Virtual Library

Abstract
I will discuss recent results from genomic sequencing studies on small cell lung cancer. In particular, results related to possible therapeutic opportunities will be a focus of my talk.

Abstract
Lung squamous cell carcinoma (lung SqCC) is the second most common histology of non-small cell lung cancer (NSCLC). While the treatment of lung adenocarcinoma has developed substantially over the past decade due to the discovery of a host of therapeutic biomarkers progress in lung SqCC has been more modest. However, large scale genomic studies of lung SqCC as well as early biomarker directed trials suggest that treatment options are likely to improve in the near future for lung SqCC given the rapid expansion in our knowledge of the molecular basis of this disease. There is now an opportunity for substantial improvement in outcomes for patients with lung SqCC and my presentation will focus on the opportunities and challenges that face our community as we try to make progress in treating this disease. Here, I will discuss several recent studies which have defined the genomic landscape of lung SqCC in multiple patient cohorts and discuss the results of these studies in contrast to lung adenocarcinoma. I will review the predictive and prognostic biomarkers identified to date for lung SqCC and present pre-clinical and early clinical data on several therapeutic biomarkers with an emphasis on Fibroblast Growth Factor Receptor alterations. I will note clinical trials in progress and those which are likely to begin soon as well as diagnostic testing for patients with lung SqCC. I will also discuss pre-clinical data which have shed light on the development of lung SqCCs and discuss opportunities for further development in this field.

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Abstract
Malignant mesothelioma (MM) is a lethal cancer whose pathogenesis results from complex interactions between host genetics and environmental carcinogens, such as asbestos and erionite fibers. Recently, BAP1 (BRCA associated protein 1) has been identified as a novel MM tumor suppressor gene. BAP1 is located at the 3p21, a region frequently deleted in MM, and encodes for a deubiquitinase enzyme known to target histones and other proteins. Originally discovered as a BRCA1 interacting protein, BAP1 appears to exert its anti-tumor activities mainly in a BRCA-independent manner, through its association in multi-protein complexes with diverse functions. For example, when associated to the Polycomb protein ASXL1, BAP1 is important for the regulation of the cell epigenome, via modulation of histone H2A ubiquitination and thus chromatin accessibility. In complex with other proteins (e.g. HCF-1, OGT, and YY1), BAP1 is also important in the transcriptional regulation of several genes and in the stability of target proteins such as PGC-1α. Recent reports also suggest a possible involvement of BAP1 in DNA repair pathways. However, the relevance of BAP1 to the biology of normal and cancer cells remains largely unexplained, in fact manipulation of BAP1 in cancer cells has often yielded unexpected or even contradictory results. For example, silencing of BAP1 in MM and uveal melanoma cell lines resulted in reduced cell growth (Bott et al; Matatall et al). We discovered that germline BAP1 mutations cause a novel cancer syndrome characterized by a significant excess of both pleural and peritoneal MM, uveal and cutaneous melanoma and possibly other tumors. In the same study, we reported that 22% sporadic MM tumors harbored somatic BAP1 mutations (Testa et al). In a separate study using 53 primary pleural MM collected in the USA, 42% of tumors harbored either BAP1 loss, BAP1 somatic mutations (detected in 23% of the samples), or both. Moreover, another 25% of tumors showed no BAP1 staining by immunohistochemistry (IHC) despite apparently normal BAP1 status, raising the possibility of post-translational deregulation of BAP1 in a subset of cases. In this MM cohort, there was a significant association between BAP1 status and patients’ age (66.7 years in mutant BAP1 compared to 58.6 years in wild-type BAP1), but there was no significant correlation with other variables such as sex, overall survival, histological subtype or asbestos exposure (Bott et al). In a recent meeting, using a bigger sample size, the same group confirmed that somatic BAP1 mutations occur in about 20% of pleural MM. They reported that the only clinical variable significantly different among those with and without BAP1 mutations was smoking (former or current), with BAP1 mutations more prevalent among smokers (75% vs. 42%). A Japanese study reported BAP1 gene alterations (either deletions or sequence-level mutations) in 61% of their 23 MM samples (Yoshikawa et al). Their data, but not those reported by Bott et al, also suggested an association between BAP1 mutations and the epithelioid histological MM subtype. Whether this discrepancy results from the different methodologies in sample preparation and detection of BAP1 mutations or it is an intrinsic difference between the two populations (e.g. due to ethnicity) has still to be determined. A third recent study, with a separate cohort of 52 pleural MM, reported absence of BAP1 IHC staining in 60% of pleural MM, confirming previous results (Arzt et al). The Authors also confirmed the absence of a correlation between BAP1 expression and asbestos exposure, and suggested that expression of BAP1 in tumor samples is inversely correlated to survival. The discovery of BAP1 germline and somatic mutations has renewed after decades the interest in MM genetics. Because germline BAP1 mutations predispose to multiple cancers and because BAP1 loss of heterozygosity is frequent in different tumor types, BAP1 would appear to act as a classical tumor suppressor. However, this definition is unsatisfactory because manipulation in vitro of BAP1 expression has often given unexpected and paradoxical results, complicating our understanding of its mechanisms of action. BAP1 absence (due to genetic, genomic, epigenomic or post-translational causes) was reported in about 60% of pleural MM. No studies so far have thoroughly investigated BAP1 expression in MMs arising from other sites. BAP1 expression is not associated to asbestos exposure, suggesting that its role in MM pathogenesis may be independent from the known asbestos-related pathways. Other clinicopathological associations are at this moment too weak to be conclusive, possibly due to limited tumor sample sizes, methodological differences in the studies or finally ethical differences of the analyzed populations. It appears, but remains unproven, that patients with germline BAP1 mutations have less aggressive MMs compared to sporadic MMs in which BAP1 mutations do not appear to influence prognosis. More experiments are urgently required to see whether BAP1 expression could be use in diagnostic, prognostic, or therapeutic settings. In fact, defining a therapeutically accessible synthetic lethal target in the setting of BAP1 loss could eventually benefit the approximately 40-60% of patients with BAP1 negative MMs. Even more speculatively, the same synthetic lethal target could be studied as chemoprevention drug targets in individuals with germline BAP1 mutations. The impact of this work obviously extends to other cancers with BAP1 mutations.

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Abstract
In the 1970s, pulmonary neuroendocrine tumors were classified into three histologically defined categories: typical carcinoid (TC), atypical carcinoid (AC) and small cell lung carcinoma (SCLC) [1)] . Later, a fourth high-grade neuroendocrine tumor of the lung, large cell neuroendocrine carcinoma (LCNEC) was recognized [2)] , and in 1999, the World Health Organization (WHO) classified LCNEC as a variant of large cell carcinoma [3)] . To date, in neuroendocrine tumors of the lung, the major categories of morphologically identifiable neuroendocrine tumors are TC, AC, LCNEC, and SCLC. Lung tumors with neuroendocrine morphology by light microscopy encompass a three-grade spectrum of low grade TC, intermediate-grade AC, and high-grade LCNEC and SCLC. WHO criteria show that the mitotic range for TC was less than two mitoses per 2 mm[2] (10 high-power field [10 HPF]), and that for AC was between two and ten mitoses per 10 HPF. A mitotic count of eleven or more mitoses per 10 HPF is the main criterion for distinguishing LCNEC and SCLC from AC. A criterion for distinguishing AC from TC is necrosis. Therefore, we classify TC as a tumor with carcinoid morphology, lacking necrosis with less than two mitoses per 2 mm[2]. Tumors with carcinoid morphology, areas of necrosis and/or 2-10 mitoses per 2 mm[2 ]are classified as AC [4)] . Immunohistochemically, neuroendocrine markers such as chromogranin, synaptophysin, and N-CAM are typically positive in TC [4)] . Analyses of molecular markers revealed that low-grade TC and intermediate-grade AC exhibit a low proliferative rate compared with high-grade LCNEC and SCLC [5)] , and TC and AC have different genetic alterations from high-grade LCNEC and SCLC [6)] . Analyses of their genetic alterations show that neuroendocrine lung tumors may represent a spectrum ranging from low-grade TC and intermediate-grade AC to highly malignant LCNEC and SCLC tumors [6)] . Carcinoid tumors can be diagnosed by cytology of bronchoscopic fine needle aspiration or bronchoscopic biopsy specimens. Distinguishing TC from AC requires examination of a surgical specimen, unless mitoses between two and ten per 10 HPF and/or necrosis are seen on a bronchoscopic biopsy [4)] . Preoperative FDG-PET imaging is frequently positive in carcinoid tumors [7)] . TC and AC occur equally in males and females, and patients with TC and AC are younger than those with LCNEC and SCLC. TC is classified as a malignant epithelial tumor of the lung [3,4)] . However, the overall survival rate is better for TC than for AC [4,8)] , and the frequency of lymph node metastases in TC is lower than in high-grade LCNEC and SCLC [8)] . Therefore, some investigators have advocated limited resection in patients with carcinoid [9, 10)] . Some reports revealed that sublobar resection was noninferior to lobectomy for survival in patients with carcinoid tumor [10)] . However, other reports advised that radical oncologic surgery with radical node dissection was needed, and segmental and other limited procedures had to be avoided because of the high frequency of lymph node involvement and multicentric forms[11,12)] . A randomized controlled trial is the best method to compare surgical efficacies. However, it may be impractical due to the rarity of carcinoid tumors. Moreover, AC has a poorer prognosis and a higher frequency of lymph node metastases than TC, and preoperative diagnoses and/or diagnoses of intraoperative frozen sections are often difficult for differentiating AC from TC because small amounts of necrosis or few mitoses are sometimes unclear in those specimens. Therefore, sublobar resection for TC might be the optimal surgical method because of lung preservation and lower mortality than lobectomy; however, limited resection for TC remains an area of controversy. References 1) Arrigoni MG, Woolner LB, Bernatz PE. Atypical carcinoid tumors of the lung. J Thorac Cardiovasc Surg 1972;64:413-21 2) Travis WD, Linnoila RI, Tsokos MG, et al. Neuroendocrine tumors of the lung with proposed criteria for large-cell neuroendocrine carcinoma. Am J Surg Pathol 1991;15:529-53 3) Travis WD, Colby TV, Corrin B, Shimosato Y, Brambilla E, editors. Histological Typing of Lung and Pleural Tumours. World Health Organization International Histological Classification of Tumors, XIII, 3rd ed. Berlin/Heidelberg: Springer-Verlag; 1999 4) Travis W.D, Brambilla E, Müller-Hermelink H.K, Harris C.C (Eds.): World Health Organization Classification of Tumours. Pathology and Genetics of Tumors of the Lung, Pleura, Thymus and Heart. IARC Press:Lyon 2004 5) Rusch VW, Klimstra DS, Venkatraman ES. Molecular markers help characterize neuroendocrine lung tumors. Ann Thorac Surg 1996;62:798-810 6) Onuki N, Wistuba II, Travis WD, et al. Genetic changes in the spectrum of neuroendocrine lung tumors. Cancer 1999;85:600-7 7) Moore W, Freiberg E, Bishawi M, Halbreiner MS, Matthews R, Baram D, Bilfinger TV. FDG-PET Imaging in Patients With Pulmonary Carcinoid Tumor. Clin Nucl Med. 2013;38:501-5 8) Iyoda A, Hiroshima K, Baba M, Saitoh Y, Ohwada H, Fujisawa T. Pulmonary large cell carcinomas with neuroendocrine features are high-grade neuroendocrine tumors. Ann Thorac Surg. 2002 ;73:1049-54 9) Afoke J, Tan C, Hunt I, Zakkar M. Is sublobar resection equivalent to lobectomy for surgical management of peripheral carcinoid? Interact Cardiovasc Thorac Surg. 2013;16:858-63 10) Fox M, Van Berkel V, Bousamra M II, Sloan S, Martin RC II. Surgical management of pulmonary carcinoid tumors: sublobar resection versus lobectomy. Am J Surg. 2013;205:200-8 11) Daddi N, Ferolla P, Urbani M, Semeraro A, Avenia N, Ribacchi R, Puma F, Daddi G. Surgical treatment of neuroendocrine tumors of the lung. Eur J Cardiothorac Surg. 2004;26:813-7 12) Chen F, Sato T, Fujinaga T, Sakai H, Miyahara R, Bando T, Date H. Surgical management of bronchopulmonary typical carcinoid tumors: an institutional experience. Interact Cardiovasc Thorac Surg. 2010;11:737-9

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Abstract
INTRODUCTION Mediastinal Neuroendocrine Tumors occur most frequently in the thymus. Primary Thymic Neuroendocrine Tumors (NETs) are rare and highly aggressive neoplasms; a little more than 350 cases have been described in the literature, many of which are single case reports. We collected one of the largest series ever reported through a multicenter International study, with the aim to evaluate factors influencing survival and recurrence development in patients with Thymic NETs. MATERIAL AND METHODS A multicenter retrospective study of patients operated for NETs between 1989 and 2012 in 9 high-volume International Thoracic Surgery Institutions, was conducted. According to the International Thymic Malignancy Interest Group (ITMIG) outcome measures, primary and secondary outcome were Cause Specific Survival (CSS) and Disease Free Survival (DFS). Competing-risks regression models (Fine and Gray method), taking into account death by any causes as competing event, were used to identify the association between individual factors and tumor related death. Cox proportional hazards regression models were used to define association between individual factors and DFS, considering R0 cases only. Univariate and multivariate analyses were also performed. RESULTS There were 52 patients (41 males –79%-, median age 49 years). The tumor was asymptomatic in 22 cases (42%). Endocrine paraneoplastic syndromes were observed in 23 cases (44%): 13 Cushing’s syndrome and 10 MEN-1 syndrome. Well differentiated neuroendocrine carcinoma (Typical and Atypical Carcinoid) was the commonest histological subtype (30 cases –58%-). Eight patients (15%) received induction therapy (3 chemotherapy, 2 chemo+radiotherapy, 2 biological therapy and 1 chemo+radio+biological therapy), because of their radiological invasiveness. Median sternotomy was the commonest surgical approach (29 cases). The median tumor size was 8 cm (range 1 – 31 cm); a complete resection (R0) was achieved in 48 cases (92%). Advanced Masaoka-Koga stage (III-IV) was observed in 35 patients (67%). Postoperative treatment was offered to 26 (50%): radiotherapy in 17, chemotherapy in 1, chemo+radiotherapy in 5 and chemo+radio+biological therapy in 3 patient, respectively. Three, 5 and 10-year survival rates were 89%, 76% and 51% (Figure 1). Recurrences were observed in 32 cases (62%): 11 local, 10 intrathoracic and 11 distant. Cumulative incidence of recurrence was 41% at 2 years and 70% at 3 years (Figure 2). Variables influencing survival were: tumor size (p< 0.00) and recurrences (p=0.01). Independents DFS predictors were: age > 50 (p= 0.02), paraneoplastic syndromes (p=0.02), symptoms at presentation (p= 0.01) and poor differentiated histology (p= 0.04). CONCLUSIONS We have confirmed that Thymic NETs are rare mediastinal tumors presenting with an aggressive biological behavior; surgery remains the mainstay of treatment and it should be proposed whenever possible, even in case of advanced diseases. Recurrences are frequent, especially in the first years after operation. Survival is statistically related to the tumor size and to the presence of recurrences, whereas, surprisingly, it is not influenced by induction/adjuvant treatment. A global International effort is needed to collect larger series and to confirm these conclusions. Figure 1: Thymic NETs overall survival curveFigure 1Figure 2: Thymic NETs: cumulative incidence of tumor recurrencesFigure 2

