used to detect LINC00152 expression in 60 human LAD tissues and paired normal tissues. In vitro and in vivo studies showed the biological function of LINC00152 in tumour progression. RNA transcriptome sequencing technology was performed to identify the downstream suppressor IL24 (interleukin 24) which was further examined by qRT-PCR, western bolt and rescue experiments. RNA immunoprecipitation (RIP), RNA pulldown, and Chromatin immunoprecipitation (ChIP) assays were carried out to reveal the interaction between LINC00152, EZH2 and IL24.

Results:
LINC00152 expression was upregulated in 60 human LAD tissues and paired normal tissues. High levels of LINC00152 expression were correlated with advanced TNM stage, larger tumor size, and lymph node metastasis, as well as shorter survival time. Silencing of LINC00152 suppressed cell growth and induced cell apoptosis. LINC00152 knockdown altered the expression of many downstream genes, including IL24. LINC00152 could interact with EZH2 and inhibit IL24 transcription. Moreover, the ectopic expression of IL24 repressed cell proliferation and partly reversed LINC00152 overexpression-induced promotion of cell growth in LAD.

Conclusions:
Our study reveals an oncogenic role for LINC00152 in LAD tumorigenesis, suggesting that it could be used as a therapeutic target in LAD treatment.

Clinical trial identification:


Legal entity responsible for the study:
The Second Affiliated Hospital of Nanjing Medical University

Funding:
National Natural Science Foundation of China (No. 81472198), the Key Clinical Medicine Technology Foundation of Jiangsu Province (No. BL2014096), the Medical Innovation Team Foundation of the Jiangsu Provincial Enhancement Health Project (No.21), “333 high class Talented Man Project” (No. BRA2016509)

Disclosure:
All authors have declared no conflicts of interest.

Background:
Mounting evidence demonstrates that long non-coding RNAs (lncRNAs) are novel transcripts governing multiple biological processes, and that their dysregulation is involved in the development and progression of multiple types of cancer. Small Nucleolar RNA Host Gene 20 (SNHG20) is a 2183 bp lncRNA. The clinical relevance of SNHG20 and its molecular mechanisms involved in non-small cell lung cancer (NSCLC) have not been well documented.

Methods:
Expression of SNHG20 was analyzed in 42 paired NSCLC tissues and five NSCLC cell lines by quantitative reverse-transcription polymerase chain reaction (qRT-PCR). Relationship between SNHG20 levels and NSCLC patients clinicopathologic feature was analyzed. Kaplan–Meier survival analysis was used to evaluate the prognosis of patients with high or low SNHG20 expression. Univariate and multivariate survival analysis were performed to further confirm the prognostic role of SNHG20. SNHG20 siRNAs and overexpression vector were transfected into NSCLC cells to knockdown or upregulate SNHG20 expression. In vitro and in vivo studies showed the biological role of SNHG20 in lung cancer cell proliferation and migration. RIP and ChIP assays were carried out to uncover the mechanism of SNHG20's regulation of underlying targets.

Results:
We found that SNHG20 expression was markedly upregulated in NSCLC tissues, and its upregulation was associated with larger tumor size (P = 0.012), lymph node invasion (P = 0.005) and TNM stage (P = 0.008). Kaplan–Meier survival analysis indicated that patients with low SNHG20 expression level had better progression-free survival (P = 0.003) and overall survival (P = 0.001) than those with high SNHG20 expression. Further univariate and multivariable Cox regression analysis suggested that increased SNHG20 was an independent prognostic indicator for this disease. Knockdown of SNHG20 repressed NSCLC cell proliferation, migration and induced cell apoptosis. Mechanistic investigations revealed that SNHG20 could interact with EZH2, thereby repressing P21 expression.

Conclusions:
Our findings indicate that SNHG20 is significantly upregulated in NSCLC tissues and it may represent a new candidate for use in NSCLC diagnosis, prognosis and therapy.

Clinical trial identification:


Legal entity responsible for the study:
The Second Affiliated Hospital of Nanjing Medical University

Funding:
National Natural Science Foundation of China (No. 81472198,81672307); the Key Clinical Medicine Technology Foundation of Jiangsu Province (No. BL2014096); the Medical Innovation Team Foundation of the Jiangsu Provincial Enhancement Health Project (No.21); “333 high class Talented Man Project” (No. BRA2016509)

Disclosure:
All authors have declared no conflicts of interest.

Background:
Pseudogenes have been considered as non-functional transcriptional relics of human genomic for long time. However, recent studies revealed that they play a plethora of roles in diverse physiological and pathological processes, especially in cancer, and many pseudogenes are transcribed into long noncoding RNAs and emerging as a novel class of lncRNAs. However, the biological roles and underlying mechanism of pseudogenes in the pathogenesis of non-small cell lung cancer are still incompletely elucidated.

Methods:
Real-time polymerase chain reaction (PCR) was used to examine DUXAP10 expression in NSCLC cell lines/tissues compared with normal epithelial cells/adjacent non-tumorous tissues. Cox proportional hazards regression models were performed to further confirm the prognostic role of DUXAP10. Cell proliferation assays were performed to detect the biological effects of DUXAP10 in gastric cancer cells. Real-time PCR, western-blot and immunohistochemistry were used to evaluate the mRNA and protein expression of LATS2 and RRAD.

Results:
This study identifies a putative oncogenic pseudogene DUXAP10 in NSCLC, which is located in 14q11.2 and 2398 nt in length. Firstly, we found that DUXAP10 was significantly up-regulated in 93 human NSCLC tissues and cell lines, and increased DUXAP10 was associated with patients’ poorer prognosis and short survival time. Furthermore, the loss and gain of functional studies including growth curves, migration, invasion assays and in vivo studies verify the oncogenic roles of DUXAP10 in NSCLC. Finally, the mechanistic experiments indicate that DUXAP10 could interact with Histone demethylase Lysine specific demethylase1 (LSD1) and repress tumor suppressors Large tumor suppressor 2 (LATS2) and Ras-related associated with diabetes (RRAD) transcription in NSCLC cells.

Conclusions:
These findings demonstrate DUXAP10 exerts the oncogenic roles through binding with LSD1 and epigenetic silencing LATS2 and RRAD expression. Our investigation reveals the novel roles of pseudogene in NSCLC, which may serve as new target for NSCLC diagnosis and therapy.

Clinical trial identification:


Legal entity responsible for the study:
The Second Affiliated Hospital of Nanjing Medical University

Funding:
National Natural Science Foundation of China (No. 81472198), the Key Clinical Medicine Technology Foundation of Jiangsu Province (No BL2014096), the Medical Innovation Team Foundation of the Jiangsu Provincial Enhancement Health Project (No.21), “333 high class Talented Man Project” (No. BRA2016509)

Disclosure:
All authors have declared no conflicts of interest.

Background:
In non-small cell lung cancer (NSCLC), histological classification dictates choice of patient therapy. In this study, we aimed to establish a gene expression based single-sample predictor (SSP) for histological classification of NSCLC tumors using archival tissue that may be used in parallel with e.g. gene fusion detection as a multicomponent single assay.

Methods:
A NanoString probe set was designed to target 12 genes routinely used as IHC markers for histological subtyping as well as fusion genes known to be frequently active in NSCLC. Gene expression data was derived from NanoString analysis of 78 formalin-fixed paraffin-embedded (FFPE) NSCLCs with known histological subtypes (development cohort). A SSP was trained using AIMS (1) in the development cohort for prediction of adenocarcinoma (AC), squamous cell carcinoma (SqCC), or neuroendocrine tumors (NE). The AIMS model was applied to 11 FFPE tumors classified as large cell carcinomas (LCC) according to the WHO2004 classification (2), and 199 fresh frozen NSCLC tumors analyzed by RNA sequencing (GSE81089)(3). Finally, the SSP will be applied to 11 NSCLC-not otherwise specified (NOS) cases (4) subjected to in-depth pathological re-evaluation.

Results:
The SSP was successfully applied to NanoString data from 11 LCCs re-classified as AC, SqCC and LCC according to the revised WHO2015 guidelines (2). Of reclassified LCC tumors, 100% of AC cases and 75% (3/4) of SqCC tumors were correctly identified. In GSE81089, the SSP was erratically successful depending on histology of the tumor classified, with 97.4% concordance for AC, 97.1% for SqCC, but mismatch for 3 out of 5 NE tumors. In summary, the SSP could successfully classify tumors of AC and SqCC histology in both validation cohorts but could less successfully classify non-AC and non-SqCC tumors respectively.

Conclusions:
Gene expression based SSP can accurately classify AC and SqCC histology. Expanded transcriptional profiling may be required to capture all aspects of lung cancer biology for precise and possibly refined histological subtyping of individual cases. Gene expression-based analysis could serve as a promising complement to existing techniques, providing a useful multicomponent assay for lung cancer diagnostics.

Clinical trial identification:


Legal entity responsible for the study:
Lund University

Funding:
The Swedish Cancer Society, the Mrs Berta Kamprad Foundation, the Gunnar Nilsson Cancer Foundation, the Crafoord Foundation, BioCARE a Strategic Research Program at Lund University, the Gustav V:s Jubilee Foundation, Skane University Hospital Foundation, and governmental funding (ALF)

Disclosure:
All authors have declared no conflicts of interest.

Background:
Diminished or absent expression of the enzyme argininosuccinate synthetase 1 (ArgSS1 or ASS1) portends chemotherapy resistance and poor prognosis in a number of tumor types, suggesting arginine depletion is a viable therapeutic strategy in ArgSS1 deficient tumors. ArgSS1 expression and its implications on prognosis have not been studied in squamous cell carcinoma of the lung.

Methods:
Resected pathology specimens were collected from patients with squamous cell carcinoma of the lung and analyzed for ArgSS1 expression by IHC. ArgSS1 expression was deemed intact if there was >50% expression in tumor cells and deficient if there was ≤50%. Chart reviews were conducted to abstract patient demographic and oncologic information. Pearson's correlations were utilized to evaluate potential associations between ArgSS1 status and oncologic variables. The Kaplan-Meier estimator was used to evaluate a potential association between ArgSS1 expression and survival which was compared with a log-rank test.

Results:
Sixty-seven specimens of squamous cell carcinoma of the lung were evaluated. Patients were diagnosed at a mean age of 66.9 years (SD 9.1). The majority of patients were male (64.2%). 97% were current or former smokers, and 89.6% had early stage disease. Most patients (64.2%) had moderately differentiated tumors. Nineteen (28.3%) tumors were ArgSS1 deficient. We did not find any significant associations between ArgSS1 expression and gender, tobacco use, stage at diagnosis, or tumor differentiation. There was no significant difference in overall survival between those who had intact ArgSS1 expression (median 42 months, interquartile range 28-not reached) and those who did not (median not reached, interquartile range 14-not reached; HR = 0.19; p = 0.66).

Conclusions:
Despite the associations of ArgSS1 deficiency and poor survival in other malignancies, we did not observe an association between ArgSS1 and overall survival in patients with squamous cell carcinoma of the lung. Our findings might be limited by our sample size. Even if ArgSS1 is not a prognostic marker in squamous cell carcinoma of the lung, it may still have predictive significance given the development of arginine deaminases in clinical trials. Preclinical work is ongoing with cell lines to study this further.

Clinical trial identification:


Legal entity responsible for the study:
Mayo Clinic

Funding:
Has not received any funding

Disclosure:
A. Mansfield: Payments to his institution from AbbVie, Genentech, BMS and Trovagene for consulting, and payment to his institution from Novartis for research. All other authors have declared no conflicts of interest.

Background:
Pre-analytical factors as fixation time has influence on morphology of diagnostic and predictive immunohistochemical staining and are increasingly used in the evaluation of lung cancer. Our aim was to investigate if variations in fixation time influence the outcome of immunohistochemical staining in lung cancer.

Methods:
From lung cancer resections specimen with tumor size >4 cm, 10 fragments were sampled: 2 received standard fixation, 5 delayed, and 3 prolonged fixation. After paraffin embedding, tissue microarrays (TMA) were made. Immunohistochemistry (IHC) of 20 antibodies were applied and scored for quality and intensity of staining. TMA slides were scored by core/case: quality of cores and IHC intensity in cores of sufficient quality.

Results:
Tissue with delay in start of fixation showed deterioration of tissue quality leading to reduction in the evaluation of staining for CK-7, Keratin MNF116, Cam5.2, CK5/6, TTF-1, CMET, Napsin-A, D2-40, PD-L1 antibodies. Prolonged fixation had no influence on the performance of immunohistochemical stains.

Conclusions:
Delay of fixation negatively effects the evaluation of IHC staining. Therefore, tissue should be fixated soon after surgery.

Clinical trial identification:


Legal entity responsible for the study:
European Thoracic Oncology Platform (ETOP)

Funding:
VU University Medical Center

Disclosure:
All authors have declared no conflicts of interest.

Background:
Increasing evidence emerges that oncogenic mutations in cancer occur at both clonal and subclonal levels. Targeted drug treatment programs based on clinical mutation testing do not consider the clonal or subclonal frequencies of oncogenic mutations but the pure presence. Our aim was to study the clonal and subclonal frequencies of (oncogenic) mutations in lung adenocarcinoma (LUAD).

Methods:
Fresh frozen and formalin-fixed paraffin embedded tumor and normal tissues of 50 LUAD patients were investigated by WES. Computational analysis for accurate estimation of purity, ploidy and absolute copy numbers followed by assessment of the cancer cell fractions (CCF, ratio of the observed and the expected allelic fraction of a mutation) for each detected mutation in the individual adenocarcinoma was performed. Statistical distribution of CCFs was performed to assign mutations to distinct clonal and subclonal clusters. Clonal and subclonal mutational status was verified by digital droplet PCR of selected cases. Tumor mutational burden was calculated as exonic non-synonymous mutations per case. Mutational signatures were determined.

Results:
In the study cohort, 14 (28%) tumor samples were composed of clonal mutations and 36 (72%) of clonal and subclonal mutations. Of the 36 cases with subclonal clusters, 22 (61%) showed 1 subclonal cluster, 11 (31%) revealed 2 subclonal clusters and 3 (8%) 3 subclonal clusters. Among the subclonal mutations, we found known oncogenic mutations: KRAS c.34G > T (p.G12C), KRAS c.35G > T (G12V), KRAS c.182_183delinsTC (p.Q61L). The average number of tumor exonic non-synonymous mutations per case was 155 (median 103, ranging from 27 to 1593). The average exonic non-synonymous mutation rate was 5 per million base pairs. We found mutational signatures that are correlated with tobacco smoking, age, AID/APOBEC.

Conclusions:
We detected clonal and subclonal mutations in the majority of LUAD. We found oncogenic mutations in KRAS and EGFR. Our findings indicate the importance of the determination of clonal and subclonal status of oncogenic mutations and could also be meaningful for the estimation of tumor mutational burden as potential clinical marker.

Clinical trial identification:


Legal entity responsible for the study:
N/A

Funding:
Swiss Cancer League

Disclosure:
R. Thomas: Ownership interests (including patents) for AstraZeneca, Bayer, Novartis, and Roche; consultant/advisory board member for AstraZeneca, Bayer, Boehringer-Ingelheim, Clovis, Daiichi-Sankyo, Johnson & Johnson, Lilly, Merck, MSD, New Oncology, Puma, Roche, and Sanofi-Aventis. All other authors have declared no conflicts of interest.

Background:
Therapeutic approaches to non-small cell lung cancer (NSCLC) have shifted toward an emphasis on molecularly targeted therapy in genotypic subsets of patients such as EGFR, ALK, ROS1. Patients with driver mutations receiving matched target drugs could have significantly longer progression free and overall survival. In this study, we aimed to analyse the genomic alterations of NSCLC.

Methods:
Formalin-fixed paraffin-embedded tumor samples of 323 Chinese NSCLC patients including 193 males (59.75%) and 130 females (40.25%) with a median age of 58 were collected for next-generation sequencing (NGS)-based 59-genes panel assay. Genomic alterations including single base substitution, short and long insertions/deletions, copy number variations, and gene fusions in selected genes were assessed.

Results:
Different histological subtypes of adenocarcinoma (278/323, 86.07%), squamous carcinoma (32/323, 9.91%), mixed carcinoma (7/323, 2.17%) and large cell carcinoma (6/323, 1.86%) were included in the Chinese NSCLC cohort. The top ranked genomic alterations were TP53 (182/323, 56.35%), EGFR (133/323, 41.18%), MSH2(51/323, 15.79%), TSC2 (46/323, 14.24%), MSH6 (30/323, 9.29%), ALK fusions (28/323, 8.67%), MET (22/323, 6.81%), KRAS (22/323, 6.81%), BRAF (20/323, 6.19%), PIK3CA (18/323, 5.57%), HER2 (16/323, 4.95%), ROS1 fusions (9/323, 2.79%), and RET fusions (8/323, 2.48%), which makes up 90.40% of the 323 patients with at least one driver mutation. In addition to common driver mutations, rare mutation types such as HIP1-ALK, CEP72-ROS1, RAD18-ROS1 and FGFR3-TACC3 were also detected by deep sequencing assay.

Conclusions:
With the help of NGS, our study revealed the landscape of driver gene mutations in 323 Chinese NSCLC patients, and we also found the most target locations that might be treated by targeted therapies. Further studies may emerge whether concurrent mutations, mutation burden and the number of actionable mutation are associated with survival outcome in NSCLC.

Clinical trial identification:


Legal entity responsible for the study:
Yueping Liu

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
Although treatment with EGFR tyrosine kinase inhibitors (TKIs) is initially effective in a subgroup of lung cancer patients, therapy resistance ultimately occurs. Resistance mechanisms consist of overexpression and co-expression of receptor tyrosine kinases (RTKs) and overexpression of STAT3. PIM1 was shown to be an important regulator of both RTKs and STAT3 expression, and inhibition of PIM1 with the pan-PIM inhibitor, AZD1208, might prevent STAT3 and RTK up-regulation after TKI treatment. This research focuses on combining TKI treatment with AZD1208 to prevent therapy resistance in different EGFR mutant NSCLC cell lines.

Methods:
Using TaqMan quantitative-PCR we studied basal mRNA expression levels of PIM1 and PIM3 in 5 EGFR-mutant NSCLC cell lines. Cells were then exposed to single osimertinib or AZD1208 treatment, or the combination, to determine the combination index (CI) and changes in cell viability. Moreover, changes in protein expression of different RTKs, STAT3 and downstream effectors of STAT3 were studied in 2 cell lines using western blotting.

Results:
The PC9 and H1975 cell lines were shown to have high PIM1 and STAT3 expression compared to the other EGFR mutant NSCLC cell lines. Combined osimertinib and AZD1208 treatment showed moderate synergism in all cell lines, with CIs ranging from 0.75 to 0.86 in triplicate experiments. Western blot experiments indicate that osimertinib treatment leads to upregulation of pCDCP1, pYAP1, pPaxillin and pSTAT3 in the PC9 and H1975 cell lines, suggesting initiation of resistance to single osimertinib treatment. In contrast, single AZD1208 treatment does not induce, or even lower expression of these proteins compared to baseline levels. When combining both treatments, the osimertinib-induced pSTAT3 up-regulation can be prevented with AZD1208. The effect of AZD1208 on RTK expression will be further explored.

Conclusions:
Single TKI treatment in EGFR mutant NSCLC induces expression of RTKs and STAT3, ultimately leading to therapy resistance. Inhibition of PIM1 with AZD1208 can abolish the osimertinib-induced phosphorylation of STAT3, and thereby prevents activation of resistance pathways.

Clinical trial identification:


Legal entity responsible for the study:
IGTP, Germans Trias i Pujol Research Institute, Badalona, Barcelona, Spain

Funding:
Fundació Obra Social “La Caixa”

Disclosure:
All authors have declared no conflicts of interest.

Background:
p21-activated kinase 1 (PAK1) stimulates growth and metastasis in several types of tumors, including NSCLC. Protein kinase C iota (PKCi) is an enzyme highly expressed in NSCLC that regulates PAK1 signaling. We have previously shown that cancer pathway-specific intervention, like EGFR inhibitors in EGFR mutant NSCLC, results in parallel compensatory activation of other pathways, including the receptor tyrosine kinases AXL and MET, the transmembrane protein CUB domain-containing protein-1 (CDCP1) or the transcriptional regulators STAT3 and YAP1. We have now explored whether a non-pathway-specific approach can be efficient in three subsets of NSCLC.

Methods:
Three lung cancer cell lines were used: HCC827 and H23 lung adenocarcinoma cells that carry EGFR and KRAS mutations respectively, and H520 PAK1 amplified squamous NSCLC cells. Cell viability assays and western blotting were applied to evaluate the effect of IPA-3 (PAK1 inhibitor) plus auranofin (PKCi inhibitor). We used a Chou-Talalay modified method for drug combination studies that offers quantitative definition for additive effect (combination index [CI] = 1), synergism (CI < 1), and antagonism (CI > 1).

Results:
We found a differential PAK1 expression or activation profile in the three models, with H520 cells being the ones with the highest PAK1 expression and activation. IPA-3 plus auranofin was highly synergistic in HCC827, H23 and H520 cells with CIs of less than 0.4. In the EGFR mutant HCC827 cell line, IPA-3 plus afatinib or osimertinib was additive (CI = 0.9), or slightly synergistic (CI = 0.8). In the same cell line, the combination of IPA-3 plus auranofin abrogated EGFR and downstream signaling (ERK, AKT, STAT3, YAP1) and inhibited the expression and activation of AXL, MET and CDCP1. IPA-3 plus auranofin was, similarly, highly synergistic in H23 (CI = 0.3) and H520 (CI = 0.3) cells.

Conclusions:
For the first time, we are reporting that a non-pathway specific combination can be effective in EGFR and KRAS mutant as well as squamous NSCLC. The combination could control the counter-regulatory pathways that are made apparent and ultimately cause resistance when a pathway specific-intervention is applied.

Clinical trial identification:


Legal entity responsible for the study:
IGTP, Germans Trias i Pujol Research Institute, Badalona, Barcelona, Spain

Funding:
International Association for the Study of Lung Cancer (IASLC)

Disclosure:
All authors have declared no conflicts of interest.

Background:
The incidence of EGFR mutations vary according to geographic region of the world. The EGFR rates in the western world are 15% whereas the incidence of EGFR mutation in the EASTERN population is 45–55%. In India, the incidence of EGFR mutation is approx. 33%. Similarly, there is a paucity of data regarding the incidence of T790 M mutation following EGFR TKIs from the Indian subcontinent. This study was therefore undertaken to analyse the incidence of T790M mutation in the Indian population following therapy with EGFFR TKIs.

Methods:
EGFR mutant NSCLC stage IV patients who received Tyrosine kinase inhibitors and progressed on TKI were analysed. T790M status was determined using the droplet digital PCR.

Results:
41 patients were selected using above selection criteria. T790M mutation was detected in 22 of 41 patients (54%). 21 of 22 patients had retained the primary EGFR mutation also. Out of these 22 patients, del19 was present in 14 patients and 8 patients had L858R mutation. Most common site of progression was pleural and plural effusion. Median duration of treatment on TKI before progression is 289.7 days, highest duration being 1290 days and lowest 45 days.

Conclusions:
Exact incidence of T790M mutations after progression on TKI s in Asian population is not exactly known and requires large data, as incidence may be different than reported in western population.

Clinical trial identification:
none

Legal entity responsible for the study:
All authors

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
Anaplastic lymphoma kinase (ALK) immunohistochemistry (IHC) is an established screening method for the detection of ALK gene rearrangements by fluorescence in situ hybridization (FISH) in patients with advanced non-small cell lung cancer. However, little is known about the correlation between ALK IHC scores and sensitivity to treatment with an ALK-tyrosine kinase (-TKI) inhibitor.

Methods:
ALK IHC score was evaluated through a 4-tiered system (0, 1+, 2+, 3+) based on the D5F3 clone (Cell Signaling). Any number of cells stained was considered as ALK positive, and the strongest staining present was the final score. H-score was assessed using the following formula: [1 × (% cells 1+) + 2 × (% cells 2+) + 3 × (% cells 3+)] resulting into a score from 0 to 300. All ALK IHC score positive tumors underwent confirmatory FISH (Vysis ALK Break Apart Probe kit).

Results:
From June 2011 to May 2017, 50 double ALK IHC/FISH-positive patients were identified at our Institution. The majority of patients had an ALK IHC score ≥2+ [5/50 (10%) score 1+; 23/50 (46%) score 2+; 22/50 (44%) score 3+], with 47/50 (94%) tumors having any ALK IHC positivity in ≥50% of cells. H-score was more commonly ≥100 [2/50 (4%) 1-<100; 14/50 (28%) ≥100-<200; 34/50 (68%) ≥200–300]. Overall, 31 patients were treated with the ALK-TKI crizotinib for advanced disease, whose main charachteristics were as follows: median age 50 years (28–80), male/female (42%/58%), never/ever smokers (61%/39%), performance status 0/1 (74%/26%), chemotherapy-pretreated (90%). The results showed no significant correlation between the intensity of ALK IHC score or H-score with regard to response to crizotinib. Similarly, no significant association was noted between the intensity of ALK IHC score as well as the H-score and progression-free survival.

Conclusions:
In double ALK IHC/FISH-positive patients ALK IHC scores are typically skewed towards higher values, and ALK protein is expressed in a mostly diffuse way. Such preferentially higher distribution of ALK IHC scores as well as diffuse ALK staining might imply difficulty in setting a discriminatory treshold of activity with regard to sensitivity to crizotinib. This, in turn, could justify the absence of predictivity of ALK IHC scores.