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Abstract
The IASLC Staging Projects The International Association for the Study of Lung Cancer (IASLC) now has four staging projects. The first one, for lung cancer, originated during an international workshop on intrathoracic staging organized at the Royal Brompton Hospital, London, UK, in 1996. (1) It is an ongoing project with two phases: a retrospective phase, during which 81,495 analyzable lung cancer patients diagnosed between 1990 and 2000 were registered: 68,463 non-small cell lung cancers (NSCLC) and 13,032 small cell lung cancers (SCLC) (2); and a prospective phase, that includes 78,640 analyzable cases of NSCLC and 5,912 cases of SCLC diagnosed between 1999 and 2010. The retrospective database was used to revise the 6[th] edition of the tumour, node and metastases (TNM) classification and prepare for the 7[th] edition; (3, 4, 5) the data of the prospective phase will be used to inform the 8[th] edition of the TNM classification due to be published in 2016. This writer chairs the Lung Cancer Domain. In 2008, mesothelioma was incorporated into the activities of the IASLC Staging Project lead by Dr. Valerie Rusch as chair of the Mesothelioma Domain. As with lung cancer, a call was made to collect retrospective series from around the world and, at the same time, an online registration system was created for prospective collection of data. The retrospective mesothelioma database contains 3,101 surgically treated patients. This population was first analysed to assess the existing TNM classification and staging system for mesothelioma. (6) These analyses showed that more data are needed to refine the classification beyond what the retrospective database can do. In essence, more detailed data on the T, N and M descritpors is needed. The prospective collection of data is an ongoing project that collects surgically and non-surgically treated patients and is intended to inform the 8[th] edition of the TNM classification. In 2009, thymic malignancies were incorporated into the IASLC Staging and Prognostic Factors Committee (SPFC). So far, more than 10,000 retrospective cases have been collected and are now being analysed by the statistitians at Cancer Research And Biostatistics (CRAB), in Seattle, WA, USA. The main objective of these analyses is to establish a TNM classification for thymomas and thymic carcinomas. The Thymic Domain of the Committee is chaired by Dr. Frank Detterbeck. (7) Finally, also in 2009, oesophageal cancer was incorporated into the activities of the IASLC SPFC under the leadership of Dr. Tom Rice, who is the chair of the Oesophageal Cancer Domain of the SPFC. More than 10,000 cases are registered in a database stored and analysed at the Cleveland Clinic, Cleveland, OH, USA. The surgical cases were used to inform the 7[th] edition. Plans are made to analyse the non-surgical series and validate data to inform the 8[th] edition of the TNM classification. How to contribute Individuals, institutions, cooperative groups and proprietors of registries can contribute by submitting their databases directly to CRAB, provided their databases include the information that is essential for the IASLC Staging Projects, i.e. clinical and pathological data on the different T, N and M descriptors, treatment modality and survival. CRAB statisticians have to be informed about the characteristics of the databases to assess if they are useful for the project prior to submission. This is, indeed, the easiest way to contribute: to submit your database. CRAB accepts databases on lung cancer and mesothelioma. Databases of thymic malignancies can be submitted either to CRAB or to the International Thymic Malignancies Interest Group (ITMIG). ITMIG will assess the data and will forward the specific staging data to CRAB for analysis. Those wishing to contribute oesophageal cancer cases should get in touch with the chair of the Oesophageal Cancer Domain of the SPFC, Dr. Tom Rice, at the Cleveland Clinic, Cleveland, OH, USA. Contribution is best through the Worldwide Esophageal Cancer Collaboration (WECC). Those who want to contribute prospective cases can use the on-line registration system that CRAB has established for lung cancer and mesothelioma. There also is an on-line registration system for thymic tumours provided by the ITMIG. Submitting retrospective databases and on-line registration of prospective cases take time and may cost money. In order to facilitate grant application to those who need the assistance of a data manager, CRAB has prepared a document describing the project that can be used to complete the grant application forms. This document can be accessed through the IASLC website at www.iaslc.org. Go to ‘Staging’ and there you will find all the necessary information about the IASLC Staging Projects. Those who cannot participate submitting cases can participate analysing data not directly related to the main staging projects. An outline of the research project has to be sent to the Chair of the IASLC SPFC stating the objectives and the variables needed for the study. Approval will be granted based on the availability of data, the relevance of the project and the willingness of the applicant to pay for the CRAB statisticians’ work required for the extraction and analysis of data. (9) References 1. Goldstraw P. Report on the international workshop on intrathoracic staging, London, October 1996. Lung Cancer 1997;18:107-111. 2. Goldstraw P, Crowley JJ. The International Association for the Study of Lung Cancer international staging project on lung cancer. J Thorac Oncol 2006;1:281-286 3. Goldstraw P, ed. Staging manual in thoracic oncology. Orange Park, FL: Editorial Rx Press; 2009. 4. Sobin L et al., eds. TNM classification of malignant tumours. 7[th] edition. Oxford: Wiley-Blackwell; 2009;138-146. 5. Edge SB et al., eds. Cancer staging manual. 7[th] edition. New York: Springer; 2010;253-270. 6. Rusch VW et al. Initial analysis of the International Association for the Study of Lung Cancer mesothelioma database. J Thorac Oncol 2012;7:1631-1639. 7. Detterbeck FC, Huang J. Overview. J Thorac Oncol 2011;6(Suppl 3):s1689-1690. 8. Rice TW et al. 7[th] edition of the AJCC Cancer Staging Manual: esophageal and esophagogastric junction. Ann Surg Oncol 2010;17:1721-1724. 9. Goldstraw P et al. We probably have the answer: now what is the question? J Thorac Oncol 2009:4:939-940.

Abstract
Clinical research in non-small-cell lung cancer is a rapidly evolving field. We conducted a survey of lung cancer surgical clinical trials listed on clinicaltrials.gov. 658 records were found, which were mainly consisted of trials studying the surgical procedure and (neo) adjuvant therapy. Phase III trials account for 15.5%. Only 34.9 %( 230 records) trials were completed, and 43 studies present results in clinicaltrials.gov. The median time to completion (MTC) of Ph III surgical procedure trials was 9.4 years. The MTC of Ph III neo-adjuvant and adjuvant trials had not been reached but are longer than 10 years. In comparison, the MTC of Ph III trials in first line setting were only 4.5 years. We summarized the characteristics of these trials with real-world case examples. Our analyses reveal that it is critically needed for regulatory authorities, clinical trial sponsors, collaborative research groups, and academic institutions to work together to build the infrastructure and research cooperation for clinical trials with surgical components. In 2007, a national collaborative clinical research group, Chinese Thoracic Oncology Group (CTONG), was established. CTONG is a network of researchers, physicians and healthcare professionals in public institutions across China. Currently, there are 22 member hospitals in the group. A CTONG-sponsored trial (CTONG1104) is discussed to illustrate our experience with surgical clinical trials. In summary, to expedite clinical research in early stage lung cancer, it is necessary for investigators to collaborate in cooperative clinical trials. As cancer treatment is multidisciplinary, while retaining a surgical focus, surgical trials require multidisciplinary collaboration.

Abstract
Background: Since video-assisted thoracoscopic surgery (VATS) was first reported in the 1990s, this approach has been rapidly gaining popularity worldwide because of its less morbidity and expedited patient recovery. As a milestone, VATS lobectomy was first introduced into NCCN Guidelines in 2006, and then has been recommended as a reasonable and acceptable alternative in the treatment of non-small cell lung cancer (NSCLC) since 2007. However, whether VATS’s superiority really exists in the domain of NSCLC has raised unprecedented dispute in the past two decades, especially when compared to other minimally invasive approaches like axillary thoracotomy. Major debates have involved surgical trauma, post-operative neuralgia, shoulder dysfunction, influence on respiratory function/quality of life (QOL), and finally oncologic outcomes. So far, strong evidence demonstrating decreased morbidity and equivalent long-term survival of the new technique is lacking. In an attempt to obtain a better answer, we designed and initiated this multicenter randomized controlled trial (RCT) in China, which compared VATS and axillary approaches in terms of various surgical and oncologic outcomes for early stage NSCLC. Methods: 400 patients were planned to be recruited in this study since 2008, and then randomized into VATS group (Experimental group) and axillary thoracotomy group (Control group). The Inclusion Criteria include: ①Clinical early stage NSCLC, no hilar and mediastinal lymphadenopathy (short diameter ≤ 1 cm assessed on computed tomography scan); ②No medical contraindications to lung resection; ③Age ≤ 75 years old and ≥18 years old; ④Ability to give informed consent. And the Exclusion Criteria are: ①Evidence of invasion into neighboring organs; ②Extensive pleura symphysis; ③Central tumors; ④Inability to tolerate single-lung ventilation; ⑤Previous thoracotomy or high-dose radiation on the chest ; ⑥Pregnant or lactating female patients; ⑦Inability to sign the informed consent form because of psychological, family and society factors; ⑧History of other malignancies in the past 5 years except for non-melanoma skin cancer, cervix cancer in situ or early-stage prostate cancer; ⑨Other uncontrolled factors (like intra-operative conversion to thoracotomy). Surgery criteria would be a radical lobectomy plus hilar and mediastinal lymph node dissection. Also, the VATS lobectomy was defined by the avoidance of rib-spreading and use of the thoracoscope for visualization. The total number of ports is not relevant in this definition, but is typically 3 and 4. Five-year overall survival (OS) and disease-free survival (DFS), as the primary endpoints will be evaluated. Peri-operative parameters, including post-operative chest pain, cytokines response, post-operative respiratory reserve, Karnofsky performance status and QOL would be explored. In addition, operation time, intra-operative blood loss, chest tube drainage, indwelling period of chest tube, etc. would be documented and compared between two groups. Lung Cancer Symptom Scale (LCSS) was adopted to estimate the QOL before operation and at post-operative standpoints of 1, 3, 6, 9 and 12 months. Post-operative respiratory function would be measured in first three months, while Karnofsky performance status and chest pain at the standpoint of 1 year after surgery. Cytokines response, to be exact, serum levels of IL-2, IL-4, IL-6, IL-10, TNF and IFN-r, would be analyzed in first 48 hours after surgery. Randomization was done via an interactive web response system with computer-generated randomization codes. This study has been registered in Clinicaltrials.gov (NCT01102517) and sponsored by Sun Yat-sen University Clinical Research 5010 plan as well as Guangdong provincial high-tech projects. Result: Five leading hospitals throughout China contributed to this RCT. 425 patients was recruited up to May 2013; nonetheless, 336 patients were finally analyzed in the study. The latest DMC review happened on May 2013 and our RCT was regarded to be strictly adhering to the protocol with good quality control. No surgery-related mortality was documented in both VATS and axillary thoracotomy groups. Unfortunately, four patients in the study group were excluded because of intra-operative conversion to axillary thoracotomy. The conversion rate was 0.94% (4/425) in our study. Another fact needs to be clarified that the remaining 85 patients were excluded due to a variety of reasons, which included extensive pleura symphysis (9 patients), benign pulmonary lesions (35 patients), small cell lung cancer (3 patients), accidental pleural metastasis (2 patients), Age > 75 years old (2 patients), invalid case report forms (13 patients), and inability to adhere to the randomized surgical approaches (21 patients). As a result, 175 patients in VATS group and 161 patients in axillary thoracotomy group were finalized and analyzed by the database. No significant difference between the two groups in terms of the anatomical location of the tumors, histological subtypes and clinical stages. Impressively, the operation time for the VATS lobectomy group was significantly shorter than that of the control group (150 min vs. 170 min, P<0.05). There was also remarkably less intra-operative blood loss in the study group (100 ml vs. 150 ml, P<0.001). Another important finding was that no significant differences were identified regarding the number of cleared lymph nodes and number of lymph node regions (10 vs 12; 5 vs 5, respectively). The peri-operative complication rates, once again, showed no significant difference between the two groups. Patients who undertook VATS lobectomy experienced significantly better post-operative QOL, and the superiority was showed in all the aspects of LCSS. When looking at cytokines response which may reflect the acute surgical injuries or trauma, IL-2, IL-4, IL-6, IL-10, TNF and IFN-r consistently demonstrated lower expression levels throughout the time in the VATS group. However, only the patients who recruited in Sun Yat-sen University Cancer Center underwent the evaluation of cytokines response (180 patients). Regarding the primary endpoints, although longer follow-up is still needed before drawing a clear conclusion, initial analyze did show no significant difference was seen between the two groups regarding OS and DFS. We considered these results were premature, but we also believed current data tended to demonstrate a statistical non-inferiority result. Conclusions: Our multicenter RCT has illustrated that VATS approach is a safe approach for the treatment of early stage NSCLC, and may be superior to axillary thoracotomy approach in terms of intra-operative blood loss, acute surgical injuries and post-operative QOL. However, we also realized that longer follow-up is necessary to determine its oncologic equivalency.

Abstract
Introduction Building translational research capacity is a daunting task if a thoracic surgeon has not inherited a fully set up laboratory. It is possible, however, for a thoracic surgeon to be involved in and even drive translational research. Given that surgeons are the major procurers of tissue and data in lung cancer, it should actually be more commonplace. It requires passion, organization, the understanding and assistance of colleagues, and the ability to seize what opportunities exist and create new ones with strategic collaboration. Creating this capacity also involves modifying surgical practice to facilitate research then building the relationships, funding and infrastructure. In this article, these building blocks are explored. A translational research project is presented as a successful application of this formula. Building Blocks As a principle, the pillars research capacity-building are: ~ Research-Based Surgical Practice ~ Relationships ~ Infrastructure ~ Funding Sources For individual surgeons and circumstances, these may differ. Some components may already exist and some may seem unattainable. It is often overlooked that simple changes to standard practice can make research a natural activity. For example, focusing audits on the procedures that are the subject of potential research, aligning timing of routine follow-up so that outcome assessment becomes automatic, or a policy that all tissue excess to diagnostic needs is routinely stored in a tissue bank. A research coordinator, at least part-time, is essential for any sustainable research activity. Beyond that, key relationships may differ. For me, the most important initial relationship is an anatomical pathologist with a keen interest in lung. Without such a person to review and precisely classify tumors, the power and applicability of any study is seriously diminished. However, a relationship with a laboratory-based clinician or scientist is necessary in order to have access, training and conduct of the benchtop component of research. The surgeon should be active in these endeavours (at least initially) to promote goodwill and a free-flowing exchange of ideas. Other clinicians or specialist scientists may then need to be involved depending on the scope of the potential research projects. Whatever infrastructure is available for research will often need to be augmented. Many useful research tests are already available in a diagnostic pathology laboratory (e.g. advanced immunohistochemistry, mutation screening, PCR). Some facilities may be shared with researchers in other specialties, resulting in synergies for both groups. This may be the way to acquire part time bench space, for example. After determining what capabilities are required to conduct the projected range of research, funding will be the next concern. It is not usually possible to get large project and infrastructure support without a track record and without the funds it is difficult to get a good track record. Therefore preliminary work needs to be funded from a range of more modest resources to pay for direct research costs and services outside any collaborative effort. Local organizations such as Rotary, Apex etc. are often keen to donate to research with a potential impact on their community. This could, for example, fund the construction of tissue microarrays or purchase of essential equipment. Anything that a name can be attached to is usually fair game for such donors. Hospital research foundations are the easiest target for competitive grants. Specialist societies commonly have foundations for distributing grants-in-aid. Participation in capitation-funded clinical trials may provide the salary for a research coordinator, allowing their spare time to be dedicated to translational projects. An Example of Surgeon Driven Translational Research After several years of building relationships, collaborations, infrastructure and funding, our group was able to assess our core research advantages. Figure 1 plots the gradual ascent to critical mass for research funding in our thoracic unit.Figure 1 Our example project investigated the genomic/transcriptomic landscape of the recently classified subtypes of lung adenocarcinoma.[1] Other than one gene expression study[2] using outdated array-based platforms and subtype classifications, no molecular signature has been reported to correlate to the morphology seen by the pathologist under the microscope. It is debated whether these subtypes are genetically different or just a spectrum of the same tumour. Inter-observer differences in classifying these subtypes are particularly problematic for the new micropapillary subtype; therefore a molecular marker is an important goal. To investigate these new subtypes (table 1), we carefully selected tumors with classical morphological regions of the differing subtypes. From this group, 29 tumours were selected with known mutations in one or more of EGFR, KRAS, BRAF and TP53. These would be the most likely cases to prove our hypothesis that there are differential genomic aberrations within subtypes of the same tumor.

Table 1. Subtypes of lung adenocarcinoma investigated, as classified in the 2011 IASLC/ATS/ERS pathological classification of lung adenocarcinoma.

Subtype	Description
Lepidic	Minimal metastatic potential. Malignant cells growing along but not invading airway walls
Acinar	Moderate metastatic potential. Glandular structures in invasive stroma
Papillary	Moderate metastatic potential. Branching structures with fibrovascular stromal cores covered by malignant cells.
Solid with/without mucin	High metastatic potential. Sheets or nests of malignant cells with or without intracellular mucin.
Micropapillary	High metastatic potential. Papillary tufts of tumor cells without fibrovascular cores either lying apparently free in alveolar spaces or surrounded by thin fibrous septa, often at a tumor’s edge.

After marking the subtypes in areas of tumor purity > 50%, punches of formalin-fixed paraffin embedded tumor were deparaffinized and DNA was extracted. High resolution melting was then used to screen for mutations in all selected subtypes of each tumor. In 3 out of 11 KRAS mutant tumors and 2 out of 4 BRAF mutant tumors, heterogeneity was found in mutation status between subtypes of lesser and higher metastatic potential. No differences were seen between subtypes for EGFR mutant tumors, however we did find a single case of very high copy number of the EGFR mutant allele mapping only to the micropapillary subtype in the tumor. The significance of this finding is far-reaching. It provides a genetic basis to support the new pathological classification and may inform its next revision. It also brings into question the accuracy of small biopsies in detecting mutations other than EGFR. It has the potential to unravel the biological evolution of lung adenocarcinoma, with EGFR apparently an early event, whereas KRAS and BRAF may be acquired later and result in a transition to a more malignant subtype phenotype within a given tumor. Conclusion This example demonstrates that surgeons can drive important translational research as well as advancing other researchers’ goals. Although it takes years to develop such programs, once critical mass is achieved the results create further opportunities to sustain future research and incorporate advances in sequencing platforms and knowledge in lung cancer biology. References

1	Travis, W. D. et al. International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society international multidisciplinary classification of lung adenocarcinoma. J Thorac Oncol 6, 244–285 (2011).
2	Bryant, C. M. et al. Clinically relevant characterization of lung adenocarcinoma subtypes based on cellular pathways: an international validation study. PLoS One 5, e11712 (2010).

Abstract

Abstract
Background Over fifty percent of all newly diagnosed lung cancer patients are aged over 65 years at the time of lung cancer diagnosis, and about 30% are aged over 70. Since lung cancer is a disease that mainly occurs in elderly, and smoking is the most important risk factor [1], many patients have (smoking-related) comorbidity at the time of lung cancer diagnosis. This may complicate the management of lung cancer and may also serve as a competing cause of death. Methods An overview of literature concerning the prevalence and prognostic influence of comorbidity in lung cancer patients as well as competing causes of death. ResultsPrevalence of comorbidity Previous studies have shown that over 70% of patients suffered from at least one serious comorbid condition at the time of lung cancer diagnosis [2, 3]. The prevalence of (especially tobacco-related) comorbidity was higher among lung cancer patients as compared to patients with other major tumour types or the general population [2, 4]. The most frequent concomitant diseases among lung cancer patients were tobacco-related, such as cardiovascular diseases (25-30%), chronic obstructive pulmonary diseases (COPD, 25-30%) and previous malignancies (about 20%) [2, 3]. Prognostic influence of comorbidity Since in most cancer trials significant comorbidity is an exclusion criteria, limited information is available on the prognostic influence of comorbidity (which is important information for everyday clinical practice). Previous studies have shown that comorbidity only had a significant influence on survival in case of a localized lung tumour or in case of severe comorbidity [2, 3, 5-7]. A poorer overall survival in patients with comorbidity might be explained by death due to complications of treatment, death from cancer due to less aggressive treatment, or an increased risk of mortality due to comorbid conditions (competing causes of death). Comorbidity may increase the risk of peroperative and postoperative complications, especially those of the cardiorespiratory system [8]. A previous population-based publication has also shown that up to 75% of elderly SCLC patients receiving chemotherapy developed grade 3-5 toxicity, and two thirds of these patients receiving chemotherapy were unable to complete the treatment [9]. Elderly patients with localized non-small cell lung cancer (NSCLC) underwent less surgery than younger patients, older patients with non-localized NSCLC received less chemotherapy or chemoradiation, and elderly with small cell lung cancer (SCLC) received less chemotherapy and chemoradiation [5, 9, 10]. Competing causes of death Increased mortality due to comorbidity is probably of less importance in case of a lethal disease as non-localized NSCLC or SCLC [2, 10, 11]. Most patients probably die of lung cancer before they become at risk of dying of the comorbid condition. Previous studies have shown that 80-90% of all lung cancer patients died of lung cancer. The most common other causes of death were other tobacco-related conditions as cancers and cardiovascular causes [12-14]. Respiratory failure is the most common immediate cause of death for patients with lung cancer, probably because most of them have lung disease besides cancer and therapy for lung cancer may also add to impairment of lung function [15]. The finding that over 90% of lung cancer patients have contributing causes of death, suggests the possibility that saving a patient from one cause may only allow another disease process to become the immediate cause of death [15]. Conclusions The majority of patients with lung cancer also have serious comorbidity, especially other smoking-related diseases as cardiovascular diseases and COPD. Besides making treatment complex, comorbid conditions may also serve as competing causes of death. References 1. Doll R, Peto R, Wheatley K et al. Mortality in relation to smoking: 40 years' observations on male British doctors. Bmj 1994; 309: 901-911. 2. Piccirillo JF, Tierney RM, Costas I et al. Prognostic importance of comorbidity in a hospital-based cancer registry. Jama 2004; 291: 2441-2447. 3. Janssen-Heijnen ML, Schipper RM, Razenberg PP et al. Prevalence of co-morbidity in lung cancer patients and its relationship with treatment: a population-based study. Lung Cancer 1998; 21: 105-113. 4. Janssen-Heijnen ML, Houterman S, Lemmens VE et al. Prognostic impact of increasing age and co-morbidity in cancer patients: a population-based approach. Crit Rev Oncol Hematol 2005; 55: 231-240. 5. Luchtenborg M, Jakobsen E, Krasnik M et al. The effect of comorbidity on stage-specific survival in resected non-small cell lung cancer patients. Eur J Cancer 2012; 48: 3386-3395. 6. Jorgensen TL, Hallas J, Friis S, Herrstedt J. Comorbidity in elderly cancer patients in relation to overall and cancer-specific mortality. Br J Cancer 2012; 106: 1353-1360. 7. Birim O, Kappetein AP, Bogers AJ. Charlson comorbidity index as a predictor of long-term outcome after surgery for nonsmall cell lung cancer. Eur J Cardiothorac Surg 2005; 28: 759-762. 8. Wang S, Wong ML, Hamilton N et al. Impact of age and comorbidity on non-small-cell lung cancer treatment in older veterans. J Clin Oncol 2012; 30: 1447-1455. 9. Janssen-Heijnen ML, Maas HA, van de Schans SA et al. Chemotherapy in elderly small-cell lung cancer patients: yes we can, but should we do it? Ann Oncol 2011; 22: 821-826. 10. Janssen-Heijnen ML, Smulders S, Lemmens VE et al. Effect of comorbidity on the treatment and prognosis of elderly patients with non-small cell lung cancer. Thorax 2004; 59: 602-607. 11. Phernambucq EC, Spoelstra FO, Verbakel WF et al. Outcomes of concurrent chemoradiotherapy in patients with stage III non-small-cell lung cancer and significant comorbidity. Ann Oncol 2011; 22: 132-138. 12. Janssen-Heijnen ML, Maas HA, Siesling S et al. Treatment and survival of patients with small-cell lung cancer: small steps forward, but not for patients >80. Ann Oncol 2012; 23: 954–960. 13. Pirie K, Peto R, Reeves GK et al. The 21st century hazards of smoking and benefits of stopping: a prospective study of one million women in the UK. Lancet 2013; 381: 133-141. 14. Thun MJ, Carter BD, Feskanich D et al. 50-year trends in smoking-related mortality in the United States. N Engl J Med 2013; 368: 351-364. 15. Nichols L, Saunders R, Knollmann FD. Causes of death of patients with lung cancer. Arch Pathol Lab Med 2012; 136: 1552-1557.

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Abstract
Results from the National Lung Screening Trial (NLST) showing a 20% reduction in lung cancer mortality in the screened arm have heightened awareness of the need for reliable risk prediction tools for estimating the probability of lung cancer. A key issue of uncertainty is which smokers should be targeted for low-dose computed tomography (LDCT) screening. The NLST used 55 - 74 years, ≥30 pack-years of smoking and up to 15 years since quitting as selection criteria. 7 million U.S. adults meet these entry criteria, and an estimated 94 million U.S. adults are current or former smokers. Validated risk prediction models could improve the outcomes of screening efforts. Such models have substantial public health implications and value in clinical decision making as well. Further, risk prediction tools could be incorporated into the design of smaller, more powerful, and “smarter” prevention trials. The first lung cancer risk prediction model was developed by Bach et al. using data from the Carotene and Retinol Efficacy Trial (CARET) of 14,000 heavy smokers and over 4,000 asbestos-exposed men. Variables included in the final model were age, gender, asbestos exposure, smoking history, cigarettes per day, duration of smoking and duration of cessation. Cronin et al. externally validated the Bach model in the Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study control arm (c statistic of 0.69). Spitz et al. expanded on this model adding epidemiologic and clinical data derived from an ongoing lung cancer case-control study. Their model included environmental tobacco smoke (for never and former smokers), family cancer history, asbestos and dust exposures, prior respiratory disease, history of hay fever, and smoking history variables. These variables have strong biologically plausibility and are relatively easy to ascertain through patient interview. However, the validated area under the curve (AUC) statistics for former and current smoker models were modest (0.63 and 0.58, respectively), although consistent with those from other risk prediction models. The LLP model based on data from the Liverpool Lung Project included age, sex and smoking, as well as family history of lung cancer, exposure to asbestos, prior diagnosis of pneumonia and of a malignancy other than lung cancer. Prior diagnoses of emphysema and lung cancer lost significance in the multivariate model. Young et al. developed a risk model using a 20-single nucleotide polymorphism (SNP) panel including cell-cycle control, oxidant response, apoptosis, and inflammation genes, as well as age, history of COPD, family history of lung cancer, and gender. When numeric scores were assigned to both the SNP and demographic data, and sequentially combined by a simple algorithm in a risk model, the composite score was linearly related to risk with a bimodal distribution. These data have not been well replicated. In 2011,Tammemagi published a carefully constructed risk prediction model based on data from 70,962 control subjects in the Prostate, Lung, Colorectal, Ovarian cancer screening trial (PLCO). Model 1 included age, education, body mass index (BMI), family history of lung cancer, chronic obstructive pulmonary disease (COPD), recent chest x-ray, smoking status (never, former, current), pack-years smoked, and smoking duration. Model 2 also included time in years since ever-smokers permanently quit smoking. In external validation, performed with 44,223 PLCO intervention arm participants, Models 1 and 2 had area under the curves of 0.84 and 0.78, respectively. Tammemagi and colleagues also showed that their risk prediction model for lung cancer incidence was a more sensitive indicator of pre-screening risk of developing lung cancer than were NLST eligibility criteria. Kovalchik et al. subsequently showed that 88% of LDCT-prevented lung cancer deaths occurred among the 60% of NLST participants with highest pre-screening risk, while just 1% occurred among the 20% at lowest risk. This finding reinforces the role for risk-based screening. Maisonneuve et al. incorporated lung nodule characteristics and CT diagnosed emphysema into the Bach model. Presence of nonsolid nodules (RR = 10.1), nodule size > 8 mm (RR = 9.89), and emphysema (RR = 2.36) at baseline CT were all significant predictors of subsequent lung cancers. Incorporation of these variables into the Bach model increased the predictive value of the model (c-index = 0.759). Hoggart et al used prospective data from the European EPIC cohort. Using smoking information alone gave good predictive accuracy: the AUC and 95% CI in ever smokers was 0.843 (0.810-0.875). Adding other risk factors (10 occupational/environmental exposures previously implicated with lung cancer, and SNPs at two loci identified by GWAS of lung cancer) had a negligible effect on the AUC. An extended model was constructed incorporating two markers of DNA repair capacity that have been shown in case-control analyses to be associated with increased lung cancer risk. Addition of the biomarker assays improved the sensitivity of the models over epidemiologic and clinical data alone. These in vitro lymphocyte culture assays, however, are time-consuming and require technical expertise, and are not applicable for widespread population-based implementation. Spitz et al. added 3 SNPS that were most significant in their GWAS data – rs1051730 from 15q25 and two SNPs from the 5p15.33 locus (rs2736100 and rs401681 that were not in strong LD) to the baseline model. The AUC for the baseline epidemiologic/clinical model including 1016 cases and 1111 controls (all ever smokers) was 0.59. There was evidence of a gene dosage effect with an odds ratio over threefold elevated in the highest genetic risk score (GRS) stratum. With addition of the GRS to the model, the AUC showed modest improvement, to 0.61, although this was significantly improved over the baseline model, (P< 0.001). Current lung cancer risk prediction models are hampered by a restricted number of potential predictors, generally low overall predictive performance, and methodological limitations. To date, one can argue that the Tammemagi 2013 model exhibits the highest AUC among all the prediction models. It is important to conduct additional external validations of all models in diverse populations.