Clinical trial identification:


Legal entity responsible for the study:
Giulio Metro

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
ALK rearrangement in non-small cell lung cancer (NSCLC) patients has recently been identified as a driver gene and benefited from crizotinib treatment. However, no data are available for ALK rearrangement NSCLC about the relationship between primary and metastatic patients. The aim of this study was to examine the positive rate of ALK rearrangement in primary and metastatic NSCLC, and to investigate their relationships.

Methods:
From January 2013 to May 2015, 384 cases of primary NSCLC, 246 cases of matched metastatic tumors, and 47 cases of normal lung specimens, as the control group, were collected in our multicenter. The positive rate of ALK rearrangement among the NSCLC population was established, and thus the consistency of ALK rearrangement in advanced primary NSCLC and associated metastases and the relationship between ALK rearrangement and clinical data was analyzed.

Results:
The positive rate of ALK rearrangement on primary tumor was 11.46% (44/384). For those 246 paired cases, the positive rate on primary tumor was 10.98% (27/246), with that of metastases 7.32% (18/246). Among the 246 cases, there were two cases whose metastases were positive but primary tumors were negative and 11 case whose primary tumors were positive but metastases were negative. Positive rate of ALK rearrangement was higher in the primary lesions than in metastases. It was of statistical significance between the two groups (χ[2] = 112.208, P < 0.001). The positive rate of primary tumors could be predicted by metastases (κ = 0.683, P < 0.001). The sensitivity was 59.26% (16/27) and the specificity was 99.09% (217/219).

Conclusions:
The metastases of NSCLC can predict ALK rearrangement of the primary lesions. It can be used as an alternative means for metastases to detect ALK rearrangement which are not readily available.

Clinical trial identification:


Legal entity responsible for the study:
Chunwei Xu

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
Lung cancer is the leading cause of cancer death in women and men. The most common mutations in lung adenocarcinoma are in EGFR and KRAS, and along with ten other genes (e.g. ALK and MET) they show a prevalence of 5% or less. As many of these mutations are clinically actionable, it is essential to know the mutation state for all of these genes. Therefore, it is necessary to evaluate multiple types of mutations (SNP, fusions, and CNV) of numerous genes in a small amount of FFPE tissue. We performed a preliminary orthogonal validation of the next generation sequencing based Oncomine Focus Assay (OFA, Thermo Fisher) for the determination of ALK gene fusion in lung adenocarcinoma samples from Chilean patients under standard clinical settings.

Methods:
This work analyzed 722 lung adenocarcinoma samples from patients recruited in the NIRVANA study by an immunohistochemistry-based ALK test (Ventana) and OFA (including an ALK gene fusion breakpoint assay). Twenty-eight ALK-positive cases by Ventana ALK, OFA or both and 22 negative samples for both tests, were analyzed using a validated (in EU and China) qPCR EML4-ALK fusion gene detection kit (AmoyDx).

Results:
Using the EML4-ALK qPCR fusion kit as benchmark, both Ventana ALK and OFA have a sensitivity of 75% [CI95%:51–91]. However, OFA presents a 96% [CI95%: 80–>99] specificity vs. 88% [CI95%:69–97] for Ventana ALK. Therefore, the positive predictive value is 94% [CI95%:68–99] for OFA and 83% [CI95%:63–94] for Ventana ALK. The most commons ALK gene fusions were exon 20 and 6 of EML4.

Conclusions:
When these techniques were compared using “real world” lung adenocarcinoma samples, OFA presented an advantage in the ability to predict positive values and was more specific than Ventana ALK test. These results indicate the need for further research to validate the use of OFA panel for the determination of these gene rearrangements.

Clinical trial identification:
NIRVANA study NCT03220230

Legal entity responsible for the study:
Pfizer Chile

Funding:
Pfizer

Disclosure:
M. Freire, R. Lizana, L. Ramos: Currently Pfizer employee and directly involved in this research initiative. G. Sepúlveda, A. Blanco: Currently Pfizer employee and directly involved in this research initiative, through the data analysis. S. Chernilo, O. Arén: Principal Investigator in one of the centers that recruit subject to this study; involved in the results discussion and review; Pfizer funding to research center for the subjects recruitment. C. Fernández: Collaborates with one of Principal Investigator and also gives Anatomopathological support to this study; Involved in the results discussion and review; Pfizer funding to anatomopathological team for the samples analyzed. R. Armisén: Currently Pfizer employee, head of research at the center where this research was done; involved in the results discussion and review.

Background:
Determination of ROS1 positivity in non-small cell lung cancer (NSCLC) is essential for appropriate identification of patients who may respond to ROS tyrosine kinase inhibitor therapy. ROS1 positivity is often clinically detected by fluorescence in situ hybridization (FISH). A ROS1 antibody that can detect ROS1 protein with high sensitivity, specificity, and consistency would allow for immunohistochemistry (IHC) screening for ROS1 positivity. Here, we present data on the feasibility of using VENTANA ROS1 (SP384) Rabbit Monoclonal Primary Antibody (anti-ROS1 SP384) for the detection of ROS1 protein.

Methods:
Anti-ROS1 SP384 has been optimized with VENTANA OptiView DAB IHC Detection Kit and on BenchMark IHC/ISH instruments. Anti-ROS1 SP384 was evaluated for sensitivity, specificity, and consistency of staining for the ROS1 protein. Sensitivity and specificity were assessed through immunoreactivity using tissue microarrays (TMAs) containing NSCLC (n = 40), cholangiocarcinoma (n = 64), melanoma (n = 90), 20 non-neoplastic tissue types, and additional 15 neoplastic tissues. The following parameters were assessed: percent target cell staining, overall intensity of target cell staining on a scale of 0–3 in 0.25 increments, and reactivity which is deemed as sample with >0% ROS1 staining. Consistency of anti-ROS1 SP384 staining was assessed on BenchMark GX, XT and ULTRA platforms and for 3 different antibody lots.

Results:
Anti-ROS1 SP384 exhibited high sensitivity and specificity in when staining TMAs containing a range of neoplastic and non-neoplastic tissues and when comparing the results to prevalence of ROS1 expression cited in the literature. The antibody showed expected expression of ROS1 in NSCLC, cholangiocarcinoma, melanoma, normal kidney tubules, and type II pneumocytes. The remaining cases included on the TMA were largely non-reactive. Staining performance of anti-ROS1 SP384 was consistent across 3 platforms and 3 antibody lots.

Conclusions:
Herein, we demonstrate that it is feasible to use anti-ROS1 SP384 to detect ROS1 protein due to the high sensitivity, specificity, and consistency of the antibody. Further studies are ongoing in previously characterized patient samples to assess antibody performance, clinical utility, and staining interpretation guidance.

Clinical trial identification:


Legal entity responsible for the study:
Ventana Medical Systems, Inc.

Funding:
Ventana Medical Systems, Inc.

Disclosure:
I. Menzl, B. Richardson, C. Le, D. Smith, A.E. Hanlon Newell, G. Pate, R.S.P. Huang: Employee of Roche/Ventana Medical Systems and owns stock in Roche. C. Bell: Employee of Roche/Ventana Medical Systems.

Background:
ROS1 rearrangement in non-small cell lung cancer (NSCLC) patients has recently been identified as a driver gene event and patients benefi from crizotinib treatment. The aim of this study was to investigate the clinical value of ROS1 rearrangement non-small cell lung cancer (NSCLC) cell blocks from pleural effusion.

Methods:
Two hundred and fifteen cases of ROS1 rearrangement non-small cell lung cancer (NSCLC) blocks cell from pleural effusion, and 404 cases of tissues were analysed by the reverse transcription polymerase chain reaction (RT-PCR) method. The consistency of ROS1 rearrangement was examined in 74 cases of patients with tissues and cell blocks.

Results:
ROS1 rearrangement was found in 7 of 215 cell blocks (positive detection rate of 3.26%). ROS1 rearrangement was detected in 8 of 404 tissue blocks (positive detection rate of 1.98%). There were 71 cases of the 74 (95.95%) cases that had the same consistency as tissue block. ROS1 rearrangement was detected in 2 of 74 (2.70%) cell blocks, and 5 of 74 (6.76%) tissue blocks.

Conclusions:
The rate of ROS1 rearrangement in cell blocks of NSCLC is higher than in matched tissue blocks. The patients with malignant pleural effusion are likely to tend to ROS1 rearrangement.

Clinical trial identification:


Legal entity responsible for the study:
Wenxian Wang

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
Cell-free DNA (ccf-DNA) can be found in healthy persons, persons with malignant and nonmalignant diseases as Chronic Obstructive Pulmonary Disease. In cancer, ccf-DNA results from tumor necrosis, lysis of circulating cancer cells or of micro-metastases and active release. Recently the first liquid biopsy test for analysis of driver gene mutation from cfDNA becomes a reality in clinical practice for patients with NSCLC with use of peripheral blood sample for EGFR mutation detection as predictive marker of response to EGFR-targeted therapy. The aim of this study was to study the concentrations and integrity index of ccf-DNA as a diagnostic and prognostic marker.

Methods:
This study was carried out in Menoufia University hospital in the period from October 2015 to September 2017. It was conducted on 140 individuals classified into: Group I: included 60 patients with NSCLC, Group II: included 40 patients with COPD. Group III: included 40 healthy controls. For NSCLC patients Staging was done according to the American Joint Committee on Cancer: the 7th edition. Real-time ALU-qPCR used to assess the concentration and integrity index of serum ccf-DNA.

Results:
The mean age was (56.8 ± 9.8, 52.9 ± 11.1 & 53.7 ± 9.0) for the three studied groups respectively with non significant difference between them. NSCLC patients demonstrated significantly higher values of each of ALU 215, ALU 247, DNA integrity than both COPD patients and controls, with non significant difference between the last two groups. The ROC curve analysis demonstrated that the total accuracy of ALU 247 was 92.1% at a cutoff point 325, 0.98 AUC, 96.7% sensitivity, 88.7% specificity, 86.6% PPV& 97.3% NPV, while ALU 115 recorded (0.93, 90%,78.7%, 76.1, 91.3 & 83.6) for AUC, sensitivity, specificity, PPV, NPV and accuracy respectively at a cutoff point 565. It was noticed that DNA integrity has AUC 0.65, sensitivity 75%, specificity 42.5%, 49.5% PPV, 69.4% NPP and total accuracy 56.4% at a cutoff point 0.48. Among NSCLC patients, ALU 115 & ALU 247 increased significantly in advanced tumor and more elevation was noticed in metastatic patients. Overall survival of NSCLC patients in relation to ALU 247, ALU 115 & DNA integrity documented a significant relationship between low DNA integrity and better survival of those patients.

Conclusions:
Serum DNA concentrations may be valuable in early diagnosis and potential prognostic marker in NSCLC patients

Clinical trial identification:


Legal entity responsible for the study:
Menoufia University

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
Lung cancer is the leading cause of cancer-related death worldwide. In India, lung cancer constitutes 6.9 per cent of all new cancer cases and 9.3 per cent of all cancer related deaths in both sexes. The propensity for tumor biomarkers to be detected in serum at an early disease stage has become an area of interest for clinicians. This study aimed to evaluate the expression of four known serum biomarkers, namely, Isocitrate Dehydrogenase-1(IDH-1), carcinoembryonic antigen(CEA), Tissue Polypeptide Antigen (TPA), cytokeratin19(CYFRA-21-1) in tumor tissue and peripheral blood of patients with non-small cell lung cancer, detected by relative quantification real-time PCR and to analyze the association with benign lung tissue samples.

Methods:
Fifty patients affected by non small cell lung carcinoma of Stage IIIB, in which histopathologically identified 21 patients were adenocarcinoma and 29 patients were squamous lung carcinoma and fifty individuals which affected by benign lung disease were studied in this study. cDNA were made from each sample after taking peripheral blood samples and tissue sample during surgery, extracting total RNA. simultaneously detecting four genes in each sample was examined by the real-time PCR technique.

Results:
The IDH1 was up-regulated in tumor patients compared with corresponding benign lung individuals in tissue samples 36 out of 50 and in blood sample was up-regulated in 40/50, its sensitivity was determined at 72% in tumor tissue sample and 80% in blood sample, CEA was up-regulated 34 out of 50 patients in tissue and in blood sample up-regulated in 41/50, its sensitivity was determined at 68% in tumor tissue sample and 82% in blood sample, TPA was up-regulated 43 out of 50 patients in tissue and in blood sample up-regulated in 45/50, its sensitivity was determined at 86% in tumor tissue sample and 90% in blood sample, CYFRA21-1 was up-regulated 37 out of 50 patients in tissue and in blood sample was up-regulated in 43/50, its sensitivity was determined at 74% in tumor tissue sample and 86% in blood sample.

Conclusions:
Hence, we further validate the known biomarkers both in tissue and peripheral blood and propose their diagnostic and prognostic utility.

Clinical trial identification:


Legal entity responsible for the study:
Institutional Ethical Committee

Funding:
King George's Medical University, Lucknow, India

Disclosure:
All authors have declared no conflicts of interest.

Background:
EGFR mutation detection on non-small cell lung carcinoma (NSCLC) is mandatory for optimal care of metastatic patients. Rearrangement/amplification of ALK or ROS, PDL1 expression level, BRAF, HER2 mutational status is also required. These different tests are time and tissue consuming. Therefore, molecular diagnostic laboratories need to elaborate strategies in order to optimize the realization of these different tests from limited biopsy specimens. The Idylla™ EGFR Mutation Test provided by Biocartis® is a fully automated sample–to–result test based on real-time PCR. The test allows the detection of 51 EGFR mutations directly from slices of FFPE tissue samples in less than three hours with an overall agreement of 96% with pyrosequencing. Nevertheless, further molecular tests need DNA and further tissue processing. In this project, the feasibility of EGFR testing from extracted DNA of NSCLC samples using Idylla™ EGFR was evaluated.

Methods:
EGFR mutational status was evaluated with the Idylla™ EGFR cartridge in two independent series of 20 retrospective and 83 prospective cases using DNA samples extracted from NSCLC instead of tissue sections.

Results:
Tumoral cellularity, DNA quantity and quality evaluated with a Tapestation Agilent® were taken into account in addition to the WT DNA CQ value calculated by the Idylla™ Explore software to optimize the DNA input. EGFR mutational status of the 20 retrospective cases previously analyzed with pyrosequencing was assessed in order to check the agreement of the fully automated method. A prospective series of 83 samples was then analyzed. All the results were interpreted and validated with the use of the Idylla™ test specific software, and qPCR curves were visualized by the Idylla™ Explore software.

Conclusions:
These results suggest some recommendations to use already extracted DNA with a fully automated sample–to–result system taking into account preanalytics and analytics features to safely characterize EGFR mutational status on lung cancer samples.

Clinical trial identification:


Legal entity responsible for the study:
University Hospital of Dijon

Funding:
Biocartis company

Disclosure:
All authors have declared no conflicts of interest.

Background:
In Morocco, bronchopulmonary cancer (CBP) is a major healthcare problem whose main etiological factor is tobacco. However, in the Eastern Kingdom region no study has been done on the epidemiological characteristics, pathological, clinical, molecular and therapeutic aspects of CBP.

Methods:
This is a descriptive retrospective study aimed at determine the epidemiological, pathological, clinical and therapy of CBP of patients at the Regional Oncology Center (ROC) Hassan II Oujda.

Results:
The study population consisted of 738 patients, 671 men and 67 women. The mean age was 59.1 ± 11.9 years (median = 58 years). Smokers are mostly men and represent 87% of patients. Average smoking consumption was 37.58 ± 20.85-pack years with an average duration of 30.92 ± 11.18 years. The symptoms that prompted the consultation were: cough in 49.59% of cases, chest pain in 45.39% of cases, hemoptysis in 32.11% of cases, dyspnea in 30.89% of cases. Adenocarcinoma was the predominant histological type (47%) followed by epidermoid carcinomas (27%) and small cell carcinomas (13%). Involvement of the right lung was frequent (55%), 36% of the lesions involved the lobe upper right. Almost all patients (97%) were diagnosed in advanced stages (III and IV). In this series, 65% of patients were treated with chemotherapy, 31% with radiotherapy and surgical treatment was only done in 6% of cases.

Conclusions:
This study reports, for the first time, the epidemiological data, pathology, clinical characteristics and therapy of CBP in the Eastern Region of Morocco for a period of 10 years (2005–2014). It was found that the diagnosis is often made at a late stage of the disease, hence the need for early detection and prevention based on the fight against tobacco.

Clinical trial identification:


Legal entity responsible for the study:
Genetic Department, Faculty of Medicine Oujda Morocco

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
Lung cancer, the most common and the leading cause of cancer death in the world, is increasingly being recognized in Bangladesh. Comprising one third of all male cancers, it is mostly presented at later stages. This study aimed at finding out the survival of lung cancer patients and also the important prognostic factors behind survival who were registered and treated in National Institute of cancer Research & Hospital.

Methods:
This study was done from Jan 2012 to June 2015 at Dept. of Medical Oncology, NICRH. The lung cancer patients attending NICRH in two years (from Jan 2012 to Dec 2013) were selected. After thorough evaluation, symptomatic and supportive management as well as chemotherapy and/or radiotherapy were given on priority basis. The patients were followed up every 4–8 weekly up to survival or maximum 42 months whichever was earlier. The patients were assessed during each visit by clinical status, investigations and treatment response. All events of death were documented properly.

Results:
Out of 2264 lung patients who were registered and treated during the period of Jan'12 –Dec'13, 1067 were in contact and eligible for the study. The male female ratio was 4.2:1 (862 male and 205 female). Female patients were younger (mean age of male 58.24 years and female 52.18yrs), 80% of all cases belonged to poor and lower middle-class families with 54% illiterate and 26% had primary education. Their performance status was mostly ECOG grade 2 & 3 (>80%). Male patients were smokers (90%) and females were mostly betel nut and/or tobacco chewers (66%) and also smokers (27%). All cases were at stage III and stage IV diseases with 86% non-small cell carcinoma and 14% small cell carcinoma. About 50% patients survived six months. One year survival of all cases was 27%; female 32% and male 25%. Mean survival of male and female patients was respectively 7.82 and 16.63 months. Survival of female patients was significant (P value-0.001) and survival of younger patients (<40 years) were also significant, 10.06 months (P value-0.001).

Survival in months according to gender and age
Gender	Mean Survival Time (months)	95% confidence interval	P-value
Male	7.820	7.300–8.341	0.001 (HS)
Female	16.638	14.153–19.124
Overall	8.780	8.237–9.322
Age group
<=40	10.063	7.723–12.403	0.001 (HS)
41–50	9.630	8.369–10.891
51–60	9.481	8.527–10.435
61–70	7.642	6.736–8.547
>70	6.171	4.944–7.399
Overall	8.780	8.237–9.322

Conclusions:
Lung cancer patients mostly presented at advanced stage (inoperable), with poor performance status. After supportive, symptomatic and anticancer treatment (chemotherapy and radiotherapy), one year survival of lung cancer was 27%. Female and young age <40 years patients’ survival was significantly higher than male and aged patients (>40yrs).

Clinical trial identification:


Legal entity responsible for the study:
Prof. Parveen Shahida Akhtar

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
Lung cancer is a major cause of morbidity and mortality worldwide, with an estimated 1.8 million new cases of lung cancer (13% of the total) and 1.6 million cancer deaths in 2012 (19.4% of the total) (GLOBOCAN 2012). The aim of this study is to determine the epidemiological characteristics of lung cancer in Morocco.

Methods:
This is a descriptive retrospective study of lung cancer cases diagnosed and treated at Al Azhar Oncology Center in Rabat between 2005 and 2015.

Results:
During the period of study, there were 615 cases diagnosed with lung cancer; 85.9% in men and 14.1% in women, giving a male-female ratio of 6.1 and representing 7.7% of all new cases of cancer reported during this period. The average age of the patients at diagnosis was 59.6 ± 11.4 years (range 4–94 years). Lung cancer is related to age with only 2.6% of cases diagnosed in persons younger than 40 years, 86.4% in those aged 40–74 years and 11% in those aged 75 years and over. Among all detected cases, 2.4% were diagnosed with metastatic disease and 21% died from lung cancer during the study period, accounting for 25.9% of all cancer deaths.

Conclusions:
Despite the limitations of the available data, it is clear that there are several barriers to access to cancer control in developing countries. This includes prevention, early detection, diagnosis and treatment.

Clinical trial identification:


Legal entity responsible for the study:
Ibn Tofail University, Kenitra, Morocco

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
Cancer outcomes in the United States (US) was shown to be influenced by insurance status for the most types of cancer. In Canada, health care access is similar for the whole population. The Affordable Care Act (ACA) was implemented to expand access to health care coverage in the US. This study aimed to compare clinical characteristics and survival of lung cancer pts in a Canadian province and in the US according to insurance status over the years.

Methods:
Data was obtained from the US SEER database and the Alberta, Canada Glans-Look lung cancer database. Pts were included if they were 18-64yo and diagnosed between 2007–2012. To account for the introduction of the ACA in the US, data was also analyzed by years 2007–2009 vs 2010–2012. Overall survival (OS) was evaluated over 26 months and the 25th, 50th and 75th percentiles of survival time, if reached, were estimated. Pearson's χ[2] was used to assess significance of associations with diagnosis year, and unadjusted associations were compared using the log-rank test. Hazard ratio's (HR) were estimated using the Cox proportional hazards model.

Results:
A total of 65,791 pts from the SEER database and 1,034 pts from the Canada Glans-Look database were included. The comparison of survival outcomes of the Canadian population vs the US population based on insurance status (insured, Medicaid, uninsured) showed that the Canadian survival was similar to the US Medicaid group (11.7 vs 10 m at percentile 50 of survival), while US insured group had a better outcome of 16 months (p < 0001). When comparing 2007–2009 vs 2010–2012, overall survival remained similar for the Canadian population (10.9 vs 13 m, p = 0.8876), while it improved in the post-ACA years for the US population (13 vs 14 m p = 0.0002). In both Canadian and US population, female sex, earlier stages and adenocarcinoma pts presented with better survival outcomes (p < 0.0001).

Conclusions:
Among lung cancer pts, the Canadian outcomes resembled the US Medicaid group for survival outcomes. In the US population, Medicaid and uninsured pts experienced worse survival. Survival rates in all insurance groups improved after the implementation of the ACA in the US, remaining similar in the Canadian population.

Clinical trial identification:


Legal entity responsible for the study:
Alberta Health Services

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
The clinical presentation and management strategies of lung cancer for lesser income women in South Asia has rarely been evaluated. We sought to compare the baseline characteristics, duration of symptoms, histology, staging, and rates of treatment between women and men at our public tertiary referral center in northern India.

Methods:
A retrospective review of patients diagnosed with lung cancer between January 1, 2008 and December 31, 2016 was completed. Baseline variables, previous treatment for tuberculosis, length of symptoms, tumor characteristics, and forms of treatment were collected and compared between women and men.

Results:
1370 total patients were selected including 230 females (16.8%). Compared to men, women were younger (mean {SD} age, 54.6 {10.9} vs. 58.4 {10.8}; p < 0.001), less likely current or previous smokers (34.1% vs. 86.1%; p < 0.001), had a lower rate of secondary education (46.3% vs. 69.4%, p < 0.001), and increased rate of previous tuberculosis treatment (37.3% vs. 29.6%, p = 0.03). No differences in duration (p = 0.47) of symptoms at time of diagnosis, rates (p = 0.92) of non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC), or rates (p = 0.20) of ultimately receiving some form of cancer treatment between women and men were observed. Women had higher rates of stage IV disease (75.0% vs. 62.2%, p < 0.001) for NSCLC but shared no difference (p = 0.48) in rates of extensive stage for SCLC compared to men.

Conclusions:
Women with lung cancer in our region are younger, more likely non-smokers, less well educated, more likely to have received recent anti-tuberculosis therapy before being correctly diagnosed, and more likely to present with metastatic disease. Clinicians should maintain a high index of suspicion even in younger women presenting with new-onset respiratory symptoms which may mimic tuberculosis.

Clinical trial identification:


Legal entity responsible for the study:
N/A

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
Lung cancer remains a major cause of death in the world, and while it was considered in the past to be primarily a male disease, the number of female patients has risen in recent years, such that rates among women are similar to those among men. Nevertheless, it has been found previously (in cardiovascular disease) that when there is a sex specific stereotype to a disease, it may remain entrenched in medical diagnostic processes, so as to cause belated diagnosis among the other sex. Here we aim to characterize the effects of sex on lung cancer diagnosis.

Methods:
We performed a retrospective analysis using two cohorts, 458,132 patients from the USA using the SEER (Statistics, Epidemiology and End Results) database, and 30330 patients from Israel. Patient cohorts were analyzed for sex-based differences by tumor type and stage at diagnosis, and results were stratified by race and analyzed with data regarding possible confounders such as smoking and socio-economic factors.

Results:
Male patients were more likely than female patients to be diagnosed at stage 3–4, consistent across lung cancer types, cancer registries, smoking, and racial and socioeconomic backgrounds. The exception to this was the arab population in the Israeli cohort, where there was no significant difference between men and women in the percentage diagnosed in later stages. The difference between the percentage of men vs. women diagnosed in stages 3–4 correlated negatively with increased female ever smokers and with squamous and small cell carcinoma, and were not correlated with the rate of cancer in women, or the difference between male and female cancer rates. Race was shown to have a significant effect on the percentage of women diagnosed in later stages.

Conclusions:
Results do not show a general belated diagnosis of lung cancer in women. In fact, the opposite appears to be the case. Results appear to point to the fact that smoking women are more likely to be diagnosed at later stages, which is consistent with current literature. Israeli arab women may suffer from belated lung cancer diagnosis, despite very low levels of smoking, perhaps owing to social and cultural causes.

Clinical trial identification:


Legal entity responsible for the study:
Institute of Oncology, Soroka Medical Center & Ben-Gurion University

Funding:
Has not received any funding

Disclosure:
N. Peled: Advisor & honorarium from AZ, BI, BMS, Lilly, MSD, Novartis, Pfizer, Roche, Takeda, FMI. All other authors have declared no conflicts of interest.

Background:
A substantial increase in the number of non-smoking lung adenocarcinoma (LAC) patients draws extensively attention in the past decades. Effective biomarkers are needed to identify high-risk patients to guide the therapy. Here, we provided a network-based signature to predict the survival of non-smoking LAC.

Methods:
Gene expression profiles were downloaded from The Cancer Genome Atlas (TCGA) and Gene Expression Omnibus (GEO). Significant gene co-expression networks and hub genes were identified by Weighted Gene Co-expression Network Analysis (WGCNA). Potential mechanisms and pathways of co-expression networks were analyzed by Gene Ontology (GO). The predictive signature was constructed by penalized Cox regression analysis and tested in two independent datasets.

Results:
Two distinct co-expression modules were significantly correlated with non-smoking status across four GEO datasets. GO revealed that nuclear division and cell cycle pathways were main mechanisms of the blue module and that genes in the turquoise module were involved in lymphocyte activation and cell adhesion pathways. Seventeen genes were selected from hub genes at an optimal lambda value and built the prognostic signature. The prognostic signature distinguished the survival of non-smoking LAC (training: hazard ratio (HR) = 3.696, 95%confident interval (CI): 2.025–6.748, p < 0.001; testing: HR = 2.9, 95%CI:1.322–6.789, p = 0.006; HR = 2.78, 95%CI:1.658–6.654, p = 0.022) and had moderate predictive abilities in the training and validation datasets.

Conclusions:
The prognostic signature is a promising predictor of non-smoking LAC patients, which might benefit to clinical practice and precision therapeutic management.

Clinical trial identification:


Legal entity responsible for the study:
Lin Xu

Funding:
National Natural Science Foundation of China (Nos. 81472702, 81501977 and 81672294)

Disclosure:
All authors have declared no conflicts of interest.

Background:
Large cell neuroendocrine lung cancer (LCNELC) is a subtype of lung cancer with neuroendocrine morphology and differentiation on immunohistochemistry, a high mitotic rate and non-small cell cytological features. However large population-based study on the clinicalpathological characteristics of LCNELC is lacking. Nomogram provides a visualized equation that the behavior of a predictor is represented in scales. In this study, we aim to explore the potential associations between clinicopathological factors and prognosis in SEER-18 database and to establish a nomogram model to predict the prognosis of LCNELC.

Methods:
We used the SEER-18 database to study the prognosis of LCNELC patients from 2000 to 2014 in the United States. All statistical analyses were performed by R software. We used packages “SEERaBomb”, “survival”, “rms”, and “rcorrp.cens” to obtain data and to build and evaluate the nomogram.

Results:
A total number of 1231 patients were enrolled. Sex, marital status, age at diagnosis, tumor size, AJCC TNM stage, and SEER histologic stage affect the prognosis of LCNELC patients. We included these factors to develop the nomogram prediction model. The Harrel's C-index showed that the nomogram model has a better prediction than traditional AJCC TNM staging system. We evaluated different surgeries for patients at early and advanced TNM stages as well as different SEER histologic stages, and suggested that early TNM stage or localized and regional SEER histologic stages patients benefit from surgical resection, especially lobectomy or bilobectomy.

Conclusions:
Age, sex, marital status, tumor size, TNM stage, SEER histologic stage, and both radiation and surgery treatment are independent prognostic variants for LCNELC. And early TNM stage or localized and regional SEER stage of LCNELC patients benefit from surgical resection, especially lobectomy or bilobectomy.

Clinical trial identification:


Legal entity responsible for the study:
The First Affiliated Hospital of Xi'an Jiaotong University

Funding:
Natural Science Foundation of Shaanxi Province (No.2017JM8019). International cooperation project in science and technology of Shaanxi province (No. 2016KW-017). Wu Jieping Medical Foundation (No. 50603020).

Disclosure:
All authors have declared no conflicts of interest.

Background:
Programmed death-ligand 1 (PD-L1) is a transmembrane protein binds to the programmed death-1 (PD-1) receptor and anti-PD-1 therapy enables the immune response against tumors. The aim of this study was to assess the clinical and pathologic characteristics of PD-L1 positive lung cancer patients in Korea.

Methods:
We retrospectively reviewed the clinical data of pathologically proven lung cancer patients, and collected 267 cases of formalin-fixed, paraffin-embedded tissue sample from single institution. PD-L1 expression was detected by immunohistochemical assay using Monoclonal Mouse Anti-PD-L1, Clone 22C3. PD-L1 protein expression is determined by using Tumor Proportion Score (TPS), the percentage of viable tumor cells showing partial or complete membrane staining. The specimen should be considered PD-L1 positive as TPS ≥ 50% of tumor cells. We categorized according to the percentage of TPS; more than 1% or 50%.

Results:
A total of 267 patients were enrolled and major histologic types were adenocarcinoma (ADC)(69.3%). The majority was smoker (67.4%) and clinical stage IV (60.7%). 31 (11.6%) cases of EGFR mutation and 17 (6.4%) cases of ALK FISH positive were included. The patients who showed TPS ≥ 1% and 50% were 116 (42%) and 58 (21%), respectively. More than 1% of TPS group was older than below (64.83 ± 9.38 vs. 61.73 ± 10.78, p = 0.014). More than 1% of TPS group was consisted of ADC (67.8%) and squamous cell carcinoma(SqC) (29.6%) histology. And more than 50% of TPS group was composed of ADC (72.4%), SqC (22.4%). More than 1% of TPS group was significantly older than less (64.83 ± 9.38 years vs. 61.73 ± 10.78 years, p = 0.014). The rate of poorly differentiated pathology was significantly higher in TPS ≥ 1% group (42(40.8%) vs. 32(25.8%)) and TPS ≥ 50% group (25(53.2%) vs. 49(27.2%)). There was no difference in smoking, EGFR mutation, ALK rearrangement status or biopsy site.

Conclusions:
In Korean lung cancer patients, PD-L1 positive group defined as TPS ≥ 1% was older than negative group. And major histology was poorly differentiated non-small cell lung cancer in both TPS ≥ 1% and 50% groups.

Clinical trial identification:


Legal entity responsible for the study:
Chonnam National University Hospital, Hwasun

Funding:
Has not received any funding

Disclosure:
The author has declared no conflicts of interest.

Background:
Advances in bronchoscopy and computed tomography (CT)-guided lung biopsy have improved the approach to small pulmonary lesions (PLs), leading to an increase in preoperative histological diagnosis. The purpose of this meta-analysis was to evaluate the efficacy and safety issues between transbronchial lung biopsy with radial endobrochial ultrasound and virtual bronchoscopic navigation (TBLB-rEBUS&VBN) as a bronchoscopic (BR) approach and CT-guided transthoracic needle biopsy (CT-TNB) as a percutaneous (PC) approach for the tissue diagnosis of small PLs.

Methods:
A systematic search for relevant studies was performed in May 2016 using five electronic databases: MEDLINE, EMBASE, Cochrane Library Central Register of Controlled Trials, Web of Science, and Scopus; the selected papers were assessed using meta-analysis. The papers were limited to those published since 2000 that studied small PLs ≤ 3 cm in diameter. To select studies of TBLB-rEBUS&VBN, rEBUS with a GS was used for peripheral pulmonary lesion (PPL) diagnosis and virtual bronchoscopy was used as a navigational method. The three methods of conventional CT-guided transthoracic needle biopsy, CT fluoroscopy-guided transthoracic biopsy, and C-arm cone-beam CT-guided transthoracic biopsy were used for CT-TNB.

Results:
From 7345 records, 9 papers on the bronchoscopic approach and 15 papers on the percutaneous approach were selected. The pooled diagnostic yield was 75% (95% confidence interval [CI], 69–80) in the BR approach and 93% (95% CI, 90–96) in the PC approach. Especially for tissue biopsy of PLs <2 cm, we recommend prioritizing CT-TNB, which had a 26% better diagnostic yield than TBLB-rEBUS&VBN. However, for PLs >2 cm but ≤3 cm, the yield in the BR approach improved to 81% (95% CI, 75–85). Complications of pneumothorax and hemorrhage were rare in the BR approach and quite common in the PC approach.

Conclusions:
CT-TNB was superior to TBLB-rEBUS & VBN for the evaluation of small PLs. However, for lesions greater than 2 cm, the BR approach was quite valuable when considering its diagnostic yield of over 80% with its low risk of procedure-related complications.

Clinical trial identification:


Legal entity responsible for the study:
Jung Hyun Chang

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
Lung cancer is one of the commonest malignant tumors threatening the health of human being. The morbidity and mortality of lung cancer increased rapidly, early detection and early treatment is the key to increase the survival rate of lung cancer patients. Studies have confirmed that air pollution is closely related to the occurrence of lung cancer. Air pollution (mainly PM2.5) has been classified as a carcinogen by the International Agency for Research on Cancer. MicroRNAs (miRNAs) are endogenous, noncoding RNAs consisting of 21–23 nucleotides which are stable existence in the blood. It is one kind of potential diagnostic markers in serum. In order to verify whether microRNA-146 can be used as early warning indicators of precancerous lesion of lung cancer.

Methods:
30 BALB/c mice were treated with noninvasive tracheal instillation of fine particulate matter suspension at different doses for 90 days (two times one week), histopathological changes, pro-infammatory factors levels, pulmonary functions and the relative expression of microRNA-146 were detected.

Results:
Histopathological changes showed atypical hyperplasia of alveolar epithelial cells, alveolar macrophages with engulfed particles and lymphocyte aggregation in bronchiole and alveolar. Pro-inflammatory factors IL-6, IFN-γ and TNF-α were increased significantly, however, PIF and PEF were decreased significantly. Lung resistance Increased and MVV reduced from the general tendency, the relative expressions of miR-146a and miR-146b were up-regulated remarkably in treatment groups compared to the control group.

Conclusions:
MiR-146a and miR-146b may be novel warning biomarkers for early detection of pulmonary precancerous lesions.

Clinical trial identification:
NO

Legal entity responsible for the study:
Peking University First Hopital

Funding:
Beijing Municipal Natural Science Foundation (Key Program: No.7161013)

Disclosure:
All authors have declared no conflicts of interest.

Background:
Lung cancer, one of the most frequent cancers worldwide has long relied on molecular testing of major biomarkers such as EGFR/ALK. Achieving superior clinical outcomes needs a comprehensive emphasis beyond contemporary EGFR and ALK. Several technologies arose in par with molecular testing for EGFR/ALK, most of them failing to comprehend beyond due to a universal skepticism among clinicians though recommended in NCCN guidelines.

Methods:
A total 137 lung cancer cases from NGS tested data (PositiveSelect) comprising 91 males and 46 females were investigated. EGFR, ALK positivity were used for data dichotomization to understand therapeutic utility of rare alterations beyond EGFR/ALK.

Results:
Upon dichotomization, 28% were identified with EGFR + ALK variants favoring direct EGFR/ALK targeted therapeutics. The remaining 72% harbored no EGFR/ALK variants descending into the category of chemotherapy in current clinical practice. Similarly, 23% harbored EGFR variants carrying the beneficial effects of EGFR TKIs and remaining 77% displayed no EGFR variants sloping towards chemotherapy. The study conquered the incompetence of targeted drug utilization on conventional diagnosis of EGFR/ALK in (EGFR) and (EGFR + ALK) negative cohorts. Based on our analysis of EGFR negative cohort, we identified clinically actionable variants in KRAS (7%), BRAF (2%), ERBB2 (1%), MET (2%) and RET (3%) expressing potential for targeted therapy excepting EGFR TKIs. Correspondingly, KRAS (6%), ERBB2 (1%), MET (1%) and RET (3%) variants were identified in EGFR + ALK negative cohort enabling the utility of targeted therapeutics apart from EGFR/ALK. Only 35% of the two negative limbs were categorized into chemotherapy which would have been entire cohort otherwise.

Conclusions:
The study accentuates the potential of comprehensive genomics in ascertaining the hallmarks of lung cancer beyond EGFR/ALK dichotomy also liaising between theory and utilization of broad spectrum genomic testing among medical professionals to circumvent chemotherapy. Thus, chemotherapy dependence in EGFR/ALK negative cohort could be effectively curtailed by clinicians evidencing better clinical outcomes.

Clinical trial identification:
NA

Legal entity responsible for the study:
Positive Bioscience

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
Reliable biomarkers are needed to prognostigate patients with advanced lung cancer following chemotherapy. This study evaluated the association of serum EGFR expression with disease severity and treatment response in advanced Squamous cell lung cancer.

Methods:
Newly diagnosed subjects with advanced Squamous cell lung cancer (stage IIIB and IV) were enrolled. Relevant demographic data were recorded, including performance status (assessed by Karnofsky performance status [KPS] and European Co-operative Oncology Group [ECOG] scoring system). Epidermal growth growth factor receptor (EGFR) expression was estimated in serum using reverse transcriptase polymerase chain reaction (RT-PCR) at baseline and following four cycles of Carboplatin – Paclitaxel chemotherapy. Response was assessed using the RECIST 1.1 criteria. Objective response rate (ORR) was defined as Complete remission (CR) or partial response (PR) and Disease control rate (DCR) was defined as CR/PR/Stable disease (SD). Kaplan meier curve was used to compare the overall survival (OS) between subjects based on median EGFR expression level as the cut-off.

Results:
A total of 82 subjects were enrolled. These included 79 (96.3%) males with mean (SD) age of 61.9 (9.8) years and 48.8% having metastatic disease. Majority were current / former smokers (97.6%); 59.7% had KPS ranging between 40 -70 and 48.1% had ECOG of 0/II. The baseline mean (± SD) serum EGFR expression was 17.8 ± 9.3 fold increase over control values, with median (min., max.) of 18.2 (4.4, 42.8). Following chemotherapy, ORR and DCR were 59.7% and 77.3% respectively. Significant reduction in EGFR expression was observed with median (min, max.) absolute and percentage reduction of 6.2 fold (−3.1, 33.6), and 54.2 % (−55.6, 78.4) respectively; p < 0.001. No significant association was observed between change in EGFR expression and age, gender, disease stage, performance status, ORR or DCR. Subjects with baseline EGFR expression of greater than 16.0 fold had significantly worse OS than those with <16.0 fold increase.

Conclusions:
EGFR is over-expressed in advanced squamous cell lung cancer and is significantly down-regulated following chemotherapy; additionally, baseline expression is a useful marker of overall survival following chemotherapy.

Clinical trial identification:


Legal entity responsible for the study:
N/A

Funding:
Department of Biotechnology, India

Disclosure:
All authors have declared no conflicts of interest.

Background:
Circulating cell free tumour DNA (ctDNA) from liquid biopsy is a potential source of tumour genetic material especially in case of non-availability of tissue biopsy for EGFR testing. Detectable levels of oncogenic driver mutations in peripheral blood have been shown to be associated with poorer prognosis and good predictor of EGFR TKI efficacy.

Methods:
Liquid biopsy was performed on 95 NSCLC patients with matched tumour tissue for genomic analysis. An EGFR mutation of one major molecular subtype in NSCLC was performed on massive parallel sequencing. Single gene EGFR mutation analysis was performed on the ctDNA by using ultra deep sequencing on the HiSeq platform. Then custom designed bioinformatics algorithms were used to detect somatic mutations at allele frequencies as low as 0.01%.

Results:
Overall concordance of mutation status between 95 pairs of tissue and plasma ctDNA samples for EGFR mutation status was about 93%. 30.5% (29/95) of the study subset was EGFR mutated on tissue typing and 27.36% (26/95) in ctDNA. Positive predictive value was 100% and negative predictive value was 95.6% – with diagnostic accuracy of 97%. A false negative rate of 4% was observed in this study. 12 out of 95 (12.63%) samples which had rare Exon19 deletions and complex indels could be confidently detected by NGS methods only. An objective efficacy response rate for Gefitinib was estimated at 70%, with a disease control rate of 94%. Median period of follow-up was 13.9 months. Median PFS was 16.8 months (95% CI 11.168–26.198).

Conclusions:
12% of newly diagnosed NSCLC patients could get the additional benefit of targeted therapy, by using the NGS which detected oncogenic driver mutations. Liquid Biopsy offer significant diagnostic, prognostic, and predictive information.

Clinical trial identification:


Legal entity responsible for the study:
Rajiv Gandhi Cancer Hospital and Research Center

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
Circulating cell free DNA (cfDNA) is an alternative to tumor tissue for molecular profiling in non-small cell lung cancer (NSCLC). Next generation sequencing (NGS) with targeted panels can concurrently evaluate multiple actionable mutations.

Methods:
NGS analysis was performed on tissue samples with the Oncomine Solid Tumour DNA kit, while plasma samples were analyzed with the Oncomine Lung cfDNA Assay. Droplet Digital PCR (ddPCR) was performed with the QX200 System to solve discordant cases.

Results:
We performed NGS analysis of tumor samples and matched cfDNA obtained from 102 patients with metastatic NSCLC before systemic treatment. NGS detected EGFR mutations in 21/25 plasma samples from EGFR-mutant patients (sensitivity 84%), and in 3/77 samples from EGFR wild type (wt) patients (specificity 96.1%), with a concordance rate of 93.1%. Analysis with ddPCR confirmed in plasma samples the absence of EGFR variants in false-negative cases according to NGS; in the 3 cases with EGFR mutant-plasma and wt-tissue, ddPCR confirmed the presence of EGFR mutations at low allelic frequency in both plasma and tissue samples, therefore confirming the specificity of NGS analysis. We also evaluated in the cohort of 77 EGFR wt tumors the concordance between tumor and plasma for the mutations in genes other than the EGFR covered by both NGS panels. The mean concordance was low (57.3%). In particular, a high discordance among KRAS mutations was observed. Out of 11 cases with KRAS mutations in tissue, only 3 showed also KRAS mutations in plasma. Analysis with ddPCR identified KRAS mutations in the cfDNA from 4/5 available samples that were negative by NGS, suggesting a low sensitivity of the panel for RAS mutations. In addition, NGS analysis revealed KRAS mutations in 3 cases that were negative on tissue. These variants were validated by ddPCR, confirming the specificity of NGS analysis and suggesting tumor heterogeneity for these variants.

Conclusions:
Our study showed that plasma-NGS is a suitable method for EGFR genotyping in NSCLC. Relatively low sensitivity and tumor heterogeneity might limit the ability of NGS to identify driver alterations other than EGFR variants.

Clinical trial identification:


Legal entity responsible for the study:
Istituto Nazionale Tumori “Fondazione G. Pascale”- IRCCS, Naples, Italy

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
KRAS mutant lung adenocarcinoma has a dismal prognosis. In the current study, we identified combination targets for trametinib, a MEK inhibitor, which acts downstream of KRAS to suppress signaling through MAPK cascade. However, we have previously shown that selumetinib (MEK inhibitor) in KRAS mutant NSCLC cells caused a rebound of ERK, AKT and STAT3, as well as YAP phosphorylation (Y357), NOTCH3 and activation of RTKs, AXL and MET. We hypothesize that, in KRAS mutant NSCLC, suppression of MAPK could lead to activation of Src-YAP1-AXL-MET. Since CUB domain-containing protein 1 (CDCP1) activates Src, we consider that CDCP1 could be a biomarker of Src activation.

Methods:
Cell viability assay, colony formation assay and western blotting were performed to assess the treatment of trametinib plus TPX-0005 in a panel of 8 NSCLC cell lines: A549, Calu6, H23, H460, H2009, H2030, H441, H727. Synergy between trametinib and TPX-0005 was assessed via the Chou-Talalay method to estimate the combination index (CI). CI values <0.7 were considered synergistic, with decreasing CI values indicating greater synergy. We examined tumor samples of 32 KRAS mutant NSCLC p for CDCP1 mRNA levels.

Results:
The combination of trametinib with TPX-0005 was synergistic or additive in all cell lines tested. H23 and Calu6 were the most synergistic, followed by H441 and H2030. In the majority of cell lines examined, the colony formation assay resulted in an almost complete abrogation of tumor cell colonies, particularly in the H23 and A549. Western blotting indicated that the combination of trametinib with TPX-0005 abolished the phosphorylation of STAT3 (Y705), paxillin (Y118), a readout of FAK, and Src (Y416). The median PFS of 32 KRAS mutant NSCLC p was 2.5 months and the overall survival was 13.4 months. According to CDCP1 levels, the median PFS was 3.5 months for those with low CDCP1 and 1.4 months for those with high CDCP1 (P = 0.012). The median survival was 16.3 months for p with low CDCP1, and only 3.2 months for those with high CDCP1 (P = 0.023).

Conclusions:
The combination of trametinib plus TPX-0005 shows significant in-vitro activity in the majority of KRAS mutant NSCLC cell lines and the mRNA levels of CDCP1 could be a biomarker in KRAS mutant NSCLC p, indicating the activation of Src-YAP signaling. Clinical trials with the combination of MEK inhibitors with TPX-0005 are warranted.

Clinical trial identification:


Legal entity responsible for the study:
IGTP, Germans Trias i Pujol Research Institute, Badalona, Barcelona, Spain

Funding:
Fundació Obra Social “La Caixa”

Disclosure:
All authors have declared no conflicts of interest.

Background:
Screening of circulating microRNAs is a promising avenue for the discovery of novel biomarkers in cancer therapy. In the LUX-Lung 8 trial, the ErbB family inhibitor Afatinib (A) provided a significant progression free survival (PFS) and overall survival (OS) benefit compared to the EGFR TKI Erlotinib (E) in 2nd line treatment of advanced SCC. To detect new markers associated with clinical outcomes, we performed a post hoc extensive screening of miRNAs in serum samples from a subset of LUX-Lung 8 trial patient population.

Methods:
1787 miRNA expression levels were measured by miRNA-seq using the Illumina HiSeq4000 platform in baseline (BL) (n = 133) and cycle 2 (C2) (n = 109) serum samples from 133 LUX-Lung 8 patients randomly selected with stratification on smoking, treatment, and interval from last dose of chemotherapy. All variables were tested for their BL prognostic and predictive value on OS in a Cox model adjusted for prognostic factors. For miRNAs with FDR adjusted p-value <0.05, a data-driven cut-off was determined and Kaplan Meier estimates were performed comparing low- and high-expressers. Analysis of C2 values was conducted.

Results:
29 miRNAs were found to be prognostic of OS and 8 to be predictive of treatment effect on OS with FDR p-value p < 0.05. MiR-3150b-3p was the most significant predictive variable (FDR p < 0.001). In the A arm, median OS was 2.7 m in miR-3150b-3p high- vs 8.5 m in low-expressers (HR = 3.4, p = 0.0001) and 5.7 m in high-expressers treated with E (HR = 2.7, p = 0.01). Furthermore, in the A arm, but not in the E arm, high miR-3150b-3p expression at C2 in patients with low BL values was associated with a shorter OS compared to patients remaining low (7.4 m vs 10.4 m, HR = 2; p = 0.08).

Conclusions:
Using a rigorous methodology, we found new highly prognostic markers and several novel markers with high predictive value of a differential treatment benefit between A and E. This suggests the two drugs have different mechanism of action. Because this was an exploratory analysis and the effect size could be over-estimated, those results should be replicated in a larger study.

Clinical trial identification:
NCT01523587

Legal entity responsible for the study:
IntegraGen

Funding:
IntegraGen

Disclosure:
Y. Gaston Mathé, S. Martin-Lannerée, C. Marcaillou, E. Lallet: Employee of the study sponsor. P. Fogel: Subcontractor of the study sponsor. N. Krämer: Subcontractor of the clinical trial sponsor and owner of the rights on afatinib, Boehringer-Ingelheim. N. Gibson, F. Solca, E. Ehrnrooth: Employee of the clinical trial sponsor and owner of the rights on afatinib, Boehringer-Ingelheim. All other authors have declared no conflicts of interest.

Background:
MicroRNA miR-31-3p and 5p have been reported to predict anti-EGFR cetuximab efficacy in metastatic colorectal cancer but have not been studied in other indications. In the LUX-Lung 8 trial, ErbB family blocker Afatinib (A) provided a significant PFS and OS benefit compared to EGFR TKI Erlotinib (E) in 2nd line treatment of advanced SCC. We retrospectively analyzed the association of miR-31-3p and miR-31-5p serum levels with treatment benefit in a sub-population of this study.

Methods:
MiRNA expression levels from baseline (BL) (n = 133) and cycle 2 (C2) (n = 109) serum samples from 133 LUX-Lung 8 trial patients selected randomly with stratification on smoking status, treatment and interval from last dose of chemotherapy were measured by miRNA-Seq using Illumina HiSeq4000 platform. MiR-31-3p, miR-31-5p or combined miR-31 were tested for their prognostic and predictive value of treatment effect on OS using Cox models adjusted for prognostic factors and Kaplan Meier estimates after determination of a data-driven cut-off defining low or high expressers.