Abstract not provided

Abstract not provided

Abstract
Adaptive clinical trials designs are sometimes claimed to have many benefits over conventional group sequential designs. Such claims are generally unfounded, though adaptive designs may be quite useful in specific situations. Adaptive designs can be quite useful in early phase dose finding trials, where the purpose is to minimize the number of patients exposed to inefficacious or overly toxic doses. Adaptive designs can also be useful in later phase trials when a biomarker (or baseline patient characteristic) is suspected to be strongly predictive of the effect of the treatment under investigation; in this case, an adaptive enrichment of the trial can greatly improve its power. Adaptive designs can also prove useful when the assumptions underlying a trial design are subsequently found to be grossly inadequate, but this is an undesirable as well as uncommon situation. Adaptive randomization, which consists of allocating more patients to the treatment that appears to have more efficacy ("play-the-winner"), is justified neither statistically nor ethically. This strategy may produce slight reductions in the number of patients exposed to the inferior treatment, but it may increase the total sample size of the trial as compared to using a fixed allocation ratio (e.g. 1:1). More importantly, this adaptive strategy conveys the misealding impression that one treatment is known to be better than the other, a situation in which equipoise is not maintained and randomization no longer ethical.

Abstract
Introduction Ipsos MORI were commissioned by the Global Lung Cancer Coalition to explore the prevalence of smoking within countries; and awareness of the symptoms of lung cancer. Two questions were asked: 1. Can I just check, do you consider yourself to be: a) A current smoker – i.e. someone who is a regular smoker at the present time; b) A former smoker – i.e. someone who used to smoke regularly but has quit; c) Someone who has never smoked – i.e. someone who has never smoked at all, or only very occasionally in the past (less than 100 cigarettes in your lifetime); d) Don’t know. 2. There are many warning signs and symptoms of lung cancer. Please name as many symptoms of lung cancer as you can think of.[1] A quantitative survey was conducted across: Argentina, Australia, Bulgaria, Canada, Denmark, Egypt, France, Germany, Great Britain, Ireland, Italy, Japan, Mexico, Norway, Portugal, Slovenia, Spain, Sweden, Switzerland, the Netherlands, and the USA. This abstract outlines the headline findings[2]. Methodology A nationally representative quota sample for each country of 500–1,204 adults was interviewed from 2 June – 16 August 2013[3], using Omnibus services (please note the lowest age varied slightly between countries)[4]. Face-to-face in-home interviewing was used in Bulgaria, France, Germany, Great Britain, Portugal and Spain, and telephone (CATI[5]) interviewing elsewhere (in Argentina, Australia, Canada, Denmark, Egypt, Ireland, Italy, Japan, Mexico, Norway, Slovenia, Sweden, Switzerland, the Netherlands, and the USA). Data have been weighted to the known adult population profile of each country. Please also note that booster surveys took place in Mexico, Norway, Sweden and Slovenia to boost the number of smokers in order to allow robust comparisons. In each country, data were weighted back to the original profile of smokers and non-smokers to ensure that smokers were not over-represented. Discussion of findings: where is smoking prevalence highest? Of all the 21 countries surveyed, people in Bulgaria are most likely to be current smokers (41%), followed by Spain (33%) and France (30%). The lowest proportions of current smokers are found in Sweden (12%) and Australia (13%). Egypt, however, has the highest proportion of people who have never smoked at all (70%). Figure 1 Spontaneous awareness of the symptoms of lung cancer The combined results from all countries show that breathlessness (40%) and coughing (39%) are the most frequently recognised symptoms of lung cancer. Other symptoms relating to coughing, as well as general or unspecified coughing, are also commonly mentioned: coughing blood (17%), a cough that doesn’t go away (14%), and a cough that gets worse (8%). Tiredness or a lack of energy (13%) and an ache or pain when coughing or breathing (11%), are spontaneously mentioned by more than one in ten people as well. It should also be recognised that approaching one in four could not name any symptoms, instead stating that they didn’t know (23%). Figure 2 Spontaneous awareness varies significantly by country. For example, fewer than one in four Japanese adults mention breathlessness (22%), compared to a high of 56% in Ireland. Likewise, whilst 27% state tiredness or a lack of energy to be a symptom of lung cancer in Bulgaria, only 5% of Australians do the same. The following table shows the most frequently mentioned symptoms in each country. Breathlessness is the symptom respondents are most commonly aware of in fifteen countries, with general or unspecified coughing emerging more frequently in the other six.

Country	Most frequently mentioned	Second most frequently mentioned	Third most frequently mentioned
Argentina	Breathlessness (31%)	A cough (26%)	Tiredness or lack of energy (12%)
Australia	Breathlessness (53%)	A cough (37%)	Coughing blood (32%)
Bulgaria	Breathlessness (50%)	Coughing blood (37%)	A cough that gets worse (30%)
Canada	Breathlessness (49%)	A cough (45%)	Coughing blood (20%)
Denmark	Breathlessness (51%)	A cough (48%)	An ache or pain when coughing or breathing (20%)
Egypt	Breathlessness (25%)	Persistent chest infections (23%)	A cough (15%)
France	A cough (54%)	Breathlessness (37%)	A cough that doesn't go away (25%)
Germany	Breathlessness (36%)	Coughing blood (34%)	A cough that doesn't go away (31%)
Great Britain	Breathlessness (46%)	A cough (43%)	Coughing blood (27%)
Ireland	Breathlessness (56%)	A cough (56%)	Coughing blood (27%)
Italy	Breathlessness (42%)	A cough that doesn't go away (32%)	A cough (29%)
Japan	A cough (50%)	Breathlessness (22%)	A cough that doesn't go away (21%)
Mexico	A cough (33%)	Breathlessness (27%)	An ache or pain when coughing or breathing (10%)
Netherlands	Breathlessness (45%)	A cough (45%)	Tiredness or lack of energy (13%)
Norway	Breathlessness (47%)	A cough (40%)	Chest and/or shoulder pains (9%)
Portugal	Breathlessness (35%)	A cough (33%)	Tiredness or lack of energy (18%)
Slovenia	A cough (52%)	Breathlessness (31%)	Coughing blood (10%)
Spain	A cough (29%)	Breathlessness (25%)	Tiredness or lack of energy (20%)
Sweden	A cough (46%)	Breathlessness (42%)	Tiredness or lack of energy (10%)
Switzerland	A cough (53%)	Breathlessness (43%)	An ache or pain when coughing or breathing (12%)
USA	Breathlessness (38%)	A cough (37%)	Coughing blood (14%)

When analysing the mean number of potential symptoms of lung cancer mentioned in each country depending on whether respondents are current smokers, former smokers, or have never smoked at all, awareness appears to be fairly consistent. Please note that people who said that they did not know any symptoms have been excluded from this analysis. The following table highlights within each country which of the three groups has the highest mean score (i.e. the most mentions of symptoms per respondent). The key finding from this is that current smokers often mention fewer symptoms of lung cancer than former smokers or people who have never smoked. In three countries (France, Ireland and Portugal), current smokers do appear to have a greater awareness of potential symptoms, whilst in Sweden, current and former smokers have the same mean score.

Mean number of mentions of symptoms of lung cancer per respondent (who named at least one symptom)
Country	Current smokers	Former smokers	Never smokers
Argentina	1.97	1.97	2.11
Australia	2.04	2.47	2.28
Bulgaria	3.63	4.18	3.97
Canada	2.57	2.53	2.77
Denmark	2.39	2.34	2.43
Egypt	3.09	3.32	3.32
France	2.54	2.53	2.40
Germany	3.02	3.66	3.69
Great Britain	2.77	2.89	2.75
Ireland	3.21	2.99	2.94
Italy	2.46	2.53	2.43
Japan	2.41	2.55	2.67
Mexico	1.98	1.84	2.00
Netherlands	1.99	2.19	2.24
Norway	1.86	2.14	2.18
Portugal	2.61	2.54	2.43
Slovenia	2.35	2.46	2.16
Spain	2.13	2.30	2.13
Sweden	1.98	1.98	1.89
Switzerland	1.94	2.31	2.23
USA	1.93	1.97	2.01

[1] A pre-coded list was provided for interviewers to code responses. Respondents were able to code multiple responses. [2] Please note that at this stage the findings are based on interim data. [3] The base sizes in each country were as follows: Argentina (500), Australia (1,000), Bulgaria (1,148), Canada (1,005), Denmark (650), Egypt (1,009), France (953), Germany (1,073), Great Britain (957), Ireland (1,000), Italy (510), Japan (1,204), Mexico (600), Norway (529), Portugal (1,203), Slovenia (580), Spain (500), Sweden (550), Switzerland (510), the Netherlands (1,004), and the USA (1,000) [4] The lowest age for each country is as follows: Germany: 14 years; Australia, Ireland, Mexico and Norway: 15 years; Sweden: 17 years; Egypt and Japan: 20 years; all other countries: 18 years. [5] Computer Assisted Telephone Interviewing

Abstract

Abstract
Lung Cancer Public Information Campaign – Striving to Ensure Earlier Lung Cancer Diagnosis Jesme Fox, Medical Director, Roy Castle Lung Cancer Foundation, UK. ________________________________________________________________________ Background Despite recent advances, lung cancer remains a disease characterized by late diagnosis and poor outcomes. Diagnosing more lung cancer patients, at an early stage, when curative treatments are an option, will save lives. In recent years, there has been a focus on lung cancer screening. In countries where lung cancer screening is available, high risk individuals are being directed to these services. In other counties, advocates are calling for further research to evaluate the benefit of screening tools. Raising general public awareness of the signs and symptoms associated with lung cancer is of importance in the pursuit of earlier diagnosis. It is a key function of many advocacy groups working in the lung cancer field. With the variety of associated signs and symptoms, this is a difficult area. Using nationally agreed guidelines, advocacy groups have produced information, such as the GLCC awareness raising leaflets, available for download, in 13 languages [1]. As noted in a 2013 survey, undertaken by Public Health England, [2], 40% of people surveyed were unaware that a persistent cough could be a symptom of lung cancer.. Challenges Much negativity surrounds lung cancer and impacts on effective campaigning. Lung cancer is seen as a ‘depressing story’ and it is often difficult to engage the media. The notion of ‘self infliction’ surrounding this disease, adds to this difficulty. Furthermore, the stigma and blame associated with lung cancer is in itself, a contributing factor to late presentation in this disease [3, 4, 5,]. Stigmatisation has a very negative impact on the disease and on advocacy initiatives. Central to the lung cancer advocacy community is its focus on reducing the stigma associated with this disease. Many diseases are life style related, yet are not impacted in this way. It is important that whilst undertaking awareness campaigns, the messages of ‘no one deserves lung cancer’ and ‘smoker, former smoker or never smoker – anyone can get lung cancer’ are distributed widely. Public awareness raising campaigns in lung cancer Much of the awareness campaigning to date has come from the emerging Lung Cancer Patient Advocacy movement. Sadly, with poor survival, the number of lung cancer advocates and advocacy groups is relatively small, as compared with other common cancers. However, a key focus has been the November, ‘Lung Cancer Awareness Month’ initiative, initially developed in the US, by the Alliance for Lung Cancer Advocacy, Support and Education (now the Lung Cancer Alliance) and adopted by the global community, through the Global Lung Cancer Coalition, in 2001. The campaign aims to raise awareness of the signs and symptoms associated with lung cancer, change public perceptions and help to de-stigmatize this disease. An early example of this was the 2002 general public and media campaign, organized in the UK by the Roy Castle Lung Cancer Foundation and Macmillan Cancer Relief [6]. In recent years, the cross country initiative, involving Australia, Egypt and the US, being the ‘Shine a Light on Lung Cancer’ campaign, originally developed by Lung Cancer Alliance [7]. Other campaigns, from across the globe, will be described. In the UK, we have seen a number of general public lung cancer awareness raising initiatives, through the National Awareness and Early Diagnosis Initiative (NAEDI). We have also seen local campaigns such as the ‘’Doncaster Cough Campaign’’ [8] – in the 11 GP surgeries studied, after its first year (2008), noted, 19% of lung cancers diagnosed in Stage I and II, an increase from 11% in the previous year. We have also seen centrally, government funded campaigns. In England, the Department of Health, in 2012, funded the national ‘Be Clear on Cancer – Lung Cancer’ campaign [9]. This campaign, focusing on ‘’persistent cough’’ and results from the pilot study noted a 22% increase in the number of patients who visited their General Practitioner with relevant symptoms and also noted an increase in Chest CTscans being performed. This campaign has been repeated in the summer of 2013. In Scotland, the ‘Detect Cancer Early’ campaign is developing a national lung cancer component. References GLCC website (lung cancer signs and symptoms awareness leaflets, for download) http://www.lungcancercoalition.org/en/download-our-awareness-leaflet Online omnibus survey for Public Health England, conducted with representative sample of 1045 adults, between 7 and 10 June 2013 by TNS BMRB. http://www.gov.uk/government/news/don’t-ignore-a-persistent-cough-warns-lung-cancer-campaign Corner, J., J. Hopkinson, and L. Roffe, Experience of health changes and reasons for delay in seeking care: A UK study of the months prior to the diagnosis of lung cancer. Social Science and Medicine, 2006. 62: p. 1381-1391. Tod, A.M., J. Craven, and P. Alllmark, Diagnostic delay in lung cancer: a qualitative study Journal of Advanced Nursing 2008. 61(3): p. 336-343. Corner, J., et al., Is late diagnosis of lung cancer inevitable? Interview study of patients recollections of symptoms before diagnosis. Thorax, 2005. 60: p. 314-319. Baird J. Raising the Public Profile of Lung Cancer – Report of a National Lung Cancer Awareness Campaign in the UK. Lung Cancer (2003) 42, 119-123. Lung Cancer Alliance – Shine a Light campaign http://www.lungcanceralliance.org/shinealightonlungcancer/ Athey, U.L., Suckling R.J, Tod, A.M, Walters, S.J, Rogers, T.K, Thorax, 2012. May: 67(5); 412-7. Early diagnosis of lung cancer : evaluation of a community based social marketing intervention. Be Clear on Cancer – Lung Cancer campaign http://www.campaigns.dh.gov.uk/category/beclearoncancer/