Results:
Mir-31-3p was detected in 19/133 BL samples and was predictive of E efficacy (p < 0.01). MiR-31-5p was prognostic of OS in the E (p = 0.03) but not in the A arm. Patients with measurable miR-31-3p or high miR-31-5p had a better OS when treated with A compared to E (miR-31-3p: 15 m [6.3;70] vs 4 m [2.7;7.8], HR = 0.3, p < 0.05; miR-31-5p: 7.3 m [4.7;16.5] vs 3.3 m [2.4;6.5], HR = 0.5, p = 0.07). No difference between treatment arms was seen in patients with no measurable miR-31-3p or low miR-31-5p expression. In the E arm only, high miR-31 expression at C2 in patients with low BL miR-31 was associated with a shorter OS compared to patients remaining low (4.2 m [2.8;9.2] vs 10.3 m [7.8;13.0], HR = 0.5, p = 0.05).

Conclusions:
MiR-31-3p/5p serum levels were predictive of E treatment efficacy. Patients with high BL miR-31 levels had lower benefit of E and higher benefit of A, suggesting different mechanisms of action for the drugs. Increase of miR-31 levels during treatment with E was associated with poor outcomes. Measurement of circulating mir-31 has potential to help optimizing treatment choice between E and A for SCC patients. Those results should be replicated in a larger study.

Clinical trial identification:
NCT01523587

Legal entity responsible for the study:
IntegraGen

Funding:
IntegraGen

Disclosure:
Y. Gaston Mathé: Employee of IntegraGen, the sponsor of the study and owner of IP rights on the disclosed results. P. Fogel: Fees from the study sponsor for the performance of the statistical analysis. S. Martin-Lannerée, C. Marcaillou, E. Lallet: Employee of the study sponsor. N. Krämer: Subcontracter for the clinical trial sponsor and afatinib product owner, Boehringer-Ingelheim. N. Gibson: Employee of the clinical trial sponsor and afatinib product rights owner Boehringer-Ingelheim. F. Solca, E. Ehrnrooth: Employee of the clinical trial sponsor and owner of the rights on afatinib, Boehringer-Ingelheim. All other authors have declared no conflicts of interest.

Background:
Epidemiologic data have indicated that chronic inflammation was highly associated with the pathogenesis of lung cancer. However, the molecular relations between inflammation and lung cancer have not been well understood. MicroRNAs could connect the inflammatory response with tumorigenesis through regulating their cancer-related targets. The aim of the present study was to identify the core miRNA in inflammation-related lung cancer and its potential mechanisms.

Methods:
RT-PCR was used to detect the expression of miRNAs and mRNAs. CKK8 and flow cytometry assays was performed for the function experiments. Microarray analysis and IPA analysis were used to predict the potential signal pathway.

Results:
Mir-125b was the most dramatically up-regulated miRNAs after treated with IFN-r, whereas after stimulated with IL-10, mir-125b was the most strikingly down-regulated ones. Restoration of mir-125b expression could completely overrode the impact of IL-10 on both cell proliferation and apoptosis in NSCLC cell lines. And the level of mir-125b was significantly lower in 30 NSCLC tumor tissues compared with normal controls (P < 0.0001). Microarray analysis found 69 up-regulated genes and 105 down-regulated genes after down-regulate mir-125b. And IPA analysis indicated that IGF-1 signaling pathway was dramatically activated. The results were validated by RT-PCR.

Conclusions:
MiR-125b might play a tumor suppressor role via inhibiting IGF-1 signaling in inflammation-related lung cancer.

Clinical trial identification:


Legal entity responsible for the study:
Yanwei Zhang

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
Tyrosine kinase inhibitors (TKIs) are effective in EGFR and ALK driven non-small cell lung cancer (NSCLC). However, drug insensitivity, tumor recurrence, and resistance caused by second mutations in the EGFR or aberrant bypass signaling are key challenges. To overcome this, the focus has been shifted to genomic analysis of various EGFRdownstream signaling pathways. One of the vital EGFR downstream signaling pathways that perhaps provide roadmaps for targeted therapy is MAP kinase pathway. We aim to study key genes of MAP kinase pathway in patients with pulmonary adenocarcinomas (PADC).

Methods:
All PADC patients since 2015 were included after obtaining clinical details. Histomorphology was ascertained prior to mutational analysis. Real-Time PCR (EGFRexon 18–21 and KRASexon 2) and Sanger Sequencing (BRAFexon 11 and 15 and MEK1exon 2) technologies were used. The clinical and pathologic correlation was done.

Results:
Of 118 PADC patients (M: F-2.3:1), 26.2% (31/118) patients harboured EGFR mutations and were predominantly females. The most common EGFR mutation was exon 19 deletion. EGFR mutation positive cases showed mostly acinar histology. KRAS mutations (G12A) were observed in 21.1% (25/118) patients and were predominantly older males with mucinous histology. Four (3.3%) patients harboured coexisting EGFR and KRAS mutations. BRAF mutations (L597V, I953V) were seen in 2.5% (3/118) patients, however, there was no coexistence of BRAF mutations with other oncogenic drivers such as KRAS, EGFR mutations or ALK fusion. Additionally, BRAFpolymorphism was seen in 15.0% cases. None of the cases showed MEK1 mutation.

Conclusions:
This study examined the genetic alterations of genes involved in MAP kinase pathway in PADC of Indian patients. The frequency of KRAS mutation is higher than reported previously in the literature. Secondly, mutations in EGFR and KRAS showed coexistence. The high rate of KRAS mutations and coexistence of genomic alterations in Indian patients should be validated in a large number of cases for better patient management.

Clinical trial identification:


Legal entity responsible for the study:
AIIMS, New Delhi, India

Funding:
ICMR, Lady Tata Trust, and AIIMS

Disclosure:
All authors have declared no conflicts of interest.

Background:
Although lung cancer is generally thought to be environmentally provoked but rare familial forms of lung cancer has been described previously, suggesting there may be genetic susceptibility factors. However, due to the apparently sporadic nature of lung cancer, little attention has been paid to the role of genetic predisposition in lung cancer. To address this, we used FLC samples obtained from the Chinese population in highly air-polluted regions to screen for novel germline mutations in lung cancer.

Methods:
Through a whole genome sequencing (WGS) analysis of the nine subjects (four lung cancer patients and five normal family members of FLC), we obtained a whole genome dataset of DNA alterations in FLC samples. A total of 1218 genes were identified with mutations of multiple types. Subsequently, the top 12 highly mutated genes were selected for validation by PCR and DNA sequencing in an expanded sample set including FLC, sporadic lung cancer, and healthy population.

Results:
Mutations of the five genes (ARHGEF5, ANKRD20A2, ZNF595, ZNF812, MYO18B) may be potential germline mutations of lung cancer. We also analyzed specific mutations within the 12 genes and found that some specific mutations within the MUC12, FOXD4L3 and FOXD4L5genes showed higher frequencies in the samples of FLC and/or lung cancer tissue, compared with the healthy population. Moreover, some genes with copy number variation may be potentially associated with a predisposition to lung cancer.

Conclusions:
Our study uncovered the mutation spectrum in FLC of the Chinese population. Insights from this study will help direct further efforts to enhance our understanding of genetic predisposition in lung cancer. The investigation of novel and known gene mutations detected by the present study may contribute to evaluate functional impacts of these mutations not only in FLC but in sporadic lung cancer as well.

Clinical trial identification:


Legal entity responsible for the study:
N/A

Funding:
National Science Foundation of China (81272617), the 973 Program (2011CB510104), and the Yunnan Province Science and Technology Department (Y103951111)

Disclosure:
All authors have declared no conflicts of interest.

Background:
The emergence of platinum resistance is a significant obstacle to clinical management of lung cancer. We aimed to analyze the EGFR signaling and efficacy of EGFR inhibitors in acquired cisplatin resistance. Better understanding forms a basis for the development of novel combination therapies that could enhance patient survival.

Methods:
An isogenic clinical model was used to induce resistance in a panel of cell lines (H838, HCC827, H1975 and H1650 NSCLC cells) and H1339, an SCLC cell line. Cells were exposed to cisplatin (1 μg/ml/3 hrs/week) followed by recovery periods over of 4 weeks, and cisplatin–resistant phenotype (CRP) derived from original, age–matched naïve cells. They were then characterized by survival, proliferation, colony formation, and apoptosis. EGFR family receptors, phosphorylation and downstream signalling was assessed by EGFR phosphorylation and the PathScan Signaling array. The effects of EGFR TKIs (erlotinib, gefitinib, afatinib, and rociletinib) on CRP cells was evaluated at clinical concentrations.

Results:
CRP cells demonstrated increased survival, proliferation and resistance to apoptosis against the cisplatin challenge. CRP cells displayed altered expression of EGFR receptor family and their phosphorylation and critical nodes of signaling. But their appearance varied from cell line to cell line in comparison to their respective controls. The EGFR TKIs (except erlotinib on H838 cells) showed similar effects on CRP and their naïve cells.

Conclusions:
Our results identified CRP of NSCLC cells, which exhibited enhanced total EGFR and Met protein expression and their phosphorylation. This altered the expression of critical oncoproteins. The information can be used to design combination therapies with other TKIs to improve patient life.

Clinical trial identification:


Legal entity responsible for the study:
Respiratory Medicine and Thoracic Oncology (LMU Klinikum der Universität München)

Funding:
German Center for Lung Research (DZL), Germany

Disclosure:
All authors have declared no conflicts of interest.

Background:
EGFR tyrosine kinases inhibitors (TKIs) are effective therapies for NSCLC patients whose tumors harbor an EGFR activating mutation, however, this treatment is not curative because of both primary and secondary resistance to EGFR TKIs. Several resistance mechanisms to EGFR-TKIs have been described, among which, there is the T790M mutation. A recently described mechanism of multidrug resistance is the FASN overexpression. FASN is a multifunctional enzyme essential for the endogenous synthesis of long-chain fatty acids.

Methods:
We have worked with the lung adenocarcinoma cell line PC9 carrying the EGFR TKI sensitizing exon 19 deletion (ΔE746-A750) and 3 gefitinib-resistant PC9 derived cell lines (2 T790M positive and 1 T790M negative). Cell viability was determined by the MTT method for Gefitinib, osimertinib and two FASN inhibitors (EGCG and G28). Apoptosis was assessed by PARP cleavage. Molecular effects were analyzed by studying changes in the expression and/or activation of EGFR signaling pathways by western blot. The effects of the double combination of EGFR TKIs and FASN inhibitors in all cell lines were studied and synergy between drugs was determined using CompuSyn software.

Results:
All cell lines have significantly different IC50 values for Gefitinib except for the two T790M positive ones. Osimertinib has a concentration-dependent cytostatic effect on sensitive cells. All the studied cell lines are sensitive to FASN inhibition. The cytotoxicity caused by FASN inhibition is independent of the T790M mutation that leads to gefitinib resistance. Apoptosis is induced in all cell lines at all treatments. While gefitinib and osimertinib activate the Signal Transducer and Activator of Transcription 3 (STAT3) in all cell lines, EGCG and G28 reduce the STAT3 activation found in all gefitinib-resistant cell lines. Combination experiments using FASN inhibitor G28 and EGFR TKIs show mostly additive effect and synergism at some concentrations.

Conclusions:
In summary, we show cytotoxicity effect of EGCG and G28 in NSCLC cells sensitive and resistant to EGFR TKIs probably due to inhibition of FASN/STAT3 signalling. FASN inhibition should overcome EGFR TKI resistance and may serve as a novel target therapy to improve EGFR-based cancer therapy in lung cancer.

Clinical trial identification:


Legal entity responsible for the study:
University of Girona

Funding:
AstraZeneca

Disclosure:
All authors have declared no conflicts of interest.

Background:
PALB2, the partner and localizer of BRCA2, binds directly to BRCA1 and is essential for homologous recombination repair and, henceforth, could influence the effect of docetaxel-cisplatin therapy. Previous studies have shown that PALB2 impedes the degradation of nuclear factor erythroid 2-related factor 2 (NRF2) through the binding and sequestration of its inhibitor Kelch-like ECH-associated protein (KEAP1). Over-expression of NRF2 could activate NOTCH signaling and lead to enrichment of cancer stem cells. In the current study, we examine the mRNA levels of PALB2 in advanced NSCLC p treated with docetaxel-cisplatin.

Methods:
We assessed PALB2 mRNA levels as potential biomarkers in tumor tissue from 177 cisplatin plus docetaxel-treated NSCLC p from the NCT00617656/GECP-BREC trial. The relationship of the PALB2 mRNA levels with the PFS, OS and response were examined.

Results:
Median age 62; 79.1% male; 51.4% adenocarcinoma. Results of PALB2 mRNA expression were as follows: PFS was 5.6 months (m) for p with high/intermediate (H-I) PALB2 and 4.1 m for p with low (L) PALB2 (p = 0.0018). OS was 13.2 m for p with H-I PALB2 compared to 9.9 for p with L PALB2 (p = 0.0377). In the univariate analysis, H-I PALB2 was a marker of longer PFS (HR = 0.56, 95% CI, 0.38, 0.80; p = 0.002) and OS (HR = 0.64, 95% CI, 0.41, 0.98; p = 0.0394). In the multivariate analysis, only H-I PALB2 was associated with longer PFS (here HR = 0.56 and p = 0.0022) and OS (HR = 0.61 and p = 0.0343). Among 143 p with data for response and PALB2 expression, 49.5% of p with H-I PALB2 were responders, compared to only 28% with L PALB2 (p = 0.0131).

Conclusions:
Higher PALB2 mRNA levels were associated with higher response, longer PFS and OS in NSCLC p treated with docetaxel-cisplatin. However, PALB2 could also be a readout of NRF2 activity and NOTCH signaling, indicative of an increase in cancer stem cells, providing hints for combinatory therapy with gamma secretase inhibitors to prevent the increase of stem-like cells and further improve outcome to docetaxel-cisplatin therapy. Experiments in NSCLC cell lines are ongoing.

Clinical trial identification:


Legal entity responsible for the study:
IGTP, Germans Trias i Pujol Research Institute, Badalona, Barcelona, Spain

Funding:
Fundació Obra Social “La Caixa”

Disclosure:
All authors have declared no conflicts of interest.

Background:
International guidelines have advocated molecular profiling as part of the standard diagnostic evaluation for advanced NSCLC, with the goal of identifying driver mutations for which effective therapies or clinical trials are available. In advanced NSCLC, immunotherapy demonstrated good response rates with some responses being remarkably durable. Understanding the molecular determinants of response to immunotherapies is a key challenge in oncology. Notably, tumor mutational burden detected by tissue next generation sequencing (NGS) was found to be correlated with response to immune checkpoint inhibitors.

Methods:
In this retrospective study, data were collected on NSCLC patients treated in multiple medical centers in Israel between 2014 and 2017. We used NGS on cell-free circulating tumor DNA (ctDNA) to evaluate whether mutational burden influences the response to immunotherapy in these patients.

Results:
Overall, 336 NSCLC patients underwent NGS on ctDNA. Of these 336 patients, 192 (57%) were females and 144 (43%) were males. The average age (range) was 64 (23–103) years. Clinical treatment information is currently available for 117 patients, of whom 50 (43%) received immune check-point inhibitors. Rates of stable disease, partial and complete responses (RECIST criteria), as well as progression-free survival and overall survival will be reported. In addition, to unravel the genomic determinants of response to immunotherapy we will use the blood-derived ctDNA to understand if hypermutated ctDNA is a predictive biomarker of response to immunotherapy.

Conclusions:
ctDNA collection was feasible in 336 patients. Prediction model to associate the ctDNA signature with response to immunotherapy will be presented.

Clinical trial identification:


Legal entity responsible for the study:
Soroka Medical Hospital

Funding:
Has not received any funding

Disclosure:
L.C. Roisman: Lectures fees from Roche, Astrazenca, MSD, Pfizer. S. Geva: Travel grant from Teva Pharmaceuticals, honorarium from Guardant Health. L. Soussan-Gutman, A. Dvir, R. Yair, T. Twito: Works at Oncotest-Teva, which is a distributor of Guardant Health in Israel. R. Larman: Employee by Guardant Health inc. N. Peled: Advisor & honorarium from AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb, Eli Lilly, FoundationMedicine, Gaurdant360, MSD, Novartis, NovellusDx, Pfizer, Roche, Takeda. All other authors have declared no conflicts of interest.

Background:
Direct intratumoural (IT) injection of chemotherapeutics into solid tumours has potential to achieve high local concentrations, reducing systemic toxicity and off target side effects. However, this approach is limited by rapid drug clearance from the tumour, resulting in inaccurate and unpredictable dosing. Thermoresponsive hydrogels undergo a characteristic phase change in response to temperature. This allows for minimally invasive administration of a liquid via needle/catheter into the tumour, with localisation and retention following gelation at physiological temperatures. Drug loading of hydrogels facilitates localised, controlled delivery of chemotherapeutics to the tumour, with reduced off site toxicity.

Methods:
Preclinical assessment of blank and drug loaded formulations was conducted in a murine A549 xenograft model (approved by the RCSI ethics committee). 1 × 10[6] A549-luciferase cells were subcutaneously injected into the right flank of female Athymic Nude-Foxn1[nu] mice (n = 6 per group). At a tumour volume of approx. 250 mm[3], 100 μL of hydrogel (blank or drug loaded) or saline was injected IT using a 22G needle. Tumour growth was assessed using callipers and an IVIS® Spectrum in vivo imaging system over 14 days. On day 14, mice were sacrificed; tumours, liver and kidney excised, fixed and embedded in paraffin for histological and immunohistochemistry studies.

Results:
Two hours after IT injection, IVIS® imaging indicated localisation and retention of the hydrogel at injection site. At day 7 and 14 following blank or drug loaded hydrogel treatment, a significant reduction in tumour growth was observed compared to saline (p = 0.001). Retention of the hydrogel at the tumour site for up to 14 days was observed in ex vivo tumour tissue. No change in welfare scoring was observed during the study, with 100% survival at day 14, indicating treatment did not result in acute off site toxicity.

Conclusions:
Preliminary preclinical studies have shown the blank and drug loaded hydrogels significantly reduce tumour growth. Further studies are required to fully elucidate the underlying mechanism of action. IT administration of this formulation may represent a potential new adjuvant approach in lung cancer treatment.

Clinical trial identification:


Legal entity responsible for the study:
Royal College of Surgeons in Ireland

Funding:
Enterprise Ireland

Disclosure:
All authors have declared no conflicts of interest.

Background:
Radiotherapy (RT) and chemotherapy (ChT) are key treatments for NSCLC, but this disease is highly resistant to cytotoxic therapy. Metabolism determines tumor cell survival and response to therapy. Oncogenic pathways like EGFR- > K-Ras- > mTOR stimulate glycolysis, protein and lipid synthesis (lipogenesis). This is balanced by the action of metabolic stress sensors like AMP-activated kinase (AMPK), which is activated by stressors, including inhibition of mitochondrial oxidative phosphorylation (OxPhos) cascade. AMPK mediates energy conservation through a global regulation on metabolism that includes suppression of lipogenesis, protein synthesis and mTOR. Canagliflozin is an approved and effective diabetes drug that blocks the Na-glucose co-transporter 2 (SGLT2), which controls glycemia by blocking glucose re-uptake in the kidney. However, we found that canagliflozin also inhibits mitochondria OxPhos Complex I and activates AMPK, leading to blockade of lipogenesis and a significant anti-tumor activity in NSCLC.

Methods:
Adenocarcinoma A549 and H1299 NSCLC cells were subjected to canagliflozin, RT and cisplatin ChT treatments and were analyzed with proliferation, clonogenic survival and immunoblotting experiments.

Results:
We report that canagliflozin enhances the response of NSCLC cells to RT and ChT. Canagliflozin, but not other clinically used SGLT2 inhibitors, like Empagliflozin or Dapagliflozin, suppresses proliferation and clonogenic survival of A549 and H1299 cells and enhances their response to RT and cisplatin ChT. Importantly, canagliflozin mediates these effects at clinically achievable low micromolar doses (5–30 mM). These effects are associated with potent inhibition of OxPhos complex I, phosphorylation and activation of AMPK, inhibitory phosphorylation of Acetyl-CoA carboxylase (ACC) and suppression of the mTOR pathway.

Conclusions:
This work suggests that canagliflozin is a promising metabolism-targeting therapy that may be able to improve clinical RT/ChT responses in NSCLC. Being, a well-tolerated, approved and widely used medication, canagliflozin may be able to enter early phase NSCLC trials in the near future.

Clinical trial identification:


Legal entity responsible for the study:
McMaster University

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
Immunotherapy using dendritic cells (DC) represents a novel and promising therapeutic method for patients with non-small cell lung cancer (NSCLC). The aim was to examine the molecular and cellular mechanisms of anticancer immune responses during immunotherapy as well identify the immune parameters that may predict DC vaccine therapy efficiency.

Methods:
One hundred patients with IIB-IIIA stage NSCLC were enrolled into the study. Patients were randomly allocated into two groups: 1st – patients received DC-vaccine after surgery, 2nd – received surgery only. Original construction of DC vaccine has been used: autologous DCs with mechanically heterogenized microparticles of tumor cells. Patients received four intravenous injections with one-month interval and immunological monitoring was performed before each injection.

Results:
The most notable changes in cell-mediated immune response was observed after the 4[th] injection of DC vaccine. Namely, the balance of Th1- and Th2-mediated immune response was changed, in particular the number of CD3[+]IFN-γ[+] lymphocytes prevailed over CD3[+]IL-4[+] lymphocytes. Moreover, the CD4[+]CD45RO[+] memory cell numbers increased in peripheral blood and the TGF-β mRNA expression level was significantly decreased in circulating leucocytes (p < 0.05) compared with that in patients without DC-vaccine treatment. According to Cox proportional hazard model, changes in the number of CD4[+]CD45RO[+] memory cells (p < 0.05), TGF-β mRNA expression level (p < 0.02) and ratio of CD3[+]IFN-γ[+] lymphocytes to CD3[+]IL-4[+] lymphocytes (p < 0.02) allow us reliably to determine the development of relapses in patients with NSCLC. Using ROC analysis, we established the optimal criteria for these immunological markers, which can separate groups by low and high risk of NSCLC recurrence: <0.74 for ratio of CD3[+]IFN-γ[+] lymphocytes to CD3[+]IL-4[+] lymphocytes (p < 0.001, AUC = 0.92, Se = 100%, Sp = 75%); ≤0.62 × 10[3] cells/mL for CD4[+]CD45RO[+] memory cells (p < 0.001, AUC = 0.91, Se = 100%, Sp = 82%); >0.034 a.u. for TGF-β mRNA expression (p < 0.05, AUC = 0.73, Se = 67%, Sp = 100%).

Conclusions:
Immunological markers with prognostic significance regarding the duration of the event-free period have been established in patients with NSCLC after DC vaccine treatment.

Clinical trial identification:


Legal entity responsible for the study:
National Cancer Institute of the MPH Ukraine

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
Cervical lymph nodes are frequently involved in patients with lung cancer and indicate inoperability. Some guidelines recommend neck ultrasound (NUS) in patients with bulky mediastinal lymphadenopathy. Positron emission tomography (PET) is indicated for patients with potentially curable disease. We aimed to assess the diagnostic yield of NUS and the diagnostic accuracy of PET for cervical lymphadenopathy among patients with suspected lung cancer and mediastinal lymphadenopathy.

Methods:
Records of all patients with lung cancer who underwent a NUS over a consecutive 5-year period were reviewed. Only patients with mediastinal lymphadenopathy on CT were included. The diagnostic accuracy of PET was assessed with NUS-guided fine needle aspiration cytology used as the reference test.

Results:
During the study period 123 patients met the inclusion criteria. Malignant cervical lymphadenopathy was confirmed in 39.8% (95% CI 31.1–49.1%). PET-CT had a specificity of 81.1%, sensitivity of 87.5%, negative predictive value of 96.8% and positive predictive value of 50% for the detection of cervical lymphadenopathy, and it contributed no additional staging information in the neck area. Overall, PET led to changes in management in only 2.2% of cases.

Conclusions:
A significant proportion of patients with lung cancer and mediastinal lymphadenopathy have cervical lymphadenopathy detected by NUS. In this group of patients PET offers minimal additional value in staging and management.

Clinical trial identification:


Legal entity responsible for the study:
Galway University Hospital

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
PET imaging with [18]F-fluorothymidine ([18]F-FLT) can potentially be used to identify tumor subvolumes for selecting dose escalation in radiation therapy. The aim of this study was to monitor tumor cell proliferation and repopulation during fractionated radiotherapy and investigate the spatial concordance of tumor cell proliferation and repopulation with [18]F-FLT tracer uptake.

Methods:
Mice bearing A549 xenograft tumors were assigned to 5 different irradiated groups (3f/6d, 6f/12d, 9f/18d, 12f/24d and 18f/36d) with 2 Gy/fractions and non-irradiated group. Serial [18]F-FLT micro PET scans were performed at different time points, the maximum of standard uptake value (SUVmax) were measured to detect the feasible time of tumor repopulation during irradiation. Ex vivo images of the spatial pattern of intratumor [18]F-FLT uptake and Ki-67 labeling index (LI) were obtained from thin tumor tissue sections. A layer-by-layer comparison between SUVmax and Ki-67 LI results, including the thresholds at which maximum overlap occurred between FLT-segmented areas and areas of active cell proliferation, were conducted to evaluate the spatial imaging pathology correlation.