Abstract
Background: In Japan and Asian countries, patient advocacy has not been popular to citizens and government, especially in patients with lung cancer compared to USA and EU countries. Therefore, a few clinicians had played a role as advocate instead of cancer survivors group or governments. Clinicians as advocates have a certain advantage to give professional information by themselves, with trained communication skill about bad news, and to use medical resources which is involved to medical society for lung cancer or hospital. West Japan Oncology Group (WJOG), non-profit organization which was established in 2000 by volunteer oncologists, has the mission to conduct and support multi-center clinical co-operative study for cancer and to provide the information about lung cancer, the importance and necessity of clinical study for standard treatment widely, therefore to contribute improving social welfare. Methods: To achieve the mission of WJOG, we carried out open lecture in city hall in major city every year and published lecture recordings in newspaper as well DVD video distribution. In another way, we planed to publish the guideline book for the patients with lung cancer and revised in five years interval. The board of directors determined the plan and the guideline editors committee was organized by WJOG member in March, 2006. The committee edited constitution, drafting, plan, writing as an enterprise in 2006, and 2011. Questions and answers style was adopted in accordance to previous US guidebook . Results: In these 12 years, 27 times of open lecture were held and medical specialists for oncology, novelists with cancer, representative or president of organization for patients advocacy, and etc gave lecture and discussed with patients. Nearly two to eight hundred people had participated in each meeting, occupied by most women and senior citizens. The questionnaire survey to participant revealed satisfaction for lecture and expectation for next meeting. The contents of lecture appeared full page in the Asahi which has a large circulation of almost 8 million (the second position in the world) as well as DVD-video was distributed widely to institute participating to our study and patients for the purpose of providing larger citizens with useful information. Furthermore WJOG official web site show the detail of each lecture in Japanese because Japanese patients with lung cancer are old and difficult to read English web site. Last year, second edition guideline book for patients was edited which consists of 118 questions and answers with full color 200 pages, as well posted to the WJOG website. GLCC international quantitative survey in 2010 showed that Japan is one of the countries with the greatest proportion of adults who think lung cancer is the biggest killer Conclusions: It seems that patient advocacy is developed to be more popular through open lecture, newspaper, web site and guideline book even in Japan. This method may be one of the ways to raise public awareness of lung cancer in Asian countries.

Abstract
Working with survivors is the foundation for every one of our programs at Lung Cancer Alliance. We examined the past nine years and the varying degrees of success of each of our initiatives based on the engagement of survivors to accomplish our goals. We will discuss the ways in which survivors join our movement and the various ways in which advocacy can help them during their journey with lung cancer.

Abstract
Background There is evidence from a variety of sources that lung cancer outcomes in the UK are worse than in many other parts of the developed world [1,2]. Part of this ‘survival gap’ can be explained by late diagnosis as evidenced by an excess of deaths within the first few months of diagnosis [3] and a high rate of patients (~40%) being first diagnosed during emergency hospital admissions [4]. However stage-for-stage survival is also worse in the UK [2], surgical resection rates are [5] and there is a clear relationship between these rates and survival [6].Methods The National Lung Cancer Audit (NLCA) had its first full year of data collection in 2005. Its aim was to collect a core dataset of around 140 items on all patients newly diagnosed and with lung cancer and mesothelioma in all hospitals in England expanding to cover the entire UK from 2008. Data is collected by the Multi-disciplinary teams and entered onto a secure national database. As of May 2013 there are almost 220,000 patient records for England alone in the database and all hospitals in the UK regularly report data for their patients. Annual reports contain a wide range of indicators including: numbers of patients diagnosed; treatment rates for surgery, chemotherapy and radiotherapy, case mix factors such as age, stage, performance status, co-morbidity and socio-economic status. Median and one-year survival rates are also reported. Data are presented both in terms of crude percentages and case-mix adjusted odds ratios. These reports, including the identification of hospitals, are available to the public. The programme has been backed up by a series of meetings with hospital teams to identify their particular strengths and weaknesses, to support them in service improvement and to share examples of best practice.Results The table below shows some examples of data completeness and the ‘headline indicators’ from England and Wales between 2005 and 2011 (the latest period for which data are available). It will be seen that data quality and completeness has improved as have all the process and outcome indicators.Figure 1 We have demonstrated that there is wide variation in treatment and survival within the UK [7,8]. One of the most dramatic and important impacts of the audit has been the realisation of just how low surgical resection rates were in some parts of the UK and that this was related to a serious shortage of specialist thoracic surgeons in many areas [9]. The number of thoracic surgeons has almost doubled since the publication of the first audit report and the overall resection rate has increased by almost 50%. In addition, we have many examples of where local practice and service configuration have been significantly improved as a result of this process. We are now assessing the extent to which these changes have been translated into improvements in survival. The Roy Castle Lung Cancer Foundation has developed a web-based system called the ‘Lung Cancer Smart Map’ [10] which allows patients to search how treatment in their area compares both with other hospitals and against national standards. Patient empowerment of this sort is potentially one of the most effective ways to drive up standards of care.Conclusions In summary, we have demonstrated that population-based data collection is feasible and as a result, the NLCA database is one of the largest and most detailed lung cancer databases in the world. The regular feedback and support that we have given to clinical teams and to patients has had a significant impact on the quality of care for patients in the UK and is now incorporated into our Cancer registration systems, with its potential value being enhanced by linkage to a wide variety of other data sources.References 1. Lung cancer survival and stage at diagnosis in Australia, Canada, Denmark, Norway, Sweden and the United Kingdom: a population-based study, 2004-2007. Walters S, Maringe C, Coleman MP, et al. Thorax, 2013;68:551-564 2. Coleman MP, Forman D, Bryant H, et al.; ICBP Module 1 Working Group. Cancer survival in Australia, Canada, Denmark, Norway, Sweden, and the UK, 1995-2007 (the International Cancer Benchmarking Partnership): an analysis of population-based cancer registry data. Lancet,2011;377:127–138 3. National comparisons of lung cancer survival in England, Norway and Sweden 2001- 2004: differences occur early in follow-up Holmberg L, Sandin F, Bray F, et al. Thorax, 2010;65:436-441. 4. Elliss-Brookes L, McPhail S, Ives A, et al. Routes to diagnosis for cancer – determining the patient journey using multiple routine data sets. Br J Cancer 2012;107(8):1220-6. 5. Recent trends in resection rates among non-small cell lung cancer patients in England. Riaz SP, Linklater KM, Page R, et al. Thorax, 2012;67(9):811-4. 6. Variation in radical resection for lung cancer in relation to survival: population-based study in England 2004-2006. Riaz SP, Lüchtenborg M, Jack R, et al.Eur J Cancer 2012;48:54-60 7. Exploring Variations in Lung Cancer Care Across the UK - The “Story So Far” for the National Lung Cancer Audit. P Beckett, I Woolhouse, R A Stanley, M D Peake. Clinical Medicine, 2012; 12:4-8 8. Health & Social Care Information Centre. The National Lung Cancer Audit Report 2012. Available at: https://catalogue.ic.nhs.uk/publications/clinical/lung/nati-clin-audi-supp-prog-lung-canc-coho-2011/clin-audi-supp-prog-lung-nlca-lap-2012-rep.pdf 9. The effects of increased provision of Thoracic Surgical Specialists on the variation in lung cancer resection rate in England. Lau KK, Rathinam S, Waller DA & Peake M.D. J Thoracic Oncology, 2013;8(1):68-72 10. Lung Cancer Smart Map, available at: www.roycastle.org/lungcancermap

Abstract
At its strategic review in September 2011 the IASLC undertook a thorough overall of its existing committee structure. As the membership of the organisation expanded and its influence globally was increasing it was felt that it was appropriate for the organisation to move beyond its traditional scientific and educational roles to embrace fundamentally important aspects of care such as advocacy, the involvement of nurses and allied professionals and tackling the scourge of tobacco dependency. There were already several established advocacy organisations, especially in North America, the UK and Australia. Our aim was not to compete but to network with these bodies to ensure that advocacy issues were included in the discussions of every one of our other committees and at every educational activity organised by the IASLC and its partners. We are thus delighted that at this World Conference, the first since our committee was established, we have high profile sessions such as this, in collaboration with the Global Lung Cancer Coalition, and those held yesterday, organised by the Australian Lung Foundation and other partners. From 2015 our World Conferences will be held annually and our programme of regional meetings in Europe, Asia, North and South America will continue. We hope that the IASLC meetings and our journal, the Journal of Thoracic Oncology, will be seen as the appropriate platform for issues such as patient advocacy, specialist nurse care, smoking cessation and tobacco control to be aired. The members of the IASLC are specialists in every research and clinical care aspect of thoracic oncology, working to improve the outcomes for lung cancer and other thoracic malignancies. You, the advocates, are our link to patients who need, deserve and demand better care. Let us work together to the benefit our patients.

Background
Lung cancer is the leading cause of cancer-deaths throughout the World. Cigarette smoke (CS) is the strongest risk factor of lung cancer. Cigarette smoking and exposure to environmental tobacco smoke account for 90% of lung cancer cases, and smokers have a 20-fold increased risk of death from lung cancer compared to non-smokers. Unregulated cell proliferation together with suppressed apoptosis is a contributory factor for lung-carcinogenesis. However, the carcinogenic mechanism of cigarette smoking is not well understood. This is particularly because CS is a complex mixture of about 4000 compounds. We consider that identifying the risk factor(s) in CS and its prevention might be a novel way to prevent lung cancer.

Methods
Cytotoxicity was evaluated by the MTT assay. Cell cycle analysis was performed by propidium iodide (PI) staining followed by flow-cytometry. Apoptosis was assessed by AnnexinV- PI staining followed by flow-cytometry, phosphorylation of p53 and activation (cleavage) of caspase 3. Reactive Oxygen Species (ROS) production was detected by 2’, 7’-dichlorodihydrofluorescein diacetate (H~2~DCFDA) using confocal microscope. Cell proliferation was assessed using “In Situ Cell Proliferation Kit, FLUOS” (Roche Applied Science, Germany). DNA double-strand break was detected using “OxiSelect DNA Double Strand Break (DSB) Staining Kit” (CELL BIOLABS, INC.).

Results
We have identified p-benzoquinone (p-BQ) as a major risk factor that is derived from CS. p-BQ has a biphasic-nature as evidenced by MTT assay, AnnexinV-PI staining, cell cycle analysis and BrdU-incorporation assay. Low concentrations of p-BQ mimicked CS-induced proliferation of cultured lung adenocarcinoma cells (A549) as well as normal human primary small airway cells (ATCC[®] PCS-301-010[™]). On the contrary, high concentrations of CS/p-BQ resulted in cell death caused by oxidative stress and apoptosis. No such cell death was observed with low concentrations of CS/p-BQ. Coimmunoprecipitation and immunoblot experiments indicated that p-BQ-induced proliferation was mediated via aberrant phosphorylation of EGFR that lacked c-Cbl mediated ubiquitination and degradation. This resulted in prolonged EGFR signaling leading to persistent activation of Ras (a potent oncoprotein), the downstream survival and proliferative signaling molecules Akt and ERK1/2, as well as the transcription factors c-Myc and c-Fos. It is known that patients with lung cancer generally have a smoking history of more than 30-40 years. We therefore exposed A549 cells repeatedly to CS/p-BQ for 2 months. Repeated exposure of AECS/p-BQ generated high levels of DNA double-strand breaks in A549 cells that might lead to genomic instability as well as mutation of different proto-oncogenes and tumor suppressor genes – the hallmark events in cancer. In addition, CS/p-BQ altered the acetylation pattern of different histone epigenetic marks, thereby regulating the transcription of several candidate genes responsible for proliferation and apoptosis. Both anti-p-BQ antibody and vitamin C (a strong reductant of p-BQ) prevented CS/p-BQ-induced proliferation of lung cells.

Conclusion
Despite major advances in the treatment and management of lung cancer, most patients eventually die. Consequently, newer approaches such as chemoprevention(s) are necessary. We consider that prevention of CS-induced proliferation of lung cells by vitamin C and/or anti-p-BQ antibody may provide a novel intervention for preventing initiation of CS-induced lung cancer.

Background
Several mechanisms have been suggested for paclitaxel resistance in cancer cells, including overexpression of the multidrug transporter gene, ATP-binding cassette, sub-family B, member 1 (ABCB1), and the presence of a point mutation in the β-tubulin gene at the paclitaxel-binding site. However, the mechanisms underlying resistance to this agent have not yet been completely elucidated.

Methods
Three human lung cancer cell lines, II18, A549, and RERF-LC-KJ, were analyzed; their 50% inhibitory concentrations of paclitaxel were -8.33, -7.69, and -4.51 logM, respectively. The cell lines did not have any β-tubulin mutation. We evaluated the expression levels of ABCB1, intracellular accumulation of paclitaxel, paclitaxel-induced stabilization of microtubules, and intracellular localization of Oregon Green[®] 488-conjugated paclitaxel in these cell lines. Moreover, we prepared paclitaxel conjugated ferriteglycidyl metacrylate (FG) beads to purify paclitaxel-binding proteins from whole cell lysates of these cells.

Results
The ABCB1 expression level was strongly correlated to intracellular [[3]H]-paclitaxel accumulation (r[2] = -0.804) but was not related with paclitaxel resistance. The changes in the quantities of polymerized tubulin and acetylated tubulin after paclitaxel exposure were not related to paclitaxel resistance. Differences were observed between the intracellular localization of paclitaxel in RERF-LC-KJ, the most resistant cell line, and in the other 2 cell lines. The use of Oregon Green[®] 488-conjugated paclitaxel enabled visualization of not only the normal microtubule formation in the partial cells but also the aggregated vesicle formation in RERF-LC-KJ cells; aggregated vesicle formation was not remarkable in the other cell lines. Affinity purification by paclitaxel immobilized beads revealed several specific bands in RERF-LC-KJ; these bands were not revealed in the other cell lines.

Conclusion
We propose that paclitaxel resistance is associated with intracellular compartments in which paclitaxel accumulates and paclitaxel-binding proteins expressed specifically in resistant cell line.

Background
Primary and acquired resistance to platinum agents such as cisplatin have become a major obstacle in the management of lung cancer patients, in particular non-small cell lung cancer (NSCLC). The availability of comprehensive genomic data on DNA copy number changes in cisplatin resistant NSCLC is limited, and little is known about the genes driving this chemoresistant phenotype. Detailed molecular portraits through high density genomic DNA arrays and genome wide mutation profiles will aid in understanding the molecular basis of individual responses to new molecular therapies.

Methods
A panel of cisplatin resistant (CisR) NSCLC cell lines were recently generated and characterised in our laboratory. In this study, high resolution array-based comparative genome hybridization (aCGH) was performed on a panel of five CisR NSCLC cell lines to examine DNA copy number gains, losses and amplifications. Cellular DNA (500ng) and control DNA was differentially labelled with Cy3 and Cy5, respectively. Labelled test (4µg) and reference DNA were hybridised to a 12-plex 135,000 probe array (Roche NimbleGen) for 18 hours in a MAUI hybridisation station (BioMicro Systems) at 42°C. Fluorescent intensities were extracted and log 2 ratios calculated and normalized using NimbleScan Software (version 2.4). Chromosomal aberrations were identified using the CGH-segMNT algorithm (NimbleScan 2.4). A significance log 2 ratio threshold of <−0.25 for loss and >0.25 for gain was used to identify DNA copy number imbalances. For mutational analysis, Sequenom®, a mass-spectrometry-based SNP genotyping technology, was used to identify mutations in our panel of resistant cell lines. Using a literature search and the Catalogue of Somatic Mutations in Cancer (COSMIC) database, a mutation panel was identified for the detection of 547 frequently occurring and potentially clinically relevant mutations in 49 cancer-related genes. Some of these include KRAS, NRAS, BRAF, PIK3CA, MET, CTNNB1, STK11, AKT, and EGFR. Matrix chips were analysed on a Sequenom® MassArray MALDI-TOF system. Visual inspection and Sequenom® typer software were used to perform genotyping based on mass spectra.

Results
Using aCGH arrays, a number of gains, losses and amplifications of various chromosomes were found across a panel of CisR cell lines, relative to corresponding PT cells. The most frequently occurring of these chromosomal imbalances included gains, losses and homozygous deletions on chromosome 3 (MOR, A549, H1299), deletions and amplifications on chromosome 7 (H460, A549, H1299) and deletions and gains on chromosome 15 (MOR, A549, H1299) and chromosome X (MOR, H460, SKMES-1). Deletions on chromosomes 4, 6, 11, 12, 14, and amplification of chromosome 5, were also identified among the different CisR cell lines. The collation and analysis of data arising from mutation analysis of CisR cells using the Sequenom® platform are currently being completed.

Conclusion
High-resolution mapping of chromosomal imbalances may offer potential in the identification of genes, including oncogenes and tumour suppressor genes, affected by these imbalances. These findings may further contribute to the delineation of the genomic profile of cisplatin resistant lung cancer, and offer perspectives for the identification of genes contributing to this disease phenotype and in assessing the response to new molecular treatments.

Background
Promoter hypermethylation plays an important role in lung cancer carcinogenesis by silencing key tumor suppressor genes (TSG). Reversing the hypermethylation of TSG by direct aerosolized administration of a demethylating agent may have a potential to inhibit lung cancer growth and development. This study examines the therapeutic potential of aerosolized azacytidine (Aza) in the orthotopic mice model of human NSCLC.

Methods
Vidaza® (the clinical grade Aza formulation for IV administration) was dissolved into sterile water for injection and aerosolized in a clinical standard aerosol system. The aerodynamic size, the lung deposition, and the Aza level in the lung and circulation of mice were measured by previously described methods. The demethylation and gene reactivation functions of aerosolized Aza were detected by qPCR methylation array and western blotting assay in the human non-small cell lung cancer (NSCLC) tumor tissues from the orthotopic intratracheally inoculated xenograft models in nude mice. The therapeutic efficacy and toxicity of the aerosolized Aza were also evaluated in mice. Mice treated with an intravenously administered Aza with clinically equivalent dose and schedules were used as a comparison.

Results
The aerosolized Aza is an appropriate pharmaceutical inhalation formulation with size distribution of about 80% of droplets from 0.1 to 5 micron. This dynamic size range ensures the aerosol droplets depositing in the lower airway as indicated by the recovery of approximately 80% Aza from the lung tissue 20 min after the aerosol administration. In efficacy and toxicity studies, aerosol administration of Aza significantly prolonged the survival of nude mice with intratracheally inoculated human NSCLC tumors. The %-increased in life span was 5- to 10-fold higher than that of a systemic treatment of Aza at a clinically equivalent dose. The aerosolized Aza, at a potentially therapeutic dose, did not cause any detectable lung toxicity or systemic toxicity (myelosuppression). After the aerosolized Aza treatment, the lung tumors were resected and the methylation levels of the 24 promoters driving the lung cancer related tumor suppressor genes (TSGs) in the lung tumors were examined by qPCR methylation array. The aerosolized Aza significantly reduced the methylation level in 9 of the 24 promoters examined. This demethylating effect also resulted in the gene reactivation at the protein level in several tested genes.

Conclusion
In our orthotopic NSCLC model, aerosolized Aza was well tolerated with good drug delivery to bronchial epithelium at non-cytotoxic doses. The pharmacodynamic effect of the TSG demethylation and reactivation was observed. Interesting therapeutic efficacy of prolonging survival was observed in our model from aerosolized 5-Aza over intravenous administration in mice. The phase I clinical trial of aerosolized Aza with pharmacodynamic endpoints will be conducted. Acknowledgement: Supported by a NIH (NCI) grant 5R01CA154755-02

Background
Squamous cell carcinoma (SCC) is the second most common form of lung cancer, a disease primarily observed in smokers. Studies have shown that preneoplastic dysplasias are the precursors for SCC. However, only a subset of these lesions progress to invasive carcinoma and predicting the fate of individual lesions is difficult. Understanding the processes associated with the development of dysplasia would therefore have significant impact on preventative therapy for high-risk lesions. To this goal we have studied N-nitroso-tris chloroethyl urea (NTCU) model of premalignant murine squamous dysplasia. Bi-weekly topical application of NTCU for 32-weeks caused endobronchial dysplasias that were pathologically similar to dysplasias encountered in human smokers. In the current study we used NTCU model to identify the events that precede dysplastic changes in murine airways.

Methods
Immunofluorescence analysis of NTCU treated airways showed abundant expression of keratin 5 positive (K5+) basal cells. In normal mouse respiratory epithelium K5+ cells are confined only in the trachea and are absent in the bronchial epithelium. Ectopic expressions of K5+ cells in the mouse bronchial epithelium therefore suggested a role for tracheal basal cells in the pathogenesis of NTCU-induced dysplasia. To explore this possibility we analyzed tracheal and bronchial histology after vehicle and 20mM NTCU treatment at 4, 8, 12, 16, 25 and 32 weeks.

Results
Low-grade dysplasia of the tracheal epithelium was observed as early as 4 weeks of NTCU exposure. On the contrary, squamous metaplasia or low-grade dysplasia of the bronchial epithelium was not seen until 25 weeks. Morphometric analysis of immunostained tracheal tissue showed a time-dependent increase in the numbers of K5+ cells and a concomitant loss of cells expressing Clara cell secretory protein (CCSP) and ciliated cells. We have shown previously that injury to the trachea upregulates expression of keratin 14 (K14) in basal cells. Consistent with this phenomenon, NTCU exposure showed a time-dependent increase in the number of K5/K14 dual-positive basal cells. To understand the mechanism by which NTCU treatment mediates ectopic expression of basal cells in the lung, we used flow-cytometry to analyze cell-surface markers expressed by tracheal basal cells. These studies revealed a time-dependent decrease in the level of integrin a6b4 (CD49f). CD49f is a hemidesmosomal protein that facilitates attachment of basal cells to the basement membrane. These findings suggested that NTCU treatment might promote migration of tracheal basal cells by destabilizing their adherence to the basement membrane.

Conclusion
Collectively, our results showed an early involvement of tracheal basal cells in the generation of dysplastic lung lesions in a murine model of SCC. By moving the focus proximal, we have discovered a realm of biological developments in the trachea that had not been previously examined. Further research of these processes will aid in the elucidation of dysplastic development in SCC.

Abstract not provided

Background
Activation-induced cytidine deaminase, AID, is an enzyme required for somatic hypermutation and class-switch recombination which diversify immunoglobulin genes and causes DNA mutations and strand breaks. Uncontrolled expression of AID is cytotoxic. AID transgenic mice invariably develop lung lesions morphologically similar to human atypical adenomatous hyperplasia (AAH), which can be a precursor of bronchioloalveolar carcinoma. About 10 % of these mice develop visible lung tumor including adenocarcinoma. However, the relationship between this mouse AAH-like lesion (MALL) and lung cancer is unclear. In the present study, we examined MALLs to elucidate their characteristics and involvement in lung cancer.

Methods
p53, KRAS, and EGFR mutation status in each laser-microdissected MALL were analyzed. The expression of airway epithelial cell markers and lung alveolar regeneration markers in MALLs were investigated by immunohistochemistry. Apoptosis assay were performed in murine lungs. For cell proliferation assay, AID Tg mice were received a daily intraperitoneal injection of 1 mg 5-ethynyl-2’-deoxyuridine (EdU) for 7 days. Then, mice were studied 1 day (day 1) or 3 weeks (day 20) after the last injection.

Results
We found mutations of p53 in 10.5% of MALLs (4/38), but no mutations of KRAS and EGFR. In immunohistochemistry, MALLs were partially positive for SP-C (lung alveolar type II cell-specific marker), but negative for CC-10 (clara cell-specific marker) and podoplanin (lung alveolar type I cell-specific marker). Frequency of apoptotic cells among lung alveolar wall cells was significantly higher in AID transgenic mice than in wild type mice. Moreover, frequency of Edu-positive MALL decreased significantly at day 20 compared to that at day 1. The expressions of p63, cytokeratin 5/14, and E-cadherin/Lgr6, the recently described markers of lung alveolar regeneration, were observed in MALLs.

Conclusion
Based on these observations, we speculate that MALL is a regenerating tissue compensating for alveolar epithelial cell loss caused by AID-induced genotoxic stress. AID expression in such regenerating tissue should predispose cells to malignant transformation by its mutagenic activity. AID transgenic mice could be a mouse model that may provide the link between lung regeneration after injury and the development of lung cancer.

Background
Interferon-γ (IFN-γ) has been well documented to have multiple functions including anti-tumorigenesis. Liver X receptors α and β (LXR) are members of ligand- activated nuclear receptor superfamily. LXR can be ac- tivated by natural ligands of some oxysterols and by numerous synthetic ligands (e.g. T317).The LXR-induced ABCA1 expression promotes free cholesterol efflux from macrophages thereby inhibiting the development of atherosclerosis. LXR has also been demonstrated the important functions in immune system . Here we tested the hypothesis that IFN-γ is a target for LXR activation, and the induction of IFN-γ expression by LXR can lead to inhibition of tumor growth.

Methods
C57 wild type or IFN-γ-/- mice (same background) in two groups were s.c. injected with2×10 5 LLC1 cells (ATCC) in the right flank to establish a carcinoma tumor model. For carcinogen-induced tumor: at the first week, C57 mice were i.p. injected with MCA (15 mg/kg body); from the second week, the mice were i.p. weekly injected with BHT for 6 weeks. The doses of BHT were: 1st injection, 150 mg/kg body weight; 2nd to 6th injections, 200 mg/kg.

Results
In this study, we observed that LXR ligand (T317) induced IFN-γ protein expression which was associated with increased mRNA and secreted protein levels in culture medium. In vivo,T317 increased wild type mouse serum IFN-γ levels and IFN-γexpression in tissues. T317 inhibited the inoculated LLC1 tumor growth in wild type mice but not in IFN-γ knockout (IFN-γ-/-) mice. In addition, T317 displayed inhibitory and therapeutic effects on 3-methylcholanthrene/butylated hydroxytoluene (MCA/BHT)-induced pulmonary carcinomas. T317 inhibits the growth of inoculated LLC1 tumor in wild type mice but not in IFN-γ-/- mice Wild type or IFN-γ-/- mice. Figure 1 T1317 inhibits MCA/BHT-induced pulmonary tumors Figure 2

Conclusion
Our study demonstrates IFN-γ is a target gene of LXR activation. LXR-induced IFN-γ expression can be attributed, at least in part, to the anti-tumorigenic properties of LXR.

Background
Regular exercise has been shown to improve the quality of life in patients undergoing treatment for lung cancer and has been associated with reductions in cancer-specific mortality in patients with colon and breast cancer. The direct effects of cardiovascular exercise on lung cancer tumor biology, however, remain unknown. This study evaluated cardiovascular exercise in a mouse model of lung adenocarcinoma, including clinically relevant endpoints such as lung tumor growth and distant metastasis. Furthermore, biologic mechanisms of action underlying clinical findings were also explored.

Methods
Luciferase-tagged A549 lung adenocarcinoma cells were injected through the tail vein of nude male mice. Mice underwent weekly bioluminescent imaging until lung tumors were clearly identified. After lung tumors were identified, mice were randomized to daily wheel-running versus no wheel-running. Mice were imaged weekly. After 4 weeks, all mice were euthanized and lung tumors were harvested. Western blots and immunohistochemistry (IHC) studies were undertaken on tumor tissue to identify potential differences in protein expression levels in exercise versus sedentary mice.