Results:
The SUVmax were observed decreases in the 3f/6d group (P = 0.000), compared to these for non-irradiated tumors. However, it was significantly increased in the 6f/12d later, and then gradually reduced with treatment time prolonged again after 6f/12d group. Proliferation changes on pathology imaging at 6f/12d were also confirmed. Significant correlations were found between the SUVmax and Ki-67 LI of all ROIs in each in vitro tumor of cell proliferation group (Ps < 0.001). Similar results were also found in each tumor of accelerated repopulation group (Ps < 0.001). Furthermore, both the mean ORRs were more than 50% in all layer of the tumor cell proliferation and accelerated groups. Regions of high-intensity [18]F-FLT uptake in the autoradiographs exhibited prominent staining for Ki-67.

Conclusions:
[18]F-FLT PET may be a promising imaging surrogate of tumor proliferative response to fractionated radiotherapy and might help make adaptive radiation oncology treatment plan.

Clinical trial identification:


Legal entity responsible for the study:
Shandong Cancer Hospital

Funding:
National Natural Science Foundation of China (81472810) and the Science and Technology Development Plans of Shandong Province (2014GSF118138)

Disclosure:
All authors have declared no conflicts of interest.

Background:
Radiomics is a promising tool for identification of new prognostic biomarkers. However, image reconstruction settings may affect the absolute values of radiomic features, which reduces their value as reliable biomarkers. PET/MR is becoming more available and often replaces PET/CT. The aim of this study was to quantify to what extend [18F]-FDG PET/CT radiomics models can be transferred to [18F]-FDG PET/MR.

Methods:
Nine patients with non-small cell lung cancer underwent first an [18F]-FDG PET/MR scan followed by an [18F]-FDG PET/CT scan (SIGNA PET/MR and Discovery PET/CT 690, GE Healthcare) with a delay time of 38 min +/−5 min. Patients had one single FDG injection for both scans. The primary tumors were segmented independently on the PET scans from PET/CT and PET/MR with two semi-automated methods (gradient-based and threshold-based). Resampling was performed to the lowest resolution. In total, 1358 radiomic features were calculated, i.e. shape (18), intensity (17), texture (137), wavelets (1186). The intra-class correlation coefficient was used to compare the radiomic features in both image modalities. An ICC >0.9 was considered stable among both types of PET scans.

Results:
The median relative volume difference of the tumors segmented on PET/CT and PET/MR was 4.8% (range 0.4–39.9%) for the gradient-based and 18.0% (range 0.7–71.2%) for the threshold-based method. A larger number of radiomic features was stable using the gradient-based method compared to the threshold-based method, which concurs with the improved reproducibility of tumor volume using gradient-based method. More than 70.6% of shape and intensity features yielded an ICC >0.9 among both segmentation methods. However, only 51.5% of texture and 27.2% of wavelet features reached this criterion (for gradient-based and even less in threshold-based method). In the wavelet features analysis, more features were robust in smoothed images (low-pass filtering) in comparison to images with emphasized heterogeneity (high-pass filtering).

Conclusions:
Shape and intensity radiomic features were robust comparing the two types of [18F]-FDG PET scans (PET/CT and PET/MR). In contrast, texture and wavelet features showed reduced stability, which needs to be considered for their use in prognostic modelling.

Clinical trial identification:


Legal entity responsible for the study:
Dr. Stephanie Tanadini-Lang

Funding:
Has not received any funding

Disclosure:
M. Guckenberger: Committee Member EORTC, ESTRO Board of Directors, Head of Working Group DEGRO. All other authors have declared no conflicts of interest.

Background:
The staging of well differentiated bronchopulmonary neuroendocrine tumours (carcinoids) is complicated by the unpredictable incidence of nodal and distal metastases. PET CECT which has become the standard for staging of lung cancers has proven ineffective in the staging of carcinoid tumours. 68 Ga DOTA NOC PET/CT which depends on radio-tracer uptake in somatostatin receptors appears to be an attractive modality for the staging of these neuroendocrine tumours.

Methods:
We performed a retrospective analysis of patients who underwent 68 Ga DOTA NOC PET/CT followed by surgical resection from October 2014 to November 2017. Data was retrieved regarding demographics, standardized uptake value (SUV), surgery performed and final histopathology report including degree of differentiation, nodal positivity and Mib index. The study included only patients who underwent resection since the focus of the study on corelation with histopathological features. An attempt was made to corelate the SUV with diagnosis of typical vs atypical carcinoid, nodal metastases and Mib index.

Results:
During the study period 38 patients underwent surgical resection following DOTA PET. All details of imaging including SUV were available for 35 patients, while complete histopathological details were available for 37 patients. DOTA PET was not able to differentiate between typical and atypical carcinoids (32 vs 3) based on SUV. The mean SUV of typical carcinoids was 41.4(SD- 41.2) whereas that of atypical carcinoids was 34.4(SD-39.4) and the difference was not statistically significant (p = 0.7). 6/37 cases had nodal metastases of which DOTA PET could corrrectly identify only 1. There were 2 false positive reports and 5 false negative reports, (sensitivity 16.6% and specificity 93.5%). The mean SUV of the false positive nodes (n = 2 cases) was 7 which calls into question the specificity of the tracer. No corelation between SUV and Mib index could be demonstrated, p = 0.37.

Conclusions:
In this study 68 Ga DOTA NOC PET CECT could not help in predicting the histopathological nature of carcinoid tumours, atypical vs typical, presence of nodal metastases or Mib index. This study is limited by the small numbers enrolled, a larger series may help us incoming to a more definitive conclusion.

Clinical trial identification:


Legal entity responsible for the study:
Tata Memorial Hospital

Funding:
Has not received any funding

Disclosure:
The author has declared no conflicts of interest.

Background:
Patients with small cell lung cancer (SCLC) younger than 40 are limited in number and are understudied. Our research aimed to assess the characteristics, timeliness of cancer development, and outcomes of this patient population.

Methods:
Records of Patients under the age of 40 with SCLC at the Chinese Academy of Medical Sciences between January 2006 and December 2015 were reviewed and evaluated.

Results:
One hundred and three patients (67.0% limited-stage, 33.0% extensive-stage) were included, along with 54 (52.4%) never-smokers. The median duration of the diagnostic interval and the median survival time (MST) were 51.0 days and 24.0 months, respectively. Survival was significantly better for limited-stage patients than for those in the extensive-stage group (MST, 28.0 vs. 14.0 months, p < 0.0001). Patients with shorter diagnostic times (≤1 month) tended to have a better prognosis than those with a longer delay to diagnosis (MST, 25.0 vs. 23.0 months, p = 0.061), which was more pronounced in the limited stage group (MST, 48.0 vs. 26.0 months, p = 0.043). A timely diagnosis also exerted a positive impact on progression-free survival (PFS) in both the limited-staged patients (36.0 vs. 13.0 months, p = 0.061) and extensive-staged patients (6.0 vs. 3.0 months, p = 0.047). Further analysis identified a correlation between the antibiotic treatment before SCLC diagnosis and the diagnostic interval (Spearman Rho = 0.294, p = 0.003). Multivariate analysis suggested that empirical antibiotherapy history, disease stage, and tumor location independently correlated with survival.

Conclusions:
Our study identified distinct characteristics of patients with SCLC under 40. More timely care could improve patient outcomes especially among those at a limited-stage.

Clinical trial identification:


Legal entity responsible for the study:
National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
When developing a patient-reported outcomes assessment strategy, empirical evidence based on literature review and therapeutic area experts should be complemented with input directly from patients to reliably reflect the patients’ experiences. Therefore, a set of research activities were initiated to identify, describe, and substantiate concepts that reflect the important and relevant symptoms, treatment-related side effects, and impacts of extensive stage (ES)-SCLC.

Methods:
Twenty-five articles were reviewed, four clinical experts participated in advice meetings and 17 US patients diagnosed with ES-SCLC were interviewed. Trained interviewers used a semi-structured interview guide to elicit information from patients. Interviews were transcribed, coded, and analysed using qualitative data analytic methods.

Results:
Patients’ mean age was 65.2 years (SD = 9.8) and patients self-reported as white (n = 11, 64.7%), black or African American (n = 5, 29.4%), and American Indian or Alaska Native (n = 1, 5.9%). Thirty-one signs/symptoms of ES-SCLC were elicited with fatigue being mentioned by most patients (n = 10). Also, the most frequently reported SCLC symptoms were shortness of breath (n = 6, 35.3%), pain (n = 5, 29.4%), and weight loss (n = 4, 23.5%). Patients also reported numerous ways that their lives were impacted by ES-SCLC (n = 68 concepts), and treatment-related side-effects they experienced (n = 41 concepts). These findings, along with evidence from literature review and clinical experts, showed that shortness of breath, pain, weight loss, cough, fatigue, nausea, paraneoplastic syndromes, haemoptysis, and loss of appetite were reported as signs and symptoms of SCLC in all three research activities.

Conclusions:
This study provides an overview of symptoms, treatment-related side effects, and impacts associated with ES-SCLC from the patient perspective. The results suggest that patients with SCLC have similar key symptoms to patients with non-small cell lung cancer, therefore similar measurement strategies can be applied. Using this evidence, recommendations can be made for ES-SCLC clinical trial outcomes that resonate with primary stakeholders including patients, healthcare providers, regulatory agencies, and payers.

Clinical trial identification:
Not applicable.

Legal entity responsible for the study:
AstraZeneca PLC

Funding:
AstraZeneca

Disclosure:
A. Rydén, H. Jiang, P. Dennis: AstraZeneca: full-time employment and stock ownership. S. Ollis, E. Love, A.L. Shields: Employee of Adelphi Values, which receives payment from pharmaceutical companies to conduct outcomes-based research.

Background:
A significant number of patients with SCLC suffer from comorbidities. In particular, heart failure and chronic obstructive pulmonary disease are often present. Comorbidity alone has been validated as an independent negative survival prognostic factor in SCLC. Despite this, comorbidities are rarely systematically assessed in relation to quality of life. Here, we examine the effect of comorbidity on HUS and quality of life in SCLC in relation to NSCLC.

Methods:
Histologically confirmed SCLC or NSCLC, were recruited from the Princess Margaret Cancer Centre. Demographics, treatment toxicity, and Patient Reported Charlson Comorbidity Index (PRO-CCI) were collected. For statistical analysis, univariable linear regression was applied to evaluate each variable and its association with HUS. A multivariable model with a backwards selection algorithm of univariable factors associated with HUS was employed.

Results:
Comorbidiity differentially drives HUS in SCLC compared to NSCLC (interaction p < 0.0001) and is an independent negative predictor of HRQoL (Table). Specifically, heart failure and COPD were two main modulators in SCLC quality of life (p < 0.05). Other prognostic factors, notably treatment-related symptom severity and performance status at diagnosis, did not differentially modulate HUS (Table). SCLC patients had a significantly higher number of comorbidities and lower HUS relative to NSCLC; nonetheless, comorbidity had the greatest magnitude of inverse relationship with HUS.

Interaction Terms	Interaction p-value	SCLC	NSCLC
CCI	<0.0001	−0.09 (−0.01, −0.06)	−0.02 (−0.05, 0.01)
Average severity of symptoms	0.70	−0.04 (−0.06, −0.02)	−0.04 (−0.05, −0.02)
Performance status at diagnosis	0.53	−0.06 (−0.11, −0.02)	−0.08 (−0.12, −0.05)

Conclusions:
Comorbidity differentially modulates HUS in SCLC compared to NSCLC and is an important criterion to evaluate prior to treatment. We suspect that extensive smoking histories in the SCLC population may be driving these differential effects on HUS (Table). Interactions between factors differentially modulating HUS in SCLC and NSCLC.

Clinical trial identification:


Legal entity responsible for the study:
Princess Margaret Hospital (University Health Network)

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
Extensive Disease Small Cell Lung Cancer (ED-SCLC) represents 30% of lung cancer. While surgery is not an option, chemotherapy is traditionally currently recommended as the standard treatment. As oncologists seek superior modality for better survival, we conducted this study to evaluate the efficacy of combined chemotherapy and thoracic radiotherapy in improving the survival of patients with ED-SCLC, and to identify the characteristics of best candidates.

Methods:
Using the SEER database, we extracted the data of 5443 patients with ED-SCLC from 2010 to 2013. There were 2665 (49%) patients who underwent combined chemotherapy and thoracic radiotherapy, while 2778 (51%) of them received chemotherapy only. Patients’ demographics and TNM classification were assessed.

Results:
Patients with ED-SCLC had better outcomes when they received combined chemoradiation, compared with those who received chemotherapy alone, where overall 1-year relative survival rates were 40.2% and 24.1%, respectively (p value <0.001). All patients’ characteristics favor combination over chemotherapy except those aged below 40 years and those over 80 years. Subgroup analysis revealed better survival rates among female patients, patients aged between 40 and 59 years, and those with metastasis to the other lung or free regional lymph nodes. On the other hand, no advantage was allocated to those of specific race or primary site.

	Survival of Patients
Variables	Chemoradiation	Chemotherapy	p value
Sex:
Male	37.1%	21.5%	<0.001**
Female	43.9%	27.0%	<0.001**
Age:
20–39	28.6%	80.1%	0.914
40–59	43.3%	25.0%	<0.001**
60–79	40.0%	24.3%	<0.001**
≥80	21.8%	19.6%	0.6
Race:
White	39.9%	23.7%	<0.001**
Black	42.5%	27.7%	0.002**
Others	40.9%	25.4%	0.002**
Primary Site:
Upper Lobe	40.3%	24.3%	<0.001**
Middle Lobe	47.5%	22.6%	0.001**
Lower Lobe	38.4%	23.9%	<0.001**
Overlapping Lesion	44.5%	25.4%	0.01*
Lymph Nodes Involvement:
No Nodes Involved	53.6%,	35.5%	<0.001**
Single Ipsilateral Node	46.8%	31.6%	<0.001**
Multiple Ipsilateral Nodes	37.5%	22.3%	<0.001**
Distant Metastasis:
Lung	37.5%,	21.0%	<0.001**
Liver	30.2%	19.2%	<0.001**
Brain	31.5%	22.4%	<0.001**
Bone	31.6%	21.2%	<0.001**

Conclusions:
Combined chemoradiation in patients with ED-SCLC shows higher 1-year relative survival rates when compared with chemotherapy alone. Further studies should be conducted to weigh the efficacy versus safety to consider using chemoradiation as an alternative modality for ED-SCLC.

Legal entity responsible for the study:
Inas Uthman

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
The survival advantage of radiotherapy (RT) for patients with extensive disease small cell lung cancer (ED-SCLC) has not been adequately evaluated.

Methods:
We analyzed stage IV SCLC patients enrolled from a large data from the Surveillance, Epidemiology, and End Results (SEER) registry through January 2010 and January 2012. Propensity score (PS) analysis with 1:1 matching and the nearest neighbor matching method were performed to ensure well-balanced characteristics of all comparison groups. Kaplan-Meier and Cox proportional hazardous model were used to evaluate the overall survival (OS), cancer-specific survival (CSS), and corresponding 95% confidence interval (95%CI).

Results:
Overall, for all metastatic ED-SCLC, receiving radiotherapy was associated with both improved OS and CSS. Generally speaking, radiotherapy for thoracic lesion and any metastatic sites could significantly improve the OS and CSS, except for brain metastasis. Before PS matching, radiotherapy significantly improved the survival of ED-SCLC patients with metastasis to brain (OS, HR = 0.71, with 95% CI = 0.61–0.83), however, the OS improvement became insignificant after PS matching (OS, HR = 0.91, with 95% CI = 0.74–1.12). For those M1a-SCLC patients without pleural effusion, radiotherapy, most likely to the primary site, also significantly improved the survival (P < 0.001). Furthermore, for those ED-SCLC patients with ≥ 2 metastatic sites, i.e., poly-metastatic ED-SCLC patients, radiation significantly improved the median OS from 6.0 months to 8.0 months (P = 0.015) and the median CSS from 7.0 months to 8.0 months (P = 0.020).

Conclusions:
The results suport radiotherapy in addition to chemotherapy might improve the survival of patients with metastatic ED-SCLC in a PS-matched patient cohort from the large SEER database. Although it should be adequately studied in phase III trials, it is prudent to select patients for radiotherapy in metastatic ED-SCLC.

Clinical trial identification:


Legal entity responsible for the study:
Dr. Zhenming Fu, Cancer Center, Renmin Hospital of Wuhan University, Wuhan, China

Funding:
National Science Foundation of China (NSFC)

Disclosure:
All authors have declared no conflicts of interest.

Background:
Prophylactic cranial irradiation in SCLC was first proposed in 1973 and is recommended for patients demonstrating good response to initial therapy. The general pattern of care amongst radiation oncologists in Germany has not been previously evaluated. We conceptualized and conducted this survey to assess patterns of care.

Methods:
We surveyed radiation oncology institutions in Germany via an online questionnaire sent by e-mail to member institutions of the German Society for Radiation Oncology (DEGRO e.V.). The questions were based on respondent and treatment characteristics with emphasis on prophylactic cranial irradiation in limited- and extensive-stage SCLC.

Results:
We received a total of 95 responses (29% response rate). Of which 64 were completed and returned and hence eligible for evaluation. Sixty-one percent of respondents were between the ages of 50–59, 88% with over 15 years of experience in the management of lung malignancies. Sixty-seven percent of the institutions stage their patients initially with 18F-FDG-PET/CT. Of the 64 responses, 97% recommended delivery of PCI in therapy responders with LS-SCLC compared to 67% with ES-SCLC. Interestingly, a quarter of respondents offered hippocampal-avoidance PCI with only 38% following their patients with serial brain imaging following PCI. Neuropsychological testing was generally not routinely performed.

Conclusions:
German radiation oncology institutions showed interesting variations in certain aspects yet in general congruence in SCLC management and PCI delivery in accordance with the updated national and international guidelines. Future randomized clinical trials will further reduce discrepancies regarding delivery of PCI especially in ES-SCLC.

Clinical trial identification:


Legal entity responsible for the study:
University Hospital, LMU Munich

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
Prophylactic cranial irradiation (PCI) remains the standard of care in patients who respond to first-line chemotherapy for ES-SCLC, although several recent studies have questioned its benefit with regard to survival.

Methods:
To see whether PCI was associated with improved survival in ES-SCLC patients, we conducted a retrospective study at a regional cancer centre in New Zealand. All ES-SCLC patients who had at least one cycle of chemotherapy from 2001 through April 2017 were included. The available medical records were reviewed to extract clinical variables: age, sex, comorbidities, metastatic sites, chemotherapy [regimen, and number of chemotherapy lines (NCL)], radiotherapy [palliative, consolidation chest radiotherapy (CCRT), or PCI], and overall survival (OS). Univariate analysis stratified by PCI status (received vs. not received) was performed. Stepwise Cox's regression was used to identify and adjust for confounders that affect survival by PCI status. The subgroups were examined by Kaplan-Meier method.

Results:
327 ES-SCLC patients who received ≥1 cycle of chemotherapy were identified; of the 245 patients with available records, median OS was 7.7 months (95% CI: 5.7–8.6 months). In 49 patients (20%) who received PCI, the median OS was 14.3 months (95% CI: 11.5–17.4), compared to 6.3 months (95% CI: 5.2–7.3) in patients who did not receive PCI (unadjusted hazard ratio (HR) for death: 0.34, 95% CI: 0.24–0.48). After adjusting for three covariates (NCL, whether ≥4 cycles of first-line chemotherapy was given, and whether CCRT was delivered), however, difference in survival was no longer significant (adjusted HR: 0.66, 95% CI: 0.42–1.04). No difference was observed in OS among subgroups. 85 patients (35%) who had <4 cycles of first-line chemotherapy (and did not receive more chemotherapy) had a dismal prognosis (median OS: 2.9 months, 95% CI: 1.8–3.4).

Conclusions:
Though ES-SCLC patients treated with PCI appear to have a better survival, but this positive association is not independent of treatment characteristics. Without further data from randomised trials, PCI should be used judiciously considering its toxicities and detriments to quality of life.

Clinical trial identification:


Legal entity responsible for the study:
Waikato District Health Board

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
Prophylactic cranial irradiation in SCLC is recommended in therapy responders to primary treatment. The landmark PCI trials largely took place in the pre-MRI era. Recently, the role of brain imaging in PCI has come under increased scrutiny. We conducted this survey to gauge the patterns of brain imaging in PCI amongst radiation oncologists in Germany.

Methods:
We surveyed radiation oncology institutions in Germany via an online questionnaire sent by e-mail to member institutions in the online directory of the German Society for Radiation Oncology (DEGRO e.V.). The questions covered aspects of brain imaging in limited- and extensive-stage SCLC.

Results:
We received a total of 39 responses. Of which 34 were completed and eligible for further evaluation. 97% and 92% of respondents recommended brain imaging prior to initial treatment in LS- and ES-SCLC, respectively with contrast-enhanced MRI being the preferred modality in 86% of cases. Ninety-one percent of respondents recommended brain imaging not older than 4 weeks prior to PCI delivery with 71% recommending commencing PCI <4 weeks after primary treatment. Of all responses, 38% followed their patients regularly with serial brain imaging following PCI with the absolute majority preferring image acquisition only in symptomatic patients. On detection of brain metastases (BMs), 59% recommended stereotactic radiosurgery (SRS) or repeat whole brain radiotherapy depending on the number of BMs.

Conclusions:
Patterns of brain imaging in Germany are in general consistent with the guidelines with contrast-enhanced MRI being the preferred modality for brain staging prior to primary treatment and especially after multimodality treatment and before PCI delivery.

Clinical trial identification:


Legal entity responsible for the study:
University Hospital, LMU Munich

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
Small cell lung cancer (SCLC) is an aggressive cancer characterised by early invasion and metastasis, the rapid emergence of treatment resistance and poor prognosis. Previous research has demonstrated that the number of circulating tumour cells (CTCs) at baseline is prognostic in SCLC, associated with poorer overall survival (OS). Our aim was to explore the prognostic utility of the quantification of CTCs at the end of treatment (EoT) and the development of disease relapse, in addition to baseline.

Methods:
This was a single-centre study assessing CTC numbers in 105 patients with SCLC recruited to a lung cancer biomarker programme between 2009 and 2017. CTC enumeration was performed with CellSearch™ at baseline and at least one further timepoint including EoT, 1[st] or 2[nd] disease relapse. Clinical data was extracted from the electronic patient records database. Data was analysed for trends between CTC number and progression free (PFS) and OS.

Results:
Baseline measurements were stratified into groups of ≥50 and <50 CTCs/7.5 ml. Patients in the ≥50 CTCs/7.5 ml group had significantly lower mean PFS (9.6 vs 5.8 months, p < 0.05) and OS (14.4 vs 9.3 months, p < 0.05). EOT CTCs were significantly lower than at baseline (mean = 73 vs 632 CTCs/7.5 ml, p < 0.05) and lower than 1[st] (mean = 202 CTCs/7.5 ml) and 2[nd] (mean = 602 CTCs/7.5 ml) relapse. EOT CTCs were split into groups of 0, 1–20 and >20 CTCs/7.5 ml. Patients in the >20 CTCs/7.5 ml group had the shortest PFS (mean = 4.6 months) and significantly shorter OS (mean = 5.6 months, p < 0.05) compared to those with less CTCs. The same CTC groups were used for the 1[st] relapse, with decreasing mean PFS (3.9 vs 6.8 months) and OS (10.1 vs 17.1 months) as patients moved from the most to the least favourable groups.

Conclusions:
This study indicates that EoT CTC number may be predictive of both PFS and OS. We also noted a negative correlation between relapse CTC numbers and survival times, but further research is required to determine the statistical significance of this relationship. With further work, CTCs may have a role in evaluating response to treatment and monitoring for relapse.

Clinical trial identification:


Legal entity responsible for the study:
The Christie NHS Foundation Trust

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
D, a chimeric monoclonal antibody that binds cell-surface GD2 expressed on SCLC, can cause significant pain. Combined tolerability with I in RR SCLC patients (pts) is unknown.

Methods:
Part 1, an intrasubject dose-escalation lead in to the main study, investigated outpatient use of D + I. Eligibility: RR SCLC following first-line platinum-based therapy with a life expectancy of ≥12 weeks, PS 0-1. Pts received intravenous (IV) D and I (fixed dose 350 mg/m[2]) on Day 1 q 21-days. D was dosed 10 mg/m[2], and increased 2 mg/m[2]/cycle, if pain was < Grade 2, no opioid medications were required, and prior dose was otherwise tolerated. Doses could be decreased based on toxicity observed. Pretreatment included IV hydration, antihistamines, and antipyretics. Pts were monitored for 4 hours after D. Pts remain on treatment until intolerance, progression, or death.

Results:
12 pts were treated (8 male) in US and Spain. Mean (range) age was 68 (47–79) years. A median (range) of 3 (2–4) cycles were completed per pt. Median (range) D dose achieved was 14 (10–16) mg/m[2]. 121 adverse events (AEs) were reported in the Table. There were no grade (gr) 5 AEs. Pain AEs, attributable to D, were mainly gr 1 (80%), with most resolving within hours of infusion; one subject experienced gr 3 AEs, and received the same D dose in the subsequent cycle. Overall, pain did not result in D dose reductions, discontinuations or hospitalizations. Most other AEs were GI in nature and likely attributable to I.