Results
Exercising mice tumors grew significantly more slowly relative to sedentary mice (figure 1). There was no change in development of metastatic lesions between the two groups. Protein analysis by Western blot or IHC demonstrated increased p53 protein levels in exercising mice relative to sedentary mice, as well as increased mediators of apoptosis including Bax, Bak and active caspase 3 in tumor tissues (figure 2 and data not shown). No normal tissue toxicity in other organs was observed in the two groups of mice. Figure 1. Figure 1 Figure 2. Figure 2

Conclusion
Daily cardiovascular exercise appears to mitigate growth of lung adenocarcinoma tumors by activation of p53 tumor suppressor function and increased apoptosis.

Background
Intralymphatic tumors in the extratumoral area are considered to represent the preceding phase of lymph node (LN) metastasis. The aim of this study was to clarify the biological properties of intralymphatic tumors susceptible to the development of LN metastasis, with special reference to the expression of cancer initiating/stem cell (CIC/CSC) markers in cancer cells and the number of infiltrating stromal cells.

Methods
A total of 2087 consecutive adenocarcinoma patients underwent complete resections and systematic LN dissections between May 1998 and December 2012 were identified. Among these cases, we selected those that had been diagnosed as having lymphatic permeation in the extratumoral area (n = 107). We examined the expression levels of CIC/CSC related markers including ALDH1, OCT4, NANOG, SOX2 and Caveolin-1 in the intralymphatic and primary tumor cells to evaluate their relationship to LN metastasis. The number of infiltrating stromal cells expressing CD34, α-smooth muscle actin, and CD204 were also evaluated. Moreover, we measured E-cadherin expression to identify a correlation between CIC/CSC related molecules and epithelial - mesenchymal transition (EMT) process.

Results
Intrathoracic LN metastases were detected in specimens from 86 patients (80%). Among the intralymphatic tissues, low ALDH1 expression in cancer cells, high SOX2 expression in cancer cells, and a high number of CD204(+) macrophages were independent predictive factors for LN metastasis (odds ratio [95%CI] = 3.25 [1.11 – 9.82], P = 0.031 for ALDH1; 4.09 [1.38 – 13.4], P = 0.011 for SOX2; and 3.45 [1.16 – 11.4], P = 0.026 for CD204(+) macrophages). However, in the primary tumors, only a high SOX2 expression level in the cancer cells within the primary tumor was significantly correlated with LN metastasis (p=0.008); ALDH1 expression in the cancer cells and the number of CD204(+) macrophages were not correlated with LN metastasis (P = 0.230 and P = 0.088, respectively). Among these factors, only low ALDH1 expression in intralymphatic cancer cells was significantly correlated with the farther spreading of LN metastasis (mediastinal LN, pN2) (P = 0.046) and higher metastatic LN ratio (metastatic/resected) (P = 0.028). Intralymphatic cancer cells expressing low ALDH1 levels exhibited lower E-cadherin expression levels than cancer cells with high levels of ALDH1 expression (P = 0.015). The expressions of other CIC/CSC related markers, including OCT4, NANOG, SOX2, and Caveolin-1, were not correlated with the E-cadherin expression.

Conclusion
Intralymphatic cancer cells expressing low levels of ALDH1 and infiltrating macrophages expressing CD204 have a critical impact on LN metastasis. Especially, intralymphatic cancer cells expressing low levels of ALDH1 might acquire a metastatic aggressiveness by the EMT process. Our study highlighted the significance of evaluating the biological properties of intralymphatic tumors for tumor metastasis and suggested the possibility of usefulness as a new molecular target, especially as an adjuvant therapy.

Background
Liver metastases appear in about 30% of non-small cell lung cancer (NSCLC) patients during the disease course with a dramatic impact on clinical outcome and quality of life. TME gene expression might be crucial for allowing tumor cells to migrate and spread to the liver. However, no candidate genes have ever been proposed as responsible for this process. Id1, a member of the gene signature that facilitates breast cancer cells to disseminate to the lungs, might be determinant for NSCLC LM development.

Methods
For the first time, a mouse model of LM from lung cancer was developed. Two cohorts of mice were compared; C57BL/6 females vs. Id1-knockout (KO) females (gently provided by Dr. Benezra, MSKCC, New York). Lewis lung carcinoma cells (500,000) were selected for intrasplenic injection. Five minutes after tumor cells injection all mice were splenectomized to avoid bulky flank tumor formation. Mice were closely followed after tumor cells inoculation. Weekly FDG-micro-positron emission tomography (PET) scans were performed to study liver metastasis formation in both groups of mice. Animals were sacrificed at the time of LM development. Liver metastatic lesions were obtained for RNA extraction (Qiagen kit). A microarray gene expression analysis (Affymetrix) with the support of Ingenuity Pathways Analysis (IPA) was performed to evaluate the potential impact of Id1 genotype on the regulation of genes mediating proliferation, invasion, migration, angiogenesis and metastasis in LM.

Results
The first week after tumor cells intrasplenic injection, FDG-PET scans showed no liver metabolic uptake in any of the mice. By week 2 however, 70% of C57BL/6 mice and 10% of Id1-KO mice showed clear LM by FDG-PET (p=0.02). Three weeks after intrasplenic tumor cells injection, 100% of C57BL/6 animals showed LM compared to 30% of Id1-KO mice (p=0.03). In addition, 50% of Id1-KO mice remained LM-free 4 weeks after tumor cells injection. No other metastatic sites were indentified at the time of necropsy. In the mircroarray gene expression analysis, only a set of 50 out of nearly 900 genes appeared upregulated in the LM of Id1-KO mice compared to C57BL/6 animals whereas the rest of the genes were downregulated. Interestingly, amphiregulin, caveolin-1, aurora kinase B, MMP3, Hsp90aa1, Cdk1, Hif1a, Cyclin D2 were among the significantly downregulated genes in the Id1-KO LM.

Conclusion
A novel mouse model for liver metastasis from lung cancer has been developed allowing the study of this complex and unexplored process. Id1 gene expression seems to be a key mediator of the development of liver metastasis from lung cancer in this in vivo model. The absence of Id1 expression in the tumor microenvironment of Id1-KO mice was sufficient to significantly delay and impair the metastatic process of lung cancer tumor cells to the liver. Id1 might be able to modulate LM through a direct downregulation of genes involved in proliferation, invasion, migration, angiogenesis and metastasis. This study has been partially funded by "UTE project CIMA" and an ISCIII-FIS grant 2011.

Abstract not provided

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Abstract not provided

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Abstract not provided

Background
It is reported that epidermal growth factor receptor (EGFR) mutation is frequent in non-small cell lung cancer (NSCLC) patients who are presenting with miliary intrapulmonary carcinomatosis. We often encountered disseminated carcinomatosis as well as intrapulmonary carcinomatosis. This study aims to investigate the clinical characteristics of patients with miliary intrapulmonary or disseminated carcinomatosis.

Methods
Patients with advanced NSCLC who harbor EGFR mutation and presented with miliary intrapulmonary or disseminated carcinomatosis were enrolled respectively, from September 2005 to January 2011. EGFR mutations in exons 18-21 were confirmed by pyroseqeuncing method after genomic DNA was extracted from paraffin-embedded tissue specimens. Clinical characteristics, responses to treatment and outcome were collected from medical records.

Results
Histology of sixty-four patients with NSCLC who have EGFR mutation revealed adenocarcinoma. The most frequent mutation was in-frame deletions in exon 19 (n=44, 68.7%). An arginine-for-leucine substitution at amino acid 858 (L858R) and point mutation in exon 18 (G719A) were detected in 19 (29.7%) and 1 (1.7%) patient, respectively. Patients with miliary intrapulmonary or disseminated carcinomatosis were more common in female (80.0% vs. 55.1%, p=0.084), non smoker (80.0% vs. 53.1%, p=0.063), and in-frame deletions at exon 19 (86.7% vs. 63.3%, p=0.087), however there were no significant difference statistically. They showed relatively shorter progression free survival (PFS) to EGFR tyrosine kinase inhibitors (median PFS 9.7 vs, 12.8 months, p=0.003) and poorer overall survival (median OS 15.9 vs. 29.0 months, p=0.077) compared to patients without miliary metastasis. In multivariate analysis, higher metabolic tumor volume (MTV) in PET-CT was confirmed to be an independent predictor of shorter overall survival, when considered together with tumor stage, gender and smoking status (hazard ratio for MTV: 1.001; p = 0.027).

Conclusion
The data indicate that NSCLC presenting miliary intrapulmonary or disseminated carcinomatosis were more common in female, adenocarcinoma, non smoker and in-frame deletions in exon 19 was comparatively frequently detected in those patients, however there were no statistically significant difference. PFS to EGFR tyrosine kinase inhibitors was less in patients with miliary intrapulmonary or disseminated carcinomatosis and overall survival was poorer compared to patients without miliary metastasis. Poor clinical course of these patients might be associated with high tumor burden represented by metabolic tumor volume or total lesion glycolysis.

Background
Detection of mutations with plasma DNA isolated from peripheral blood is an alternative method of biopsy. The gatekeeper T790M mutation of EGFR has been observed in half of patients who acquired resistance to EGFR tyrosine kinase inhibitor (EGFR-TKI). Considering that majority of lung cancer recurrence occurs as distant metastases, determination of T790M using a non-invasive mutation detection system with plasma DNA would be useful. We recently developed a novel non-invasive, fully-automated monitoring system, MBP-QP (mutation-biased PCR and quenching probe) method, to detect T790M using plasma DNA. The detection limit was two copies of control plasmid and 0.2 ng of genomic DNA, the T790M mutation was detected in plasma DNA from 53% of lung adenocarcinoma patients who acquired resistance in the previous retrospective study. Compared with the other methods such as PNA-LNA PCR clamp, the cycleave PCR technique, and digital PCR, the MBP-QP method is simple, sensitive, and reflective of clinical course. To determine the usefulness of the MBP-QP method for monitoring T790M during treatment of EGFR-TKI, a prospective clinical study has been performed.

Methods
This is a prospective, multicenter observational study involving lung adenocarcinoma patients carrying EGFR activating mutations such as L858R and exon 19 deletions treated with EGFR-TKI. Primary objective was to determine whether T790M was detected with plasma DNA at the time point of progressive disease (PD), and the secondary objective was correspondence of T790M with plasma and cancer specimens. The association between detection of T790M and effect of EGFR-TKI were also investigated as the exploratory objective. Plasma DNA was isolated from the patients before treatment of EGFR-TKI, every four months during treatment, at the time of occurrence of PD, and after two courses of post-chemotherapy.

Results
Ninety lung adenocarcinoma patients treated with EGFR-TKI were enrolled, in whom 51% of L858R and 49% of exon 19 deletions were determined in tumor specimens before treatment. Most of the patients, 92.1%, had adenocarcinoma. 62% (55/90) was stage IV, and 29% (26/90) had postoperative recurrent disease. 43% (38/90) of the patients were treated with EGFR-TKI as the first-line therapy, and the rest of them were previously treated including 17% of the patients experienced with EGFR-TKI. T790M was detected in 23% (21/90) among the entire patients. Forty patients showed PD two years after beginning of this trial, and T790M was detected in 13 patients among the patients who acquired resistance to EGFR-TKI; the frquency of T790M positive among the patients with PD was 32.5% (13/40). Although T790M was temporarily detected during treatment of EGFR-TKI in 8 patients who were still responded to EGFR-TKI, is disappeared after that.

Conclusion
T790M was detected in plasma DNA isolated from lung cancer patients whose diseases were progressed. Continuous detection of T790M in plasma DNA seemed to be related with occurrence of PD.

Background
Treatment allocation by EGFR mutation and maintenance therapy are two new standards for patients (pts) with metastatic non-small cell lung cancer (NSCLC). This multicenter phase II trial (NCT01116219) for the first time prospectively tested pemetrexed and bevacizumab maintenance therapy in pts with EGFR wild type NSCLC, and included repeat biopsy at progression to study molecular mechanisms of drug resistance. Pts with EGFR mutation were treated with erlotinib and bevacizumab, based on the results of the previous SAKK19/05 trial.

Methods
100 pts were enrolled with metastatic nonsquamous NSCLC, sufficient material for mutation analysis and translational research, and consent to repeat biopsy at progression. Pts with EGFR wild type received 4 cycles of bevacizumab 7.5mg/kg, cisplatin 75mg/m2 (or carboplatin AUC5) and pemetrexed 500mg/m2 every 3 weeks, followed by maintenance therapy with bevacizumab and pemetrexed until progression. Pts with EGFR mutation received bevacizumab 7.5 mg/kg every 3 weeks and erlotinib 150 mg daily until progression. Pts were followed by CT-scan every 6 weeks and repeat biopsy was performed at progression. The primary endpoint was progression free survival (PFS) at 6 months. For an unpromising PFS at 6 months rate of ≤20% and a promising rate of ≥35%, 77 patients with EGFR wild type were needed to reach a power of 90% and an alpha level of 5%. Secondary endpoints were median PFS, overall survival (OS), best response rate of CR+PR (RECIST), and further biomarkers including KRAS, thymidylate synthase (TS), and multigene expression.

Results
Seventy-seven pts with EGFR wild type and 20 pts with EGFR mutation were evaluable, 3 pts were not evaluable. Pts on bevacizumab and chemotherapy received on average 9 cycles (range 1-25). No unexpected toxicities were observed. PFS at 6 months was 45.5% (CI: 34.1%, 57.2%), median PFS was 6.9 (CI: 4.6, 8.3) months, OS was 12.1 (CI: 8.7, 14.7) months, and best response rate of CR+PR was 62%. Sixteen pts remain on treatment. Repeat biopsy at progression was successful in 31 of 39 (79%) of patients on trial treatment, and except for one transient pneumothorax, no relevant complications occurred. KRAS mutation was associated with poor overall survival (HR 2.0, CI: 1.05, 3.88; P=0.03), but not with PFS or best response. Pts on bevacizumab and erlotinib received on average 16 cycles (range 6-37). PFS at 6 months was 70.0% (CI: 45.7%, 88.1%), median PFS was 14.0 (CI: 8.8, NA) months, median OS is not yet reached, best response rate of CR+PR was 70%, 11 pts remain on treatment. Further analysis of serial serum and tumor samples is ongoing.

Conclusion
Compared with the previous POINTBREAK trial of pemetrexed and bevacizumab maintenance in genetically unselected pts, this trial demonstrates almost identical survival rates in pts with EGFR wild type. KRAS mutation was prognostic, repeat biopsy at progression was feasible, and laboratory analysis is ongoing to validate TS and to develop a predictive gene signature. Firstline therapy with erlotinib and bevacizumab is promising in pts with EGFR mutation, and this combination is further tested in the ongoing ETOP 2-11 BELIEF trial.

Background
The IPASS study reported that in a clinically selected lung cancer patient population (East Asian, light ex-/nonsmokers with adenocarcinoma) gefitinib (G) provided superior progression-free survival (PFS) than chemotherapy with carboplatin/paclitaxel; however, the benefit was restricted to patients with epidermal growth factor receptor gene (EGFR)-mutant tumors whereas patients with wild-type (WT) tumors had inferior outcomes. Pemetrexed, in combination with cisplatin, (PC) has demonstrated improved efficacy in first-line treatment of nSqNSCLC and is a preferred chemotherapy choice. The primary objective was to compare PC induction therapy followed by G as maintenance therapy to G monotherapy, in terms of PFS, as first-line treatment in a similar “IPASS” patient population.

Methods
Patients with unknown EGFR mutation status (N=236) were randomized 1:1 to PCG treatment for 6 cycles or G. Patients on Arm A without progressive disease after 6 cycles received G maintenance therapy. Stage IIIB/IV nSQ NSCLC, light ex-smokers or never-smokers, and ECOG PS 0-1 patients with no prior systemic therapy were eligible. Primary endpoint analysis was conducted using a Wilcoxon test after 169 PFS events. This assessment provided 80% power if the true hazard ratio (HR) was 0.65. Tissue samples from consenting patients were analyzed for EGFR mutation status.

Results
Baseline characteristics were balanced across treatment arms. One-hundred-forty-one patients provided tissue for EGFR mutation analysis (59.7%). Mutation status was determined for 74 samples (52.5%);50/74 samples (67.6%) had mutations (mutation type: EX19_DEL, n=25; L858R, n=23; other, n=2). The primary analysis of PFS showed no significant difference between treatment arms (Wilcoxon p=0.217). The unadjusted HR was 0.85 (95% CI: 0.63, 1.13). During most of the study period, the KM curve for PC remained above the G curve. In a prespecified subgroup analysis, EGFR-by-treatment interaction was statistically significant (p=0.008), showing treatment effect significantly differed by EGFR mutation status. The HR for PFS favored PC in both EGFR-mutated and EGFR-WT patients, but the magnitude of benefit was greater in EGFR-WT patients [EGFR-mutated patients HR=0.83 ([95% CI: 0.42, 1.62], p=0.585); EGFR-WT HR 0.18 ([95% CI: 0.06, 0.51], p=0.001)]. HRs for ITT and EGFR-mutated patients should be interpreted with caution as they were not constant. Arm A had more patients with ≥1 possibly drug-related CTCAE grade 3/4 TEAEs but similar rates of all-grade TEAEs during induction. Selected grade 3/4 or all-grade TEAEs which occurred significantly more included anemia, neutropenia, emesis, and neuropathy in Arm A and AST/ALT elevations, diarrhea, pruritus, and skin rash in Arm B. The toxicity profile was similar in both arms during the G maintenance period.

Conclusion
In the ITT population, the PFS difference was not statistically significant. In the biomarker assessable population, results are consistent with the existing consensus that patients with WT EGFR do not benefit with front-line EGFR TKI treatment. Overall, the results show that identification of the EGFR mutational status is key in the management of advanced NSCLC. Even in the presence of clinically favorable predictors of EGFR mutation positivity (>60% in our population), “empirical” choice of EGFR TKIs as front-line therapy may be detrimental to NSCLC patients without EGFR mutations.

Abstract not provided

Background
NVBo and P are an established regimen in advanced NSCLC. The approval of Pem and P in NS NSCLC recognises histology as treatment driver even if the higher chemosensitivity of NS NSCLC is recognised and reported with other chemotherapies (Ardizzoni. JNCI 2007). NVBo + P also showed better survival in NS NSCLC than in Squamous NSCLC (Tan. Ann.Oncol. 2009). The current randomised (2:1) phase II trial assessed disease control (DCR) (SD + PR + CR) of NVBo/CDDP or PEM/CDDP in NS NSCLC.

Methods
Stage IIIB/IV untreated/relapsed NS NSCLC pts were randomised to receive q3w NVBo 80 mg/m² D1D8 (60 at Cycle 1) + P 80 mg/m² D1 (Arm A) or Pem 500 mg/m² + P 75 mg/m² D1 (Arm B). After 4 cycles of combination, non PD pts received single agent NVBo (Arm A) or PEM (Arm B) as maintenance until progression or toxicity. Pts were randomised on a 2/1 basis and stratified according to Stage (IIIB - IV - relapse), non SCC confirmed by histology or cytology, gender, smoking status and centre.

Results
From 11/09 to 02/11, 153 patients were enrolled in 31 centers and randomised to Arm A (102 pts) or Arm B (51 pts). DCR after combination and maintenance was 75.0% (95% CI, 65.3 to 83.1) in Arm A and 76.5% (95% CI, 62.5 to 87.2) in Arm B. Median PFS was 4.2 (95% CI, 3.6 to 4.7) and 4.3 months (95% CI, 3.8 to 5.6) in Arm A and Arm B, respectively. Median OS was 10.2 months (95% CI, 7.8 to 11.9) and 10.8 months (95% CI, 7.0 to16.4) in Arm A and Arm B, respectively. During the combination period Grade 3/4 neutropenia was 44.0% in Arm A and 18.3% in Arm B but febrile neutropenia was 2% in both arms; grade 3/4 thrombopenia was 0% and 6% in Arm A and Arm B, respectively.

Conclusion
Both doublets reported good efficacy and acceptable tolerability. The maintenance allowed continuation of effective treatment with either oral vinorelbine or pemetrexed as single agent, with an acceptable safety with both agents. These results are sufficiently compelling to consider whether a phase III randomised non inferiority study with oral vinorelbine maintenance after induction vinorelbine/cddp could be as effective as pemetrexed maintenance. An oral maintenance may be a definite advantage over intravenous maintenance.

Background
Metronomic regimens, in which small, frequent doses of chemotherapy are administered, have been suggested to lower treatment-associated toxicities while maintaining, or even improving, efficacy. The high frequency of administration aims to expose tumour cells continuously to the drug, preventing recovery between cycles and possibly improving tumour control. We present the clinical and pharmacokinetic data of a phase I dose finding study in which the maximum tolerated dose (MTD) of daily oral vinorelbine was determined in pretreated patients with advanced NSCLC.

Methods
Patients (pts) were treated daily with oral vinorelbine (Navelbine® Oral) at fixed doses of 20 mg/d, 30 mg/d, 40 mg/d or 50 mg/d for 21 days of each four-week cycle. Blood sampling for pharmacokinetic assessment was carried out in the first cycle just before drug intake (trough concentrations) on days 1, 8, 15 and 21 and additionally at 1 h, 3 h and 24 h after drug intake on days 1 and 21.

Results
Daily administration of oral vinorelbine was well tolerated up to 30 mg/d without any dose limiting toxicities (DLT). At 40 mg one of three patients experienced DLT in cycle 1 and another patient in cycle 2. The MTD was reached at 50 mg/d when three out of six pts experienced DLT in cycle one. The reported DLTs included febrile and non-febrile neutropenia (6 DLTs) as well as fatigue (1 DLT). One patient had an exceptionally good clinical response with a long-lasting tumour remission. Twenty-one pts were evaluable for pharmacokinetic analysis. Blood concentrations of vinorelbine increased with escalating dose levels. Pts were continuously exposed to the drug over the 21-day treatment period as indicated by measurable trough concentrations on days 8, 15 and 21. A slight accumulation of vinorelbine was observed until day 8 based on residual concentrations (ratio c~24h ~ranged 1.96-2.03 between day 1 and either day 8, 15 or 21). The accumulation had no impact on global exposure at repeated dosing, as only minor differences in blood concentrations were detected between day 1 and day 21 (ratio d21/d1 median AUC~0h-24h~: 0.81, 0.92, 1.07, 0.56 at 20 mg/d, 30 mg/d, 40 mg/d and 50 mg/d, respectively). Data on four pts experiencing DLT were available (1 pt at 40 mg/d, 3 pts at 50 mg/d). Only one DLT correlated with an evidently high 24 h blood exposure to vinorelbine.

Conclusion
The recommended dose for daily administration of oral vinorelbine is 30 mg in cycle 1 followed by 40 mg in subsequent cycles in the absence of DLT. Further studies are necessary to determine the clinical impact, and possible anti-angiogenic profile of the daily administration schedule of vinorelbine.

Background
Vascular endothelial growth factor (VEGF)-mediated angiogenesis plays an important role in NSCLC pathogenesis. RAM is a human IgG1 monoclonal receptor targeted antibody that inhibits VEGF receptor-2 (VEGFR-2) binding and signaling. This study investigates RAM in combination with first-line platinum-pemetrexed chemotherapy in advanced NSCLC.

Methods
Eligible patients had Stage IIIb/IV NSCLC, ECOG PS ≤ 2, and no prior chemotherapy or VEGF/VEGFR therapy for metastatic disease. Non-squamous (NSQ) pts with advanced NSCLC were randomized 1:1 to either Arm A: pemetrexed + carboplatin/cisplatin (PEM + Cb/Cis) followed by PEM maintenance or Arm B: Ramucirumab 10 mg/kg + pemetrexed + carboplatin or cisplatin (RAM + PEM + Cb/Cis), followed by RAM + PEM maintenance once every 3 weeks. Patients received the first-line therapy from 4 to 6 cycles (21-day cycle); patients without evidence of disease progression entered a maintenance phase. The primary endpoint was progression-free survival (PFS). Secondary endpoints included objective response rate (ORR), disease control rate (DCR), overall survival (OS), change in tumor size, duration of response, and safety.

Results
From Oct 2010 to 2012, 140 pts were randomized (PEM + Cb/Cis: 71; RAM + PEM + Cb/Cis: 69). Overall, baseline patient characteristics were balanced between arms. The median PFS was 5.6 m PEM + Cb/Cis and 7.2 m for RAM + PEM + Cb/Cis; HR 0.75 (90% CI, 0.55, 1.03; p =0.132). ORR (CR + PR) was 38% for PEM + Cb/Cis and 49.3% including one complete response in the RAM + PEM + Cb/Cis arm (p=0.18). Disease control rate (CR + PR + SD) was 70% PEM + Cb/Cis and 86% for RAM + PEM + Cb/Cis ( p = 0.031). Median OS at the time of final PFS analysis was 10.4 m for PEM + Cb/Cis and 13.9 m for RAM + PEM + Cb/Cis; HR 0.83 (90% CI, 0.56, 1.22; p=0.43). Grade ≥ 3 adverse events (AEs) occurring in >10% of patients on RAM containing arm were: anemia, neutropenia, thrombocytopenia, nausea, fatigue, back pain, and hypertension.

Conclusion
While the primary endpoint of significant prolongation of PFS was not met, RAM has evidence of clinical activity in combination with PEM + Cb/Cis in patients with NSQ NSCLC. Addition of RAM to PEM + Cb/Cis did not result in excessive or unexpected toxicity.

Abstract not provided

Background
Bevacizumab has been shown to amplify efficacy against n-Sq NSCLC in combination with platinum doublet, especially taxane including regimens. Docetaxel is one of best taxane composition combined with cisplatin for first line treatment for NSCLC, and known to have anti-angiogenic effect and may act synergistically with VEGF inhibiting agent. The object of this study was to assess the efficacy and safety of bevacizumab, cisplatin and docetaxel combination treatment in patients with chemonaive n-Sq NSCLC patients. (Trial Registry: UMIN 000004368)

Methods
Eligible patients had advanced or recurrent n-Sq NSCLC with no prior chemotherapy. Patients having brain metastasis or history of hemoptysis were ineligible. Patients received 4 cycles of docetaxel (60mg/m[2]), cisplatin (80mg/m[2]) and bevacizumab (15mg/kg) on day1 every 3 weeks followed by Bev alone as maintenance every 3 weeks until disease progression or unacceptable toxicity. The primary endpoint was response rate (RR) and planned sample size of this phase II study was 47 patients (Simon's two-stage minimax design). We measured circulating endothelial cells (CEC) count day1 and 8 of first cycle for exploratory analysis of efficacy and safety prediction.

Results
From Oct 2010 to Apr 2012, 47 patients (28 males/ 19 females, median age, 61 years, 39-73) were enrolled. Stage IIIB/IV/recurrent: 5/39/3, ECOG PS 0/1: 31/16. All patients were adenocarcinoma, EGFR status: mutated/wild/unknown: 13/31/3. Bevacizumab maintenance were administered in 87% (41/47) of the patients and 9 was median number of delivered course, 4 course of induction and 5 course of maintenance. Dose reduction was required in 28% (13/47) of the patients. Thirty-five partial responses and 11 stable diseases were observed among 47 patients, yielding a RR of 74.5% (95% confidence interval: 59.7-86.1%) and disease control rate of 97.9% (88.7-99.9%), respectively. The median progression free survival duration in the patients was 9.0 (7.0-11.3) months. Grade 3/4 leukopenia, neutropenia, hypertension, nausea and febrile neutropenia were observed in 60, 96, 47, 13 and 9% of the patients, respectively. Alveolar hemorrhage (Grade 5) after 4 cycle occurred in one patient.

Conclusion
Bevacizumab, cisplatin and docetaxel combination followed by bevacizumab maintenance treatment was highly effective in patients with n-Sq NSCLC, with acceptable toxicity. Exploratory analysis of CEC is ongoing and will be presented.

Background
Standard front-line treatment for patients with unresectable or metastatic non-small cell lung cancer (NSCLC) is a platinum-based doublet with bevacizumab regimen, which achieves objective response rates (ORR) of 35% and median survival of 12 months. However, many patients with lung cancer are not eligible for cisplatin because of baseline neuropathy, hearing loss, renal insufficiency, or comorbid medical conditions. Although carboplatin is often substituted for cisplatin, it also is associated with similar toxicities, albeit with a smaller risk. This phase II trial of paclitaxel, pemetrexed, and bevacizumab was designed to avert the toxicities of platinum-based chemotherapeutic regimens and determine the efficacy of such a "non-platinum" containing doublet with bevacizumab.

Methods
Patients with untreated, advanced NSCLCs were enrolled if they had measurable disease (RECIST 1.0) and adequate organ and marrow function. Patients