AE	Grade, N subjects (%)
	1	2	3	4
Pain
Back pain	5 (41.7%)	1 (8.3%)	1 (8.3%)	0
Pain in extremity	3 (25.0%)	0	0	0
Abdominal pain	1 (8.3%)	1 (8.3%)	0	0
Arthralgia	1 (8.3%)	0	1 (8.3%)	0
Headache	2 (16.7%)	0	0	0
Non-pain
Diarrhea	10 (83.3%)	2 (16.7%)	0	0
Nausea	5 (41.7%)	3 (25.0%)	0	0
Cough	3 (25.0%)	1 (8.3%)	0	0
Vomiting	3 (25.0%)	1 (8.3%)	0	0
Anaemia	2 (16.7%)	0	1 (8.3%)	0
Constipation	3 (25.0%)	0	0	0
Decreased appetite	3 (25.0%)	1 (8.3%)	0	0
Asthenia	2 (16.7%)	1 (8.3%)	0	0
Dehydration	2 (16.7%)	0	0	0
Fatigue	1 (8.3%)	1 (8.3%)	0	0
Hypomagnesaemia	1 (8.3%)	1 (8.3%)	0	0
Infusion related reaction	1 (8.3%)	0	0	0

Conclusions:
D up to 16 mg/m[2] + I have been tolerated with no unanticipated AEs. Part 2 of the study has begun and will randomize ∼460 subjects to: I vs. D + I vs. topotecan.

Clinical trial identification:
EudraCT 2017-000758-20 ClinTrials NCT03098030

Legal entity responsible for the study:
United Therapeutics Corporation

Funding:
United Therapeutics Corporation

Disclosure:
M.J. Edelman: Primary investigator for this corporate-sponsored research. O. Juan, A. Navarro: Principal investigator for this corporate-sponsored research. G. Golden, A. Saunders: Employed by United Therapeutics Corporation who is the sponsor of this study.

Background:
Small cell lung cancer (SCLC) represents approximately 10–15% of all lung cancers and is characterized by an aggressive disease course. Despite being a relatively chemotherapy- and radiation- sensitive disease, recurrence and eventual chemoresistance is frequent. prognosis in these patients remains poor, with a median survival of 10–12 months from diagnosis. These patients may experience significant physical and psychological distress throughout the course of their disease, resulting in impaired quality of life (QOL). Early implementation of palliative care can lead to improved symptom control, reduced distress, limit hospitalizations and aid in the decision making with regards to the delivery of care, ultimately providing improved satisfaction with end of life care.

Methods:
A retrospective, single-center audit of all patients diagnosed with small cell lung cancer over a six-year period (Jan 2010–Dec 2016). Patients were identified using the Hospitals’ Inpatient Enquiry (HIPE) database. Clinical data were retrieved from hospital pathology and imaging reports as well as patient records. Statistical analysis was performed using a Kaplan-Meier analysis and Pearson correlation coefficient.

Results:
115 patients were diagnosed with SCLC. 91/115 patients (79%) were diagnosed with extensive stage disease (40 female patients (44%) and 51 male (56%)). Median age at diagnosis was 66 years. Median ECOG performance status was 1. 63/91 of these patients (69%) received a palliative care review within one month of diagnosis. 51 patients (56%) were alive at six months, with 29 (32%) alive at one year. Patients in the group receiving early palliative care intervention demonstrated improved overall survival, and this correlation was statistically significant (p = 0.01). The median number of hospitalizations in this cohort was also lower (median = 1) than those with delayed palliative care input (median = 2), however, this result was not statistically significant.

Conclusions:
Early palliative care input improves quality of life and translates into a survival benefit. Increased awareness of the benefits of palliative care in extensive stage small cell lung cancer at diagnosis is paramount in ensuring optimal patient outcomes and patient satisfaction with their oncological care.

Clinical trial identification:
not clinical trial

Legal entity responsible for the study:
HSE

Funding:
Has not received any funding

Disclosure:
The author has declared no conflicts of interest.

Background:
SCLC accounts for approximately 14% of lung cancer. There are a large number of symbiotic microorganisms in the intestinal tract of the human body. Under normal circumstances, intestinal flora, the body and the external environment maintain a relative balance to maintain the health of the body. If the balance is broken, the body will show an alteration of intestinal flora, which may cause disease.

Methods:
(1) Clinical fecal specimens collection: Fresh fecal samples were collected before the first cycle of chemotherapy and labeled as 1–14. 14 healthy people were matched. (2) Intestinal bacteria DNA extraction. (3) The changes of intestinal flora were analyzed by PCR-DGGE. Cutting of the bands with significant differences in sequencing to determine the classification of bacteria. (4) Results analysis: Quantity One software and SPSS19.0 software were used to analyze the results.

Results:
(1) Intestinal flora analysis in SCLC group and healthy group: The diversity index and abundance of the healthy group was higher than those of the SCLC group, the difference in diversity index was statistically significant (P < 0.05), but the difference in abundance was not significant (P > 0.05). (2) Sequencing results analysis: Brightness of bands 1, 3, 7 and 8 were higher in the SCLC group than in the healthy group; brightness of bands 2, 4, 5, 6 and 9 were higher in the SCLC group than in the healthy group. The results show that the sequence similarity of bands 1 and 3 with Eubacterium xylanophilumisis were 98% and 97%, respectively; the sequence similarity of bands 2 and 6 with Prevotella copri 91% and 97%, respectively; the sequence similarity of band 4 with Blotia sp.was 93%; the sequence similarity of band 5 with Dialister succinatiphilus was 92%; the sequence similarity of band 7 with Eubacterium eligens was 100%; the sequence similarity of band 8 with Clostridium sp. was 99%; the sequence similarity of band 9 with Pseudobutyrivibriorum inisis 100%.

Conclusions:
(1) Intestinal flora differ between SCLC patients and healthy people, the difference in diversity index is significant, but the difference in abundance is not significant. (2) The increase of Eubacterium xylanophilum, Eubacterium eligens and Clostridium sp.are positively correlated with the occurrence of SCLC. The decrease of Prevotellacopri and Pseudobutyrivibriorum inis are positively correlated with the occurrence of SCLC.

Clinical trial identification:


Legal entity responsible for the study:
2nd Hospital Affiliated to Dalian Medical University

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
With the rapid advances of LDCT screening for lung cancer, the opportunity to detect subcentimeter NSCLC is gradually increasing. But, even subcentimeter NSCLCs are not always in the early stage. Thus, it is quite important for us to judge the possibility of malignancy for these patients, even the tumor size is less than 10 mm. Chronic inflammation is well established as a hallmark in lung carcinogenesis. The aim of the present study is to evaluate the correlation between inflammation biomarkers and the risk for subcentimeter lung adenocarcinoma.

Methods:
Inflammatory biomarkers were measured in 71 subcentimeter lung adenocarcinoma patients and 71 age-, sex- and smoking-matched healthy controls by using the Luminex bead-based assay.

Results:
The expression level of TNFRII is significantly down-regulated in subcentimeter lung adenocarcinoma patients compared with the healthy controls (P < 0.001). And the results were validated by oncomine data mining analysis. Elevated levels of TNFRII were associated with an 89% reduced risk for subcentimeter lung adenocarcinoma. (OR = 0.11, 95% CI: 0.04–0.30, P = 2.4 × 10[−5]). BLC was associated with a 2.70-fold (95% CI: 1.31–5.58, P = 7.0 × 10[−3]) increased risk of subcentimeter lung adenocarcinoma for the comparison of patients in the higher-level group with the lower-level group. To yield more information, the BLC/TNFRII ratio was created to examine their prediction for the risk of subcentimeter lung adenocarcinoma, and there was a 35-fold increased risk for patients in the higher-level group relative to patients in the lower-level group. Further ROC curve analysis revealed that TNFRII was a significant diagnostic biomarker for subcentimeter lung adenocarcinoma, with the area under the curve of 0.73 (95% CI: 0.65–0.82, P = 2.0 × 10[−6]). The sensitivity, specificity and accuracy were 0.75, 0.72 and 0.73, respectively.

Conclusions:
Our findings demonstrated that TNFRII was associated with the significant risk of subcentimeter lung adenocarcinoma and could be a promising biomarker for accessorily diagnosing subcentimeter lung adenocarcinoma.

Clinical trial identification:


Legal entity responsible for the study:
Yanwei Zhang

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
Epidermal growth factor receptor (EGFR) is considered to be one of the key driver genes in non-small cell lung cancer (NSCLC). This study explored the potential association between EGFR and DNA damage repair gene expression (Ku70 and Rad51), and their relationship with prognosis in patients with NSCLC.

Methods:
We reviewed the clinical information of 79 patients. The expression of Ku70 and Rad51 were determined via immunohistochemistry in surgically resected of lung adenocarcinoma and densitometry analysis using image-pro plus 6.0 software. The clinical prognostic value of protein expression was investigated with univariate and multivariate survival analysis.

Results:
Compared with EGFR mutant patients, mean integral optical density (IOD) of Rad51 and Ku70 had no statistically significant difference in the wild type. Separating patients into low and high expression group according to the median value of IOD, Spearman's test showed no significant correlation between Ku70 and Rad51 expression level and EGFR gene status, while tumor tissue with T1-T2 staging had a lower Ku70 protein expression than T3-T4 (p < 0.05) according to the IOD. No statistical significant difference was found between in mean IOD of Ku70 and Rad51 between recurrence and non-recurrence. Kaplan-Meier analysis revealed that patients with Ku70 low expression tended to have poorer DFS than high expression group (20.6 vs. 22.7 months, p > 0.05). PFS of both Ku70 and Rad51 low expression group had an improving tendency comparing to high expression group (Ku70: 9.0 vs. 6.0 months, and Rad51: 10.0 vs. 7.0 months, both p > 0.05). Multivariate analysis showed, (negative vs. positive) was an independent impact factor of DFS; gender (female vs. male), EGFR status (mutant vs. wild type) and Ku70 expression level (low vs. high) were independent impact factors of PFS.

Logistic regression between different proteins and possible impact factor
Protein	Variables	SE	Exp(B)	p
Ku70	EGFR	0.488	0.684	0.688
	T-stage	0.833	0.044	0.044
Rad51	EGFR	0.478	0.925	0.925
	T-stage	0.732	0.164	0.164

Conclusions:
We provide clinical evidence that Ku70 protein expression level is lower in higher T-stage tumor tissue than the lower. DNA damage repair protein expression level has not been detected to have significant correlation with EGFR gene status and disease recurrence, while tumor high expression level of Ku70 protein might have worse response to systemic therapy. However, further study is required.

Clinical trial identification:
This is an retrospective study and approve by the clinical trial committee of the hospital.

Legal entity responsible for the study:
Thoracic Oncology Center, West China Hospital

Funding:
State Key Laboratory of Biotherapy and Cancer Center of Sichuan province in China

Disclosure:
All authors have declared no conflicts of interest.

Background:
Recurrence after surgically treated non-small cell lung cancer (NSCLC) is frequent. A subset of NSCLCs harbors mutations that are routinely analyzed in tumor tissue but can also be detected in cell-free circulating tumor DNA (ctDNA). We performed mutation analysis of tumors to subsequently quantify corresponding mutated ctDNA in pre-operative plasma. Furthermore, we analyzed five tumor markers in pre-operative serum to study the potential of these blood-based methods to predict lung cancer recurrence.

Methods:
Plasma and serum were collected pre-operatively from 167 patients surgically treated for primary lung adenocarcinoma at the Lund University Hospital 2005–2014. Tumor specimens were analyzed with Next-Generation Sequencing (NGS). 76/167 tumors harbored at least one mutation in either of the EGFR, BRAF or KRAS genes. Cell-free DNA from corresponding plasma (0.6 to 1.4 mL) was analyzed for mutations in these three genes using the IBSAFE method, an innovation upon standard droplet digital PCR. The tumor markers carcinoembryonic antigen, neuron-specific enolase, cancer antigen 125, human epididymis protein 4 and carbohydrate antigen 19–9 were analyzed in serum with electrochemiluminiscence immunoassay.

Results:
So far ctDNA and tumor markers have been analyzed in 41 cases. Twenty-nine patients had ≥1 elevated tumor markers and 10 had detectable ctDNA. Information about recurrence was missing in two patients. Sixteen patients were diagnosed with recurrence. Of these, nine had ≥1 elevated tumor markers, three had detectable ctDNA and two had both ctDNA and ≥1 tumor markers. Of 16 patients without recurrence, 10 had at ≥1 elevated tumor marker, one had detectable ctDNA, and one patient had positive ctDNA in combination with one elevated tumor marker. Four patients had stage IV disease at time of diagnosis, two of them with ctDNA and all four with ≥1 tumor markers.

Conclusions:
In summary, ctDNA and/or tumor markers might be useful to identify NSCLC patients with increased risk of recurrence but it remains to be investigated in larger studies and with greater plasma volumes how these biomarkers may fit into lung cancer management.

Clinical trial identification:


Legal entity responsible for the study:
Lund University

Funding:
The Swedish Cancer Society, Skane University Hospital Foundation, the Mrs Berta Kamprad Foundation, the Gustav V:s Jubilee Foundation, the Gunnar Nilsson Cancer Foundation, BioCARE a Strategic Research Program at Lund University, and governmental funding (ALF)

Disclosure:
A.M. George, L.H. Saal: Named inventor of related intellectual property and shareholder of SAGA Diagnostics. All other authors have declared no conflicts of interest.

Background:
In recent years, non-intubated video-assisted thoracic surgey has gained popularity worldwide, especially in elderly lung patients. The main goal of this surgical practice is to achieve an overall improvement of patient management and outcome thanks to the avoidance of side-effects related to general anesthesia (GA) and single-lung ventilation. In this study we tried to compare a non-intubated general anesthetic technique with an intubated general anesthetic technique for VATS.

Methods:
Sixty patients aged 80 and more scheduled for VATS lung surgery, were allocated randomly into two groups with 30 patients each. The first group received standard general anesthesia with double lumen tube. The second group underwent a non-intubated anesthetic technique. Heart rate, mean arterial pressure, end-tidal CO~2~ and the visual analog pain score (VAS) measurements were recorded during the surgery and 24 hours after the surgery. Both groups received ultrasound guided paravertebral block before surgery with single injection of 20 ml of 0.25% levobupivacaine. VATS lung biopsy, sublobar or lobar resection were equally distributed in both groups of patients.

Results:
Time for anesthetic procedure was shorter in the non-intubated group. VATS lobecotomy was performed in the usual manner in all patients without any intraoperative complications. VAS scores in the first 24 hours werecomparable. We found significantlly shorter recovery times, reduced oxygen requirement, and shorter hospital stays in the non-intubated group. There were no significant differences in intraoperative blood loss, the operation time or postoperative complications between the non-intubated group and the intubated group of patients.

Conclusions:
In this study, our experience has shown that non-intubated VATS is a safe and feasible surgery for elderly lung cancer patients with certain advantages for the patients undergoing VATS. Our results indicate that we can achieve day surgery for selected patients. Further clinical studies should be carried out in order to improve surgical outcomes in elderly LC patients.

Clinical trial identification:


Legal entity responsible for the study:
Ilic Nenad

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
Lung resection remain the treatment of choice especially for bronchogenic carcinoma and as well as for intractable end stage localized lung disease such as tuberculosis, bronchiectasis, lung abscess and complicated hydatid cyst. The development of bronchopleural fistula (BPF) remain the most devastating complications that may arise after lung resection especially after pneumonectomy. Bronchial stump reinforcement has been shown to significantly reduce incidence of BPF. There have been described various coverage techniques as: intercostal muscle flap, pleural flap, pericardial fat pad, diaphragm and azygous vein. The aim of this study is to compare the efficiency of bronchial stump reinforcement with flap versus non-reinforcement after major lung resection.

Methods:
This is a retrospective study where was analised the data for 300 patients who underwent major lung resections. 38 patients underwent pulmonectomy and the rest lobectomy, bilobectomy and sleeve lobectomy. The follow up period varied from 6 months up to 10 years. The patients were divided into 2 groups according to method of bronchial stump reinforcement or not. Two groups were matched as regard to: patient age, sex distribution, lung pathology and risk factors.

Results:
78.1% of patients had the diagnosis of NSCLC where 10% of them were subjected to neo-adjuvant chemotherapy. Only in 50% of patients that underwent pulmonectomy, the bronchial stump was reinforced by diverse nature of flap. Meanwhile, according to patients that underwent the other types of lung resections, the bronchial stump was reinforced by flap only in 7% of cases. There was 3% mortality in both groups for a period of postoperative follow up 3 months. Complications were observed in both groups, but BPF happened in 20 patients where only in three of them was performed the bronchial stump reinforcement.

Conclusions:
Intercostals muscle flap, pericardial fat pad and pleural flap are valuable and effective methods in prevention of broncho-pleural fistula following lung resection especially in pulmonectomies and broncho-sleeve lung resections. Surgical techniques using flap reinforcement seems to play a major role in the prevention of BPF especially after neo-adjuvant chemotherapy.

Clinical trial identification:


Legal entity responsible for the study:
Fatmir Caushi

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
The aim of the study is to establish “multistep” criteria to clarify the high-risk patients with resectable lung cancer. The purpose of the present study was to identify preoperative risk factors in lung cancer patients.

Methods:
Retrospective review of the clinical records of all patients operated on thoracic department in 2010–2011. None of the patient received preoperative chemo and/or-radiotherapy. Patients older than 70 years, benign lung lesions, lung metastases, or patients after non-curative lung resection were excluded. A total of 168 patients met criteria for the study. All factors were divided into 3 groups: initial (36 factors incl. TNM, histology, presence of comorbidities etc), functional (29 factors – lung function parameters, echocardiography), and surgery-related (14 factors incl. type of surgery and lymphadenectomies etc.). We analyzed postoperative mortality, pulmonary complications, arrhythmia and hypertension. All of the variables that were found to be significant in the univariate analyses were entered into the multivariate analyses using a forward step-wise logistic regression model in all group separately.

Results:
Group 1. Our model identifies no risk factors for postoperative mortality and hypertension. Diabetes mellitus is associated with higher rates of arrhythmia. Predictors that are associated with pulmonary complication include: the history of second primary cancer, neuroendocrine tumours, rare type of lung tumours. Group 2. There are no risk factors for arrhythmia and hypertension. Left ventricular ejection fraction <45 is associated with postoperative mortality, forced expiratory flow at 25% – pulmonary complication. Group 3. The following criteria related with postoperative mortality – number of unobstructed (by tumours) lung segments, pulmonary complications – ventilation time, arrhythmia – number of resected lymph nodes, hypertension – surgery with resection adjacement structures.

Conclusions:
There are risk factors associated with higher rates of specific postoperative mortality and morbidity but need to be validated by prospective study.

Clinical trial identification:


Legal entity responsible for the study:
Lviv Medical University

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
Hospital-acquired adverse events are a measure of quality of care delivered and may adversely impact patient outcomes. It is unknown if there been a change in the rates and impact of these adverse events with their increasing recognition as quality measures. We analyzed hospital-acquired adverse events in patients with lung cancer undergoing lung resection using the National Hospital Discharge Survey (NHDS) database from 2001 to 2010.

Methods:
NHDS collects clinical information on patients dismissed from non-Federal short-stay United States hospitals. Demographics, diagnoses, procedures, and dismissal information were abstracted using ICD-9 diagnosis (162.X) and procedure codes (32.9, 32.3X, 32.4X, and 32.5X). The Agency for Healthcare Research and Quality Patient Safety Indicators (PSIs) were utilized to identify hospital-acquired adverse events. Weighted analyses were performed using SAS version 9.4.

Results:
An estimated 585,408 patients with lung cancer underwent lung resection during the study period and were included in the analysis; 58.3% were >65 years, 49.1% women, 66% white. Of these, 153,609 (26.2%) suffered from ≥1-PSI event during their hospitalization. The proportion of patients suffering from ≥1-PSI event consistently increased from 22.0% in 2001–2002, to 34.8% in 2009–2010, p value <0.01. Compared to those with no PSI, patients with ≥1-PSI experienced higher in-hospital mortality (2.2%, vs 15.7%, adjusted odds ratio, 7.8, 95% CI 5.1–11.8), and prolonged length-of-stay (7.8 days, vs 12.5 days, adjusted mean difference, 4.6 days, 95% CI 3.7–5.5), p value for both <0.01.

Conclusions:
There was a substantial increase in the frequency of potentially avoidable adverse events in this national database of lung cancer patients undergoing resection, associated with worse outcomes. Although this may in part be due to increasing recognition, interventions are required to prevent these potentially avoidable events.

Clinical trial identification:
Not applicable

Legal entity responsible for the study:
Arjun Gupta

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
Surgical resection is being increasingly used for stage IIIA-N2 small cell lung cancer (SCLC). The aim of this study was to determine the prognostic factors in patients with pathologic N2 (pN2) stage IIIA SCLC.

Methods:
A retrospective analysis of 163 consecutive patients with pN2 stage IIIA SCLC who underwent pulmonary resections and systemic lymphadenectomies was conducted. Potential clinicopathological factors that could influence OS were statistically analyzed. The prognostic significance was examined by Cox regression analysis.

Results:
The median overall survival (OS) was 10.6 months. Multiple-station lymph node metastasis indicated a poorer prognosis than single-station involvement (p = 0.003). With respect to the station of lymph node metastasis, the OS was only related to the involvement of the subcarinal node, regardless of tumor location (p < 0.05). Multivariate analysis showed two statistically significant risk factors for survival, including multiple-station lymph node and subcarinal node metastasis (hazard ratio [HR] = 1.76, 95% confidence interval [CI]:1.11–2.78, p = 0.015; HR = 1.61, 95% CI: 1.03–2.50, p = 0.036, respectively).

Conclusions:
We found multiple-station N2 metastases and subcarinal node involvement were independent prognostic factors for worse survival in pN2 stage IIIA SCLC patients, which may be helpful to identify a valid subpopulation of N2 patients who can benefit from surgical intervention and guide postoperative adjuvant therapy.

Clinical trial identification:


Legal entity responsible for the study:
Shanghai Chest Hospital

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
Lung cancer causes 27% of all cancer deaths. About 10% of the patients are diagnosed in UICC stages I-IIa. Although pathological proof is compulsory before cancer treatment, some patients are unable or reluctant to undergo invasive diagnostic procedures. Nonetheless, these individuals are frequently treated similarly to patients with histologically confirmed disease, which might bear the risk of treating indolent or even benign tumors. A SEER-analysis [1] found a significantly better OS in patients with clinically diagnosed tumors without pathological confirmation, which made the authors conclude that patients with such lesions are probably overtreated. We analysed our own data as a non-selected single centre cohort to compare survival data of patients with and without pathological proof.

Methods:
163 patients with NSCLC UICC I-IIa irradiated between 2002 and 2016 were eligible. Of these, 123 patients had pathological proof of disease. In these cases, irradiation treatment was administered in the same way as if these patients had a confirmed malignant disease. In accordance with international guidelines, the decision was based on the patient's age and smoking history, new or growing nodule on CT and positive PET-scan.

Results:
Both overall (OS) and cancer specific survival (CSS) did not differ between patients with pathological confirmation compared with those without: median OS 40,1 (range: 0,3–147,5) months versus 39,4 (range: 0,5–162) months (p = 0,958), median CSS 51,7 (3,7–129,5) months versus 113,4 (0,5–162) months (p = 0,585). Patients with pathological confirmation had higher UICC stage (p-value = 0,002) and received more chemotherapy (p-value < 0,001).

Conclusions:
Our study revealed no difference in OS and CSS for irradiated stage I-IIa lung cancer patients with and without histological confirmation, thus indicating a comparable benefit from treatment. A main reason probably lies in the strict adherence to a modern diagnostic work-up including PET-CT scan for all patients.[1] Shaikh T (2016) Absence of Pathological Proof of Cancer Associated with Improved Outcomes in Early-Stage Lung Cancer. J Thorac Oncol 11 (7):1112–1120.

Clinical trial identification:


Legal entity responsible for the study:
Paracelsus Medical University, University Hospital Salzubrg, Department of Radiation Oncology

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
Stereotactic body radiation therapy (SBRT) is the primary alternative to surgery for patients with clinical stage I or II non-small cell lung cancer (NSCLC) who have significant comorbidity that precludes safe resection and for those who refuse surgery.

Methods:
Patients with clinical stage I or II NSCLC treated with SBRT in our institution, between January 1[st] 2015 and March 31[st] 2017, were retrospectively analyzed. Control and survival rates were calculated using the Kaplan-Meier method. Acute and late toxicities were graded according to the CTCAE v4.0.

Results:
78 patients were identified, 58 men and 20 women, with a median age of 73 years (range 50–90), and a ECOG performance status of 0 or 1 in 69% of these patients. Of the biopsy proven patients (63%), 53% were adenocarcinomas and 37% were squamous cell carcinomas. 52 patients were staged as IA (T1N0), 23 as stage IB (T2aN0) and 3 as stage IIB (T3N0), all of which were clinically staged with PET-CT. The majority of the tumors (72%) were peripherally located, with a median size of 23 mm. 48Gy in 4 fractions was the most prescribed scheme (76%), followed by 50Gy in 5 fractions (14%). 70 patients were eligible for assessment of recurrence. With a median follow-up of 17.5 months (range 3.5–50.6), 17 (24%) had disease recurrence, of which 11 (65%) had metastatic disease and 10 (59%) failed locally, with isolated distant or local relapse occurring in 5 (29%) cases each. The 1- and 2-year local control was 94% and 81%, respectively. The 2-year regional control, distant metastasis free survival and overall survival (OS) was 87%, 76% and 65%, respectively. Median OS was 37.8 months. The performance status was correlated with survival (p < 0.0001), whereas the tumor histology (adenocarcinoma) predicted for distant relapse (p = 0.03). No grade 3 toxicity was reported. Late grade 2 toxicity occurred in 29% of patients (15% pneumonitis, 9% fatigue, 3% rib fracture, 6% chest wall pain, 2% esophagitis).

Conclusions:
In our population of early stage lung cancer patients treated with SBRT, high rates of local control were achieved, with overall survival outcomes and toxicity profile comparable to other published data, confirming the established role of SBRT in stage I/II non-small cell lung cancer patients.

Clinical trial identification:


Legal entity responsible for the study:
Instituto Português de Oncologia de Lisboa

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
Hypoxia in the center of large tumor directly leads to radiation resistance. Concurrently, heat loss results in incomplete ablation oflarge tumors abutting airways or blood vessels. The combining stereotactic body radiation therapy (SBRT) and radiofrequency ablation (RFA) for non-small cell lung cancer (NSCLC) treatment could overcome respective shortcoming.

Methods:
In this study, we report our experience with combined SBRT and RFA in 27 medically inoperable patients with biopsy-proven T2aN0M0 NSCLC. Patients were treated with SBRT to a dose of 50 Gy followed by CT-guided RFA within 7 days.

Results:
There were no treatment-related deaths. At a mean follow-up period of 29.6 months (range, 3 to 56 months), 15 patients (55.6%) died, with 1-year, 2-year, and 3-year cumulative survival rates of 77.8%, 63.0% and 48.1%, respectively. Threeof the deaths were cancer related. Four (14.8%) and five (18.5%) patients had local and distant recurrence, respectively.

Conclusions:
We concluded that SBRT followed by RFA appears effective for centrally located NSCLC. Survival rates appear to be better than with SBRT or RFA alone. Interactions between the two modalities warrants deeper investigation.

Clinical trial identification:


Legal entity responsible for the study:
N/A

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
The 8[th] edition of the TNM classification for non-small cell lung cancer (NSCLC) has recently been approved. Lymphovascular invasion (LVI) has been reported to be a strong risk factor for stage I patients. Meanwhile, the efficacy of adjuvant chemotherapy for surgically resected pathologic stage I NSCLC is controversial. This study aimed at exploring the association between adjuvant chemotherapy and survival in stage I NSCLC patients with LVI.

Methods:
A total of 2600 patients with stage I NSCLC treated in the Shanghai Chest Hospital (2008–2012) were included in the analysis, of which 221 were pathologically diagnosed with LVI. We divided these patients into an ACT (adjuvant-chemotherapy) group and a surgery alone group. By using the Kaplan–Meier method and Cox proportional hazard regression model, we explored whether lymphovascular invasion was a poor prognostic factor and the application of adjuvant chemotherapy could improve the prognosis.

Results:
For all stage I NSCLC patients, it was observed that patients with LVI had an unfavorable Lung-cancer specific survival (LCSS) (hazard ratio [HR]: 1.604; 95% confidence interval [CI]: 1.124–2.289; P = 0.009) and recurrence-free survival (RFS) (HR: 1.943; 95% CI: 1.491–2.532; P < 0.001). The presence of LVI was suspected to be correlated with larger tumor size, and adenocarcinoma. Analysis of 221 patients with LVI indicated an increased LCSS (HR: 0.31; 95% CI: 0.161–0.595; P < 0.001) and RFS (HR: 0.53; 95% CI: 0.530–0.286; P = 0.044) with adjuvant chemotherapy treatment. We saw significant differences in LCSS and RFS in patients treated with adjuvant chemotherapy with both stage IA and stage IB disease.

Conclusions:
For all stage I NSCLC patients, LVI was correlated with poorer prognosis, which was improved by adjuvant chemotherapy. Our preliminary study suggests that adjuvant chemotherapy might be an appropriate option for stage I NSCLC patients with LVI.

Clinical trial identification:


Legal entity responsible for the study:
Wang Shuyuan

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
Cisplatin-based adjuvant chemotherapy improved overall survival and relapse free survival (RFS) of patient with completely resected stage II and III non-small cell lung cancer (NSCLC). However, the adverse effects of cisplatin-based regimen have not satisfied both patients and clinicians yet, and most of patients have to be hospitalized during chemotherapy. Recently, pemetrexed regimen as adjuvant chemotherapy was reported to result less toxicity than vinorelbine. Additionally, safety of short hydration method for cisplatin administration has been reported. The aim of our study was to investigate the feasibility of pemetrexed plus cisplatin with short hydration as adjuvant chemotherapy in patients with completely resected NSCLC.

Methods:
21 completely resected non-squamous NSCLC patients with pathological stage IIA, IIB, and IIIA were enrolled. Adjuvant chemotherapy was started between four and eight weeks after surgery, and consisted of 4 cycles of pemetrexed (500 mg/m[2]) plus cisplatin (75 mg/m[2]) every 3 weeks with short hydration. The first cycle of each patient was administered with hospitalization, and the others were in outpatient clinic in principle. The primary endpoint was the completion rate of treatment, and secondary endpoints included toxicity, two-year RFS rate, and outpatient treatment rate (rate of outpatient chemotherapy at second cycle).

Results:
Patients were median age 66 years (range 57 to 75) and gender 57% male/43% female. All cases were adenocarcinoma. Pathological stages were IIA 52%, IIB 19%, and IIIA 29%. 81% of patients received 4 cycles of therapy as scheduled. Only 1 patient needed decrease of chemotherapy dose and the reason was prolonged anorexia. No grade 3 or 4 hematologic toxicity was observed. Except for one grade-3 pulmonary thromboembolism and two grade-3 anorexia the adverse events were relatively mild. Increased serum creatinine was observed only one patient (grade 1). Outpatient treatment rate was 90%. Two-year RFS rate was 59%.

Conclusions:
Adjuvant pemetrexed and cisplatin chemotherapy with short hydration for resected non-squamous NSCLC is safety and able to be performed in outpatient basis.

Clinical trial identification:


Legal entity responsible for the study:
Kobe University

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
The adjuvant chemotherapy(ACT) of stage IB lung adenocarcinoma remain controversial, and solid ingredients were supposed to be connected to the poor survival. We are intended to explore the benefits adjuvant chemotherapy made on patients in IB with solid ingredients.

Methods:
a number of 334 completely resected patients with lung adenocarcinoma in stage IB from 2006 to 2015 were reviewed. All the pathological slides were evaluated with solid ingredients composed.

Results:
Our data showed that although disease-free survival (DFS)(p = 0.661) and overall survival (OS)(p = 0.130) were not significantly different in solid growth pattern with or without ACT, patients with solid predominant patterns tend to have longer DFS [hazard ratio (HR) 0.403, p = 0.021)]and OS (HR 0.286, p = 0.009) with ACT. In patients with solid non-predominant patterns, receiving ACT had little influence in DFS(p = 0.231) and OS (p = 0.611).

Conclusions:
the solid predominant pattern in postoperative patients of stage IB could benefit from adjuvant, and solid non-predominant pattern couldn't.

Clinical trial identification:


Legal entity responsible for the study:
Shanghai chest hospital

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
This is a meta-analysis to evaluate the impact of various follow-up intensities and strategies on the outcome of patients after definitive therapy for early stage NSCLC.

Methods:
All the original RCTs comparing the follow-up protocols of different definitive therapies on early stage NSCLC were considered up to November 2017. Specifically, the Jadad score was used to evaluated and appraise the quality of the selected randomized trials.

Results:
In the five RCTs, a total of 1,826 patients with early stage NSCLC undergoing various definitive therapies were randomized into less intensive or minimal follow-up group (n = 984) and intensive follow-up (n = 842). The female: male ratio was 1: 1.45 and 1.26:1 in the intensive and less intensive follow-up groups, respectively. A critical evaluation of all the articles that were included in the present meta-analysis revealed that most of the patients that took part in the study had a follow-up of at least 3 years. Nonetheless, three studies reported a drop out rate that varied between zero and 7% for the less intensive follow-up category and from zero to 38.2% for the minimal or less intensive follow-up group.

Conclusions:
The meta-analysis revealed that in selected patients with stage IIIA-N2 NSCLC, surgical resection does not improve the overall survival rate as is the case with radiotherapy. None of the follow up protocols was associated with increase in recurrence rate or overall survival rate. The ideal follow up should be individualized.

Clinical trial identification:


Legal entity responsible for the study:
Durgesh Wankhede

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
Sublobectomy is an optimal choice for selected early-stage non-small cell lung cancer (NSCLC) patients. However, the criteria for the choice of two different types of sublobectomy methods (wedge resection and segmentectomy) is not clear yet. It was reported that tumor size and the percentage of the ground glass opacity (GGO) were the key parameters for the choice of the surgeries. The study was designed to verify the presumption that for GGO-dominant early stage NSCLC patients (cT1a-T1bN0M0, and GGO component ≥75%), wedge resection is equal to segmentetomy in long term survival.

Trial design:
The trial is a multi-center, prospective randomized, open-labelled, active-control, non-inferiority study. In the study, the cT1a-T1bN0M0 NSCLC patients with GGO component ≥75% who intended to have surgeries were enrolled. Patients were randomized into wedge resection + hilum and mediastinal lymph nodes dissection or sampling group (experimental group) and segmentectomy + hilum and mediastinal lymph nodes dissection or sampling group (control group). The primary endpoint was 5-year disease-free survival (DFS) rate. The secondary endpoints consist of 3-year DFS rate, 5/10-year overall survival rate (OSR), rates of morbidity and 30-day mortality rates, and lung function change. All the study data were descriptively analyzed. Comparison for the differences in DFS was performed by the Log-rank test. The CMHX[2] tests were completed to compare the differences in 3-year DFS and 5/10-year OSR after taking the center effects into considerations. The differences in effectiveness were compared accordingly. In the case that statistical significance was confirmed between the groups, the non-inferiority comparisons would be completed afterwards. The impact factors of effectiveness were measured by the or the Cox modeling, or the Logistic regression analysis. The safety was measured by (serious) adverse events with a Chi-square test. To summarize, the purposes of the study are to seek for a reliable criteria of selection of different type of sublobectomy for early stage NSCLC.

Clinical trial identification:
NCT02718365

Legal entity responsible for the study:
Lunxu Liu

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
Radioresistance occurs in a high proportion of patients with lung adenocarcinoma (LA), resulting in poor response to radiation and dim prognosis. Early identification of radioresistance would accordingly guide adjustment of treatment regimens. Cell-derived exosomes containing proteins and nucleic acids can contribute to intercellular communication. Emerging evidence demonstrates exosomes are intimately involved in therapeutic resistance, and thus exosomes potentially can be used to predict radioresistance.

Methods:
Five patients with radioresistant LA and five healthy volunteers as negative controls were enrolled. Exosomes in 1 ml plasma were isolated with lipid nanoprobe approach, and miRNA from each sample was isolated with Qiagen miRNeasy kit. miRNA expression profiling was analyzed using microarrays, and quantitative real-time PCR was further used to validate miRNAs showing differential expression among two groups. Subsequently, selected miRNAs were validated in additional 27 patients with LA to evaluate their diagnostic potential.

Results:
Microarray analysis revealed there were 7 miRNAs expressed at a remarkably higher level in patients with radioresistant LA in comparison with that of healthy volunteers, and qRT-PCR further validated 3 miRNAs. Of note, exosomal miR-96-3p miR-10b-5p and miR-21 highly expressed in patients with radioresistant LA. The corresponding diagnostic specificity in predicting radioresistance was 0.916, 0.902 and 0.871, respectively. Moreover, exosomal miR-96-3p intensely indicates poor overall survival (with hazard ratio [95% confidence interval]: 2.38 (1.41–3.86), p < 0.001). However, it does not show significant correlation with tumor size and differentiation degree (p > 0.05).

Conclusions:
Our preliminary results indicate three exosomal miRNAs potentially can be used as non-invasive diagnosis biomarker of radioresistant LA.

Clinical trial identification:


Legal entity responsible for the study:
International Ethical Guidelines for Biomedical Research Involving Human Subjects

Funding:
Youngth Programm of Natural Science Foundation of Jiangsu Province (BK20170134)

Disclosure:
All authors have declared no conflicts of interest.

Background:
To evaluate the changes in pulmonary function parameters (PFT) after moderate hypofractionated image-guided thoracic irradiation (Hypo-IGRT) in locally advanced node-positive non-small cell lung cancer patients with very limited lung function.

Methods:
PFT was measured in 8 patients with NSCLC UICC stage IIIA, IIIB and IIIC (UICC 8[th] Edition) and very limited PFT (FEV1 ≤ 1 L and/or DLCO ≤ 40% and/or long-term oxygen therapy) prior to as well as 3 and 6 months after Hypo-IGRT. Vital capacity (VC), forced expiratory volume in 1s (FEV1), and single-breath diffusing capacity of the lung for CO (DLCO-SB) as PFT parameters were analyzed. Hypo-IGRT was delivered to a total dose of 45 Gy (ICRU) in 15 fractions under daily image-guidance.

Results:
Eight patients (5 men/3 women) were treated with Hypo-IGRT. The median follow-up was 20 months. COPD GOLD III and IV was diagnosed in 2 (25%) and 4(50%) patients, respectively. Five (63%) patients were on long-term oxygen treatment. The median initial VC, FEV1 and DLCO-SB was 1.69L/64.8% predicted (range: 1.36–2.66/33–80%), 1L/39.4% predicted (range: 0.78–1.26/28–60%) and 33.3% (range: 13.3–54), respectively. The median value for VC, FEV1 and DLCO-SB 3 months after Hypo-IGRT was 2.05L/56.35% predicted (range: 1.34–2.33/47–81.5%), 1.08L/47.5% predicted (range: 0.74–1.60/30.8–59.59%) and 38.55% (range: 24–68), respectively. At 6 months post-treatment, the mean value for VC, FEV1 and DLCO-SB was 1.64L/66% predicted (range: 1.41–2.79/35.5–75.5%), 1.0L/47% predicted (range: 0.65–1.28/24.5–54.10%) and 31% (range: 27–43%), respectively. The estimated median overall survival (OS) was not reached for the entire cohort.

Conclusions:
No significant decrease in all tested parameters was found until 6 months after Hypo-IGRT. In this small study, Hypo-IGRT was safely delivered in locally advanced node-positive NSCLC patients with very limited lung function who were not suitable candidates for conventional treatment.

Clinical trial identification:


Legal entity responsible for the study:
University Hospital, LMU Munich

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
Heart and pulmonary artery (PA) radiation doses following radical (chemo) radiotherapy to non-small cell lung cancer (NSCLC) correlate with overall survival (OS). We aimed to quantify radiation doses delivered to heart and PA during radical (chemo) radiotherapy in NSCLC, and to analyse dose volume histogram (DVH) based parameters that were associated with poor OS.

Methods:
NSCLC patients who underwent radical (chemo) radiotherapy using 3-D conformal radiotherapy between 2015 and 2017 were identified from our institutional radiotherapy electronic database. Heart and PA were contoured according to the Radiotherapy Oncology Group Trial 1106 contouring atlas. Maximum, minimum and mean radiation doses delivered to heart and PA were quantified. DVH based parameters, volume of heart received 5 Gy (V5), and volume of PA received 40, 45, 50, 55 and 60 Gy (V40, V45, V50, V55 and V60 respectively) were obtained from radiotherapy plans and compared with values that showed correlation with poor OS in NSCLC.

Results:
Out of a total of nineteen patients, 63% had stage III tumours. Twelve patients were treated with 60 Gy/30 (over 6 weeks) and seven were treated with 55 Gy/20 (over 4 weeks) radiation dose-fractionation schedules. For heart, average radiation doses of mean, minimum and maximum radiation doses were 7.49, 0.33 and 44.18 Gy and corresponding PA radiation doses were 27.14, 5.37 and 52.67 Gy. Evidence suggests mean radiation dose of heart >7.8 Gy and heart V5 of >72.3% correlate with poor OS. In our study, we observed mean heart dose and V5 were less than these values in 74% and 89% patients respectively. PA DVH based parameters, V40 ≥ 80%, V45 > 70%, V50 ≥ 45%, V55 ≥ 32% and V60 > 37 correlates with poor OS. In our cohort of patients, V40, V45, V50, V55 and V60 were less than these values in 95%, 89%, 79%, 74% and 89% patients.

Conclusions:
In this retrospective study, we found heart and PA DVH based radiation dose parameters in NSCLC radical (chemo) radiotherapy were less than those of published values that were associated with poor OS. It is possible to achieve this in 3-D conformal radiotherapy planning for most patients. Including these DVH based parameters during radiotherapy planning would ensure radiation doses to these critical organs are optimised.

Clinical trial identification:


Legal entity responsible for the study:
N/A

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
The purpose of this study is to compare Conformity (CI) and Homogeneity (HI) Index values of different IMRT techniques (VMAT vs non-VMAT) in lung cancer patients who treated in our clinic.

Methods:
We evaluated 37 locally advanced lung cancer patients who previously treated as curatively with IMRT (Volumetric and non-Volumetric (Forward or Inverse) planning techniques) in Eskisehir Osmangazi University Hospital between 2015 July and 2017 September. For each patient, CI and HI values were calculated retrospectively using different formulas according to literature.

Results:
Median prescribed dose was 64Gy (range: 57.5–66). When we compared CI values, there was a statistically different result in favor of VMAT only which is calculated according with Paddick's formula. When we compared HI values, there were no statistically different results between IMRT techniques (Table).Table:Calculated CI and HI values of VMAT and non-VMAT techniques

			VMAT(n = 21)	Non-VMAT(n = 16)	p
Dose (Gy)		Min	57.50	57.50	NS
		Max	64.00	66.00
		Mean	61.52	61.37
		Median	64.00	61.00
CI (RTOG)	PIV/TV	Min	1.0706	1.2558	NS[a]
		Max	1.8617	3.9451
		Mean	1.4787	1.9063
		Median	1.4193	1.6721
CI (Knöös)	TV~PIV~/TV	Min	0.9421	0.9016	NS[b]
		Max	1.0000	1.0000
		Mean	0.9902	0.9833
		Median	0.9984	0.9881
CI (Paddick)	TV~PIV~[2]/(TV × PIV)	Min	0.5372	0.2535	0.040[a]
		Max	0.8439	0.7895
		Mean	0.6784	0.5656
		Median	0.7046	0.5830
HI (Shaw et al.)	D~max~/D~mean~	Min	1.0753	1.0931	NS[b]
		Max	1.3799	1.2472
		Mean	1.1555	1.1620
		Median	1.1350	1.1589
HI (Salt-Lomax)	D~%98~/D~presc~	Min	0.9846	0.9814	NS[b]
		Max	1.0446	1.0424
		Mean	1.0220	1.0157
		Median	1.0263	1.0161
HI (Paddick)	D~%2~/D~%98~	Min	1.0309	1.0484	[b]
		Max	1.1315	1.1092
		Mean	1.0632	1.0769
		Median	1.0563	1.0737
HI (ICRU 83)	(D~%2~–D~%98~)/D~%50~	Min	0.0304	0.0472	NS[b]
		Max	0.1217	0.1015
		Mean	0.0608	0.0731
		Median	0.0547	0.0707

PIV = Prescribed isodose volume TV = Target volume TV~PIV~ = Intersection of Prescribed isodose volume and Target volumeaMann-Whitney TestbStudent T-Test

Conclusions:
The VMAT technique is superior to the non-VMAT techniques in achieving the conformity index which is obtained by the Paddick's approach that a more complex and comprehensive formula is used to calculate the conformity index.

Clinical trial identification:


Legal entity responsible for the study:
Eskisehir Osmangazi University

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
To determine the feasibility of moderate hypofractionated image-guided thoracic irradiation (Hypo-IGRT) in locally advanced node-positive non-small cell lung cancer patients with very limited pulmonary function.

Methods:
Eight patients with NSCLC stage IIIA-C and highly diminished pulmonary function (FEV1 ≤ 1.0 L and/or DLCO-SB ≤ 40% and/or long-term oxygen therapy) were treated with Hypo-IGRT. Planning was based on 18F-FDG-PET/CT and 4-D computed tomography (4D-CT). GTV included primary tumor and involved lymph nodes (short-axis ≥1 cm and/or PET-positive). CTV was not generated. ITV was defined through the overlap of GTVs on 10 phases of 4D-CT. Isotropic margin of 5 mm was added to ITV to generate the PTV. Hypo-IGRT was delivered to a total dose of 45 Gy (ICRU) in 15 fractions under daily image-guidance.

Results:
Eight patients completed Hypo-IGRT. The median follow-up was 20 months. The median age was 64 years. Two (25%), 4 (50%) and 2 (25%) patients presented with NSCLC stage IIIA, IIIB and IIIC, respectively. There were 7 (88%) patients with ECOG 2 and 1 (12%) patient with ECOG 3. Three patients received chemotherapy prior to Hypo-IGRT. Median initial DLCO-SB was 33.3% (range: 13.3–54) and the median initial FEV1 was 1L/39% predicted (range: 0.78–1.26L/28–60%). The median PTV was 226.9 cm³ (range: 100.17–379.80). The median overall survival (OS), progression-free survival (PFS) and distant metastasis-free survival (DMFS) for the entire cohort were not reached. Mean OS was 42 months (95% CI: 31.7–52.6). Mean PFS was 38 months (95% CI: 17.8–45.7). The 1- and 2-year OS rates were 100% and 87.5%. The 6- and 12- months PFS rates were 100% and 62.5%. Three patients developed local failure. Median mean lung dose was 9.4 Gy (range: 5.3–11.6). V15 and V20 for both lungs were 22% (range: 10–25) and 15% (range: 6–19). Median mean esophageal dose was 12.76 Gy (range: 2.1–26.7). There was no case of radiation pneumonitis. Four patients developed grade 2 acute radiation esophagitis.

Conclusions:
This analysis shows that Hypo-IGRT can be considered in locally advanced node-positive NSCLC patients with very limited pulmonary function who are inadequate for conventional therapy.

Clinical trial identification:


Legal entity responsible for the study:
University Hospital, LMU Munich

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
To compare the Response Rates, acute and late toxicities and Time to Progression (TTP) in the 3 arms.

Methods:
Patients with unresectable NSCLC were prospectively analysed from August 2011 – September 2013. They were randomized to 3 arms of Sequential Chemoradiation (ARM A), Concurrent Chemoradiation followed by consolidation chemotherapy (ARM B) and Concurrent Chemoradiation (ARM C). Arm A received 2 cycles induction while Arm B received 2 cycles consolidation chemotherapy. Arm C was the Control arm. Drugs used were Paclitaxel (175 mg/m[2])/Carboplatin (AUC 5). Their dose in concurrent setting were 45 mg/m[2] and AUC 2 respectively. The dose of radiation used was 60 Gy in 30 fractions. Response Rate was assessed using RECIST v1.1 criteria while acute and late toxicities were assessed by RTOG/EORTC (skin, upper GI, Dysphagia) and CTCAE v4.0 (dyspnoea, haematological and peripheral neuropathy) criteria. For TTP Kaplan Meier survival analysis with Log rank was used for inter-treatment comparisons.

Results:
72 patients (male = 68, female = 4) were randomised in the 3 arms in 1:1:1 allocation of whom 64 patients (all males) were available for analysis (Arm A = 20, Arm B = 21, Arm C = 23). All the 3 arms were comparable in their baseline parameters. Chi Square test analysis showed non-significant statistical difference in response rates between the 3 arms. TTP was superior with median PFS of 7 months (95% C.I. 5.2mths, 8.8 months) in Arm C (Concurrent Chemoradiation arm). Grade 2 & 3 acute skin toxicities in Arms B (33% & 9.5%) & C (21.7% & 4.3%) were more (p < 0.001). Grade 2 & 3 upper GI toxicity in Arms B (57.1% & 28.6%) & C (87.0% & 13%) were higher (p < 0.001). Grade 2 & 3 Haematological toxicity was more (p < 0.001) in Arms B (42.9% & 57.1%) & C (52.2% & 47.8%). Grade 2 & 3 Dysphagia was more (p < 0.001) in Arms B (57.1% & 28.6%) & C (87% & 13%). Peripheral neuropathy was higher in Arms B & C (p < 0.001) with Arm C having the maximum Grade 2 neuropathy (78.3%). There was no difference among the late skin toxicity among the 3 arms (p = 0.869).

Conclusions:
There was no difference in the response rates across the 3 arms. The Concurrent Chemoradiation arm had the maximum Time to progression with maximum acute toxicities.

Clinical trial identification:


Legal entity responsible for the study:
IPGMER and SSKM Hospital

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
Concurrent chemoradiation therapy (CCRT) has been established as the standard of care for patients with stage IIIB non-small cell lung cancer (NSCLC). The comparative benefits of two extensively used regimens: cisplatin/etoposide (PE) and paclitaxel/carboplatin (PC), with thoracic radiation therapy (TRT) remain largely undefined. To explore the distinct advantage of multiagent CCRT with taxane (PC) over CCRT with traditional platinum doublet therapy (PE), an interventional study was designed and conducted at the Department of Radiotherapy of Dhaka Medical College Hospital.

Methods:
Patients were randomly assigned to receive the following treatments: PE arm, cisplatin (50 mg/m[2]) on days 1,8 and 29 and etoposide (50 mg/m[2]) on days 1–5 and 29–33 plus 45 Gy of TRT; PC arm, weekly paclitaxel (45 mg/m[2]) and carboplatin (AUC = 2) plus 45 Gy of TRT. RECIST criteria, Kaplan-Meier method and RTOG morbidity criteria were employed to determine treatment response, survival and acute & late toxicity respectively. Student's t test, Chi squared test, Fisher's exact test and Log rank test were used to compare across the arms in different aspects.

Results:
A total of 60 patients (30 in each arm) were randomized. The objective response and disease control rate were 51.85% in PE and 60.71% in PC (P = 0.61) and 85.19% in PE and 78.57% in PC (P = 1) respectively. Treatment with PE had significant survival advantage in terms of 1-year overall survival (60.6% vs. 42.9%; P = 0.04) and 1 year progression free survival (44.6% vs. 31.0%; P = 0.04). Grade 3/4 neutropaenia occurred in 20% of PE and 16.67% of PC patients (P = 1). Acute oesophagitis (grade 1/2, 53.33% vs. 70%; grade 3/4, 13.33% vs. 30%, P < 0.01) and upper GI symptoms (grade 1/2: 63.33 vs. 100%; P < 0.01) were significantly more pronounced in PC group. PC arm developed significantly greater rate of pneumonitis (grade 1/2, 16.67% vs. 36.67%; grade 3/4, 0% vs. 10%; P = 0.02). PC arm had 4 treatment related deaths.

Conclusions:
There was substantial incongruity between PE and PC based CCRT regimen in the treatment of stage IIIB NSCLC. With meticulous patient selection and follow up, CCRT with PE can be an acceptable protocol in this setting.

Clinical trial identification:
German Clinical Trials Register. DRKS00012599. Date 20.07.2017

Legal entity responsible for the study:
Ethical Review Committee of Dhaka Medical College Hospital, BD on 22.10.2014 (Ethical Clearance Certificate # ERC-DMC/ECC/2014/168). Registered by Bangladesh College of Physicians and Surgeons (BCPS) on 11.11.2014 (Registration # PSN-0037)

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
Combination platinum-based chemo-radiotherapy is considered as a standard treatment of locally advanced unresectable NSCLC. The exact sequence, optimal and effective chemotherapy regimens to be used in combination with radiation therapy are all still subject of debates. Cisplatin/Etoposide (EC) and Paclitaxel/Carboplatin (PC) both demonstrated efficacy in the treatment of locally advanced unresectable NSCLC and are considered as most widely used regimens in this setting. However, there are very limited number of randomized trials comparing EC vs PC face to face.

Methods:
In our open labeled prospective study a total 52 patients were randomized (1:1) to receive 60–66 Gy intensity-modulated radiotherapy with either Etoposide 50 mg/m[2] d1-5, 29–33 and Cisplatin 50 mg/m[2] d 1, 8, 29 and 36 (ARM1) or Paclitaxel 45 mg/m[2] weekly and Carboplatin AUC = 2 mg/mL/min weekly (ARM2). Study inclusion criteria were: unresectable stage IIIA/IIIB/IIIC, NSCLC proved by pathology; treatment naïve, age 18–70; ECOG ≤ 2; no serious comorbidities; no contraindications to chemo-radiotherapy, chest CT in recent 2 weeks. The primary endpoint of the study was progression-free survival and 1year survival. Secondary endpoints were toxicity profiles of two regimens.

Results:
With median follow-up time 48 months 1-year survival was significantly higher in the EP arm than that of PC arm. Estimated difference was 27% (p value = 0.05). PFS was also higher in EP arm compared to PC arm (46% vs 5%, p value = 0.05). No significant difference in incidence of Grade >2 radiation pneumonitis and Grade >2 radiation esophagitis was observed among two arms. Incidence of Grade >3 hematologic toxicities was also similar in two groups.

Conclusions:
CP used concurrently with thoracic radiation showed better 1year survival and PFS than weekly PC. In terms of toxicity profiles these two regimens did not show statistically significant difference in our study. To determine which regimen is associated with better long term survival or PFS larger randomized studies with longer follow-up periods are needed.

Clinical trial identification:
GYOG0005

Legal entity responsible for the study:
Georgian Young Oncologists Group

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
Approximately 30–35% of patients present with locally advanced NSCLC(LAD-NSCLC) The majority of them can be treated with a combination of chemo. and radiation; however, a subset of stage III pat. are considered surgical candidates may require a modification of this plan. The purpose of this study is to compare effectiveness of primary surgery and chemotherapy versus chemoradiation in patients with LAD-NSCLC. To evaluate the survival parameters and treatment complications.

Methods:
NSCLC pat. with clinical stage IIIA and selected IIIB from 2014 to 2016 were identified retrospectively in two Institutions. Medical records reviewed. All patients were grouped in 2 treatment arms. Surgical arm: surg.+adj.chemotherapy and ChRT arm: Definitive Chemoradiotherapy.

Results:
The medical records of 75 patients (39 Surgical and 35 ChRT arm) were reviewed. More than 1/2 in both arms were with scc (51% and 61%). The type of surgery was 15 lobec- and 24 pneumonectomies with complete mediastinal l/node dissection. In CHRT arm G3-4 hematology toxicity occurred in 19pat. and 6 patients had acute non-hematology toxicity(G3). No acute G 4 radiation toxicity developed. In surg. arm only 1 severe bleeding developed and reoperation was performed. 2 patients had wound healing problems. 5 treatment related deaths occurred: 3 in the surgical arm (2 pulmonary embolus and 1 cardiac complication) and 2 patients in chemoradiation arm(2 PE). The 1-year survival rate was 69% vs 61% in surg. and ChRT arms respectively, which was not statistically significant (p = 0.4604). No difference in the 1-year survival was observed in Stage IIIA 68% vs 58% (p = 0.5627) and in Stage IIIB 72% vs 62% (p = 0.5540) between arms. No difference on median survival time (17.5 vs 16.8 m).

Conclusions:
Treatment effectiveness, complications and 1-year survival rate were equal between the surgical and ChRT arms. These results seem to indicate primary surgery as the treatment of choice for stage IIIA and selected patients with stage IIIB NSCLC, whenever a complete resection is thought to be technically feasible and the patient's conditions compatible with the extent of the planned surgery. Further results of 3- and 5-year survival rates are awaited.

Clinical trial identification:
GYO LAD-NSCLC 002

Legal entity responsible for the study:
Georgian Group of Young Oncology

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
This retrospective analysis was designed to assess pathological tumor response to radical (60 Gy) radio-chemotherapy (RTx/CTx) and surgery in stage III NSCLC (TNM 8th edition).

Methods:
We included patients treated from a phase II trial and a few patients with salvage surgery after multidisciplinary decision by Lung Committee (05/2012–10/2017). Induction CTX (CDDP/Carbo doublets) was with concurrent RTx (59–62 Gy). Pathologic N2 were by mediastinoscopy (Md) or endobronchial ultrasound (EBUS). CT scans were performed within 3–4 weeks of treatment. Pathologic examination of residual viable tumor was take in account pT and pN, downstaging and pCR.

Results:
Median age: 59 years (range 41–77). Gender: 65.5% was male. Stage: 58.6% IIIA, 37.9% IIIB, 1 3.4% IV (brain metastases treated with radiosurgery). TNM: 27.6% T2b, 24.1% T3, 20.7% T4, 10.3% T2b, 10.3% T1c and 6.9% T1b, 6.9%; N0 86.2% N2,6.9% N3; 3.4% M1b (Brain). Histological: Adenocar 62.1%, 34.5% squamous, 3.4% NSCLC. N2-N3: 62.1% by EBUS, 3.4% by Md, 20.7% needed both. Nodal station distribution: 37.9% 1- N1 and 1-N2; 31% 1-N2, 13.8% 2-N2 and 1-N1, 6,9% 1-N1, 1-N2 and 1-N3, 3,4% 2-N2 and 6,9% N0. CTx: CDDP + Vp16 - 58.75% and CDDP + VNR 27.6%, Toxicites CTx/RTx: Anemia G3 (13.8%), G4 (3.4%); leucopenia, G3 (20.7%), G4 (17.2%); neutropenia, G3 (24.1%), G4 (10.3%). Esophagitis G2 (31%); 27,6% were hospitalised by toxicities. Radiological response: 1 (3.4%) progression, 12 (41.4%) stable, 16 (55.2%) partial response. Surgery: 86.2%; 58.6% lobectomy (LB), 3.4% biLB, 3.4% pneumectomy, 3.4% LB + bronchoplasty, 10.3% LB + ribs resection, 6.9% LB + ribs+ hemivertebral resection. Downstaging: 69%. pCR: 20.7%; Histological tumor viability (Tv): 24.1% pCR, 20.7% a 5% Tv, 17.2% between 10–15% Tv, 13.7% between 20 and 30% Tv, 6.8% between 40 and 50% Tv, 3.4% with 90% Tv; Histological lymph node Nv: 72.4% pCR, 6.8% between 5 and 10% Nv, 6.8% between 40 and 100% Nv.

Conclusions:
RTx/CTx and surgery in stage III NSCLC presents high rates of downstaging with a high percentage of toxicities that required an experienced multidisciplinary team able to anticipate and treat these conditions. We consider the different pathological responses must be correlated with an adequate and long follow-up that led us to analyze possible recurrence patterns with an impact on the management, survival and quality of life of these patients.

Clinical trial identification:


Legal entity responsible for the study:
Clinic

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
Recently it was shown that 15% of stage III NSCLC patients, treated with thoracic radiotherapy in dose-escalated trials, suffer from late cardiac events.[1] However, the prevalence of pre-existent cardiac co-morbidity in daily clinical practice in these patients and the development of cardiac events during follow-up is still unclear. As these patients are treated with curative intent and have a five survival rate 25%, there is need for a study to investigate the development of cardiac events and the relation with pre-existent cardiac co-morbidity.

Methods:
In this retrospective cohort study a thorough patient file search was carried out in 153 patients diagnosed with stage III NSCLC, treated with (chemo-)radiotherapy between 2006 and 2011 in our center. Primary endpoint was the incidence of pre-existing cardiac comorbidity and relation with the development of serious cardiac events, defined as CTCAE 4.0 grade >2, within five years after a curative treatment with (chemo)radiotherapy. Cardiovascular risk prediction was calculated for each patient according to WHO/ISH, which indicates the 10-year risk of a serious cardiovascular event.

Results:
Pre-existing cardiac comorbidity was seen in 46 patients (31.1%) with most frequently myocardial infarct/ coronary artery disease (9.8%) and arrhythmia (7.8%). WHO/ISH cardiovascular risk prediction was > 10% in 60.1% of the patients. Serious cardiac events appeared in 26% of the patients in the second year after treatment (20.3%). Most frequent cardiac events were arrhythmia (9.2%), myocardial infarction (6.5%), congestive heart failure (4.6%) and pericardial effusion (4.6%).Table:Serious cardiac events within subgroups of the study population

	Total N = 153	Cardiac history N = 46	No cardiac history N = 102	WHO/ISH Cardiac event risk > 10% N = 78
Cardiac events CTCAE-score > 2 (N/%)	38 (26%)	14 (30%)	24 (23%)	18 (23%)
Missing (N)	7	-	-	-
Median time to event 1–2 years (N/%)	17 (11.6%)	6 (13%)	11 (10.8%)	16 (20.5%)

Conclusions:
In daily clinical practice 1/3th of patients with stage III NSCLC, treated with (chemo-)radiotherapy, have pre-existing cardiac comorbidity. In addition, 26% develop a serious cardiac event during follow-up, even in patients without cardiac history. Therefor it is important to identify patients at risk in order to prevent these cardiac events.

Clinical trial identification:


Legal entity responsible for the study:
Maastricht University Medical Center

Funding:
Has not received any funding

Disclosure:
D. De Ruysscher: Consulting or advisory role to disclose: Bristol-Myers Squibb I have research funding to disclose: Brsitol-Myers-Squibb (BMS). A-M. Dingemans: Reports other from Roche/Genentech, other from MSD Oncology, other from AstraZeneca, other from Pfizer, other from Lilly, other from Boehringer Ingelheim, other from Bristol-Myers Squibb, other from Clovis Oncology, outside the submitted work. All other authors have declared no conflicts of interest.

Background:
At diagnosis, 60% of NSCLC patients (pts) have potentially curable locally advanced disease with N0, N1 or N2 lymph node status. Guidelines recommend surgical resection of locally advanced NSCLC followed by adjuvant chemotherapy (SIGN 370). The selection of pts for curative treatment requires a PET scan and pathological nodal staging. Accurate clinical staging of lung cancer ensures best treatment. NICE guidelines recommend consideration of brain imaging in pts selected for treatment with curative intent especially if N2 disease is diagnosed. In clinical practice, many relapse within 1 year despite combination treatment. Brain metastases (mets) are common in NSCLC but there are now more treatment options available. We investigated the frequency of brain mets in pts with post-operative pN2 (pathological N2) disease.

Methods:
A retrospective audit of West of Scotland Cancer Network was performed of pts with pN2 NSCLC between September 2011 and November 2016. Data collection included demographics, staging investigations, and clinical outcomes using electronic patient records.

Results:
We identified 169 NSCLC pts (86 females, 83 males) with pN2 disease. Clinical staging showed 73 pts (43%) cN0, 42 (25%) cN1 and 53 (31%) cN2. 32 pts (19%) had pre-treatment brain imaging. This was higher among pts with cN2 disease (34%). Imaging modality was primarily CT, with MRI used for 9 pts (28%). Follow-up imaging included brain in another 12 (8%). Distant relapse occurred within 3 months of treatment for 11 pts of whom 2 had symptomatic brain mets. Overall 84 (50%) pts experienced distant relapse of which 23% (19/84) had brain mets. Median overall survival of all pts was 25.3 (95%CI 18.5–29.8) months. There was no statistically significant difference in the survival of pts with brain mets compared to other distant mets; median survival 20.3 (8.1–25.3) months vs 17.8 (14.5–21.8) months respectively, log-rank test p = 0.56.

Conclusions:
This audit shows that only 34% of cN2 pts underwent pre-operative brain imaging. 1% relapsed within 3 months of surgery with brain mets and overall 23% were diagnosed with brain mets. The median overall survival for this group is comparable with the published series and there was no survival difference between pts with brain mets and other distant metastatic disease.

Clinical trial identification:


Legal entity responsible for the study:
NHS Greater Glasgow and Clyde

Funding:
Has not received any funding

Disclosure:
All authors have declared no conflicts of interest.

Background:
Improving the outcome of locally advanced non-small cell lung cancer (NSCLC) is one of the major challenges in thoracic oncology. SAKK substantially contributed to establish a standard of care for patients with stage III NSCLC: The trial SAKK 16/96 established neoadjuvant chemotherapy with three cycles of cisplatin and docetaxel. The randomized trial SAKK 16/00 showed no benefit by adding neoadjuvant radiotherapy as third treatment modality. Our results consistently showed a 5-year overall survival (OS) of 37%. Recently, the PACIFIC trial showed significantly improved progression-free survival for durvalumab as consolidation therapy after definitive chemoradiotherapy in unresectable stage III NSCLC.

Trial design:
This is a single-arm phase II clinical trial designed to evaluate the addition of perioperative immunotherapy with durvalumab to the previously established standard of care for stage IIIA(N2) patients. Eligible patients with WHO performance status 0–1 and age of 18–75 years must have pathologically proven NSCLC stage IIIA(N2) (T1-3 N2 M0) according to the 7th edition of the TNM classification, irrespective of histological subtype, genomic aberrations or PD-L1 expression status. Tumor tissue has to be available for the mandatory translational research. Patients whose tumor is deemed resectable at diagnosis receive three cycles of chemotherapy with cisplatin 100 mg/m[2] and docetaxel 85 mg/m[2] every three weeks followed by two cycles of durvalumab 750 mg every two weeks. Following surgery, patients will be treated with durvalumab 750 mg every two weeks for 12 months. The primary endpoint of the trial is event-free survival at 12 months. Secondary endpoints include OS, objective response, nodal down-staging, complete resection, pattern of recurrence and toxicity. Additionally, a large translation research program accompanies the trial investigating potential predictive biomarkers of anti-PD-L1 therapy. Based on the data of first 25 operated patients and given that the results showed that their 30-day post-operative mortality is less than 10%, according to the decision rule described in the protocol of the trial there is no reason for further detailed safety analysis (evaluated by an IDMC) and thus shall continue as per protocol.

Clinical trial identification:
NCT 02572843

Legal entity responsible for the study:
Swiss Group for Clinical Cancer Research

Funding:
Swiss Group for Clinical Cancer Research; AstraZeneca; Rising Tide Foundation, Gateway for Cancer Research

Disclosure:
S.I. Rothschild: SAKK 16/14 study is supported by AstraZeneca. All other authors have declared no conflicts of interest.

Background:
Patients with NSCLC who undergo incomplete resection (R1) have significantly worse survival compared to those with complete resection (R0). The efficacy of Stereotactic Body Radiotherapy (SBRT) in treating small lung tumors is established, but its use as neo-adjuvant therapy in locally-advanced (LA)-NSCLC is not investigated. We hypothesized that pre-operative SBRT can be done safely and could improve rates of R0 resection in LA-NSCLC. This concept could introduce a rapid, convenient and less toxic neoadjuvant therapy in LA-NSCLC to help improve rates of complete resection. LINNEARRE I is single institution phase I study that investigates the safety and feasibility of delivering, timely, neo-adjuvant hypo-fractionated RT of escalating Biological Equivalent Doses (BED) approaching those of SBRT.

Trial design:
A total of twenty patients with biopsy proven T3-T4, N0-1, M0, NSCLC will be enrolled. Patients must be deemed as medically operable, by a thoracic surgeon, but at risk of
Clinical trial identification:
NCT02433574

Legal entity responsible for the study:
Juravinski Cancer Center

Funding:
Juravinski Cancer Center Foundation

Disclosure:
All authors have declared no conflicts of interest.

Background:
Next-generation sequencing (NGS) enables a comprehensive genomic analysis of lung cancer patients. It has uncovered many novel genetic abnormalities and identified actionable genomic alterations in lung tumors that previously tested “negative” by conventional non-NGS tests. In this study, we evaluated the clinical impact of NGS on overall survival of advanced non-small cell lung cancer (NSCLC) patients.

Methods:
In this retrospective study, 234 consecutive stage IIIb/IV NSCLC patients who performed hybrid capturing NGS were enrolled in Israel, between 2011–2017. Hybrid capture-based NGS was performed by Foundation Medicine and Guardant 360[TM] if tissue was not available.

Results:
234 consecutive NSCLC patients were included in this study. 62% (145/234) performed tissue NGS and 38% (89/234) performed liquid NGS. Median age at diagnosis was 63 years. 84% had adenocarcinoma. 37% were never-smokers. The patients were divided into 4 groups according to the identification of NCCN-approved actionable genomic alterations on NGS analysis: Group A did not have an actionable target; Group B discovered an actionable target but did not receive targeted treatment, due to high performance status or preference to use immunotherapy for PD-L1 positive patients; Group C received targeted therapy subsequent to NGS analysis, among them 75 received treatment according to NCCN guidelines, 9 off-protocol and 7 received immunotherapy due to high tumor mutation burden found on NGS analysis; Group D received targeted therapy due to standard molecular tests, as PCR, IHC and FISH performed prior to NGS. Median Overall survival (OS) is summarized in the Table (p = 0.0278).Table: (Abstract 145P)Overall Survival

	Total Cohort (n = 234)	Group A 46% (108/234)	Group B 5.5% (13/234)	Group C 39% (91/234)	Group D 9.5% (22/234)
Median OS	20.9 months (95% CI: 19.0–28.7)	17.8 months (95% CI: 13.1–24.2)	10.8 months (95% CI: 4.1–NA)	25.7 months (95% CI: 19.9–41.7)	37.7 months (95% CI: 26.7–NA)

Conclusions:
This study evaluates the clinical impact of comprehensive NGS testing by demonstrating the survival advantage of patients with actionable targets discovered through NGS. Comprehensive tissue and liquid-based NGS have revealed targeted treatment options for a significant number of patients. Overall Survival of patients treated with tailored therapy subsequent to NGS analysis was positively impacted in comparison to patients without an actionable target, only exceeded by patients who received targeted treatment subsequent to upfront standard molecular tests.

Clinical trial identification:


Legal entity responsible for the study:
Soroka Cancer Center, Ben-Gurion University, Beer Sheva, Israel.

Funding:
Has not received any funding

Disclosure:
S. Geva: Travel grant from Teva Pharmaceuticals, Honorarium from Guardant Health. L.C. Roisman: Lectures fees: Roche, MSD, Pfizer, Astrazenca. M. Ilouze: Honorarium from Pfizer, MSD, Roche and Takeda. A. Zer: Personal fees from Roche, grants and personal fees from BMS, personal fees from AstraZeneca, personal fees from BI, outside the submitted work. N. Peled: Advisor & Honorarium from AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb, Eli Lilly, FoundationMedicine, Gaurdant360, MSD, Novartis, NovellusDx, pfizer, Roche, Takeda. All other authors have declared no conflicts of interest.

Background:
Next-generation sequencing (NGS) of cell-free circulating tumor DNA (cfDNA) enables a non-invasive option for comprehensive genomic analysis of lung cancer patients. Currently there is insufficient data in regard to the impact of cfDNA analysis on clinical decision making. In this study, we evaluated the clinical utility of cfDNA sequencing on treatment strategy and progression-free survival in non-small cell lung cancer (NSCLC) patients.

Methods:
In this retrospective study, data was collected from files of 116 NSCLC patients monitored between the years 2014–2017 in Israel. Plasma samples from stage IIIb/IV NSCLC patients were analyzed by a commercial test (Guardant 360), using hybrid capture, single molecule barcoding and massively parallel paired-end synthesis to sequence a targeted gene panel. This test allows the detection of somatic alterations such as point mutations, indels, fusions and copy number amplifications.

Results:
116 consecutive NSCLC patients were included in this study. Median age at diagnosis was 63 years, male:female ratio was 1:1.7. 40% (47/116) were never-smokers, 83% (96/116) had adenocarcinoma. 41.4% (48/116) were tested before 1[st] line therapy (Group A), 34.5% (40/116) upon progression on chemotherapy or immunotherapy (Group B1) and 24.1% (28/116) upon progression on EGFR TKIs (Group B2). The most common genes were EGFR sensitizing mutations (25.9%, 30/116), MET amplifications and/or exon 14 skipping mutations or resistance point mutation (9.5%, 11/116) and EGFR T790M mutations (6.9%, 8/116). Clinical outcome of cfDNA analysis and targeted therapy for the entire cohort and for each group are summarized in the Table.Table: (Abstract 146P)Clinical Outcome of cfDNA Analysis and Targeted Therapy

	Total (n = 116)	Group A (n = 48)	Group B1 (n = 40)	Group B2 (n = 28)
Drug-associated actionable Mutations (On/Off Lable)	65% (75/116)	65% (31/48)	52.5% (21/40)	82% (23/28)
Lung Cancer Related Actionable Mutations (NCCN guidelines)	41% (48/116)	31% (15/48)	32.5% (13/40)	71% (20/28)
Tretmanet change (Impact on Decision)	26% (30/116)	23% (11/48)	25% (10/40)	32% (9/28)
Response Evaluable	93% (28/30)	82% (9/11)	100% (10/10)	100% (9/9)
Response not Evaluable	7% (2/30)	18% (2/11) Early cessation of treatment d/t toxicity	0% (0/10)	0% (0/9)
Response Assessment (RECIST): CR	4% (1/28)	0% (0/9)	0% (0/10)	11% (1/9)
Response Assessment (RECIST): PR	39% (11/28)	44% (4/9)	30% (3/10)	44% (4/9)
Response Assessment (RECIST): SD	32% (9/28)	56% (5/9)	20% (2/10)	22% (2/9)
Response Assessment (RECIST): PD	25% (7/28)	0% (0/9)	50% (5/10)	22% (2/9)
Objective Response Rate	43% (12/28)	44% (4/9)	30% (3/10)	55.5% (5/9)
Disease Control Rate	75% (21/28)	100% (9/9)	50% (5/10)	78% (7/9)
Median Duration of Treatment	5 months (6/28 ongoing)	9 months (4/9 ongoing)	3.5 months (0/10 ongoing)	4 months (2/9 ongoing)
Durable Disease Control Rate (over 4 months)	43% (13/30)	64% (7/11)	20% (2/10)	44% (4/9)
Median PFS	3.6 months	7.3 months	2.5 months	3.3 months

Conclusions:
This study extends the evidence for clinical utility of comprehensive NGS testing by demonstrating durability of response to plasma-detected genomic alterations. cfDNA NGS changes treatment decisions in a significant number of patients in this retrospective study. It also has the potential to reduce undergenotyping of advanced NSCLC patients, while reducing costs and complications of biopsies, and facilitating more precise use of targeted therapy as well as immunotherapy.

Clinical trial identification:


Legal entity responsible for the study:
Soroka Cancer Center, Ben-Gurion University, Beer Sheva, Israel.

Funding:
Has not received any funding

Disclosure:
S. Geva: Travel grant from Teva Pharmaceuticals, Honorarium from Guardant Health. A. Dvir, L. Soussan-Gutman: Employee of Oncotest (subsidiary of Teva pharmaceuticals), the distributor of Guardant360 in Israel. L.C. Roisman: Lectures fees: Roche, MSD, Pfizer, Astrazenca. A. Zer: Personal fees from Roche, grants and personal fees from BMS, personal fees from AstraZeneca, personal fees from BI, outside the submitted work. N. Peled: Advisor & Honorarium from AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb, Eli Lilly, FoundationMedicine, Gaurdant360, MSD, Novartis, NovellusDx, pfizer, Roche, Takeda. All other authors have declared no conflicts of interest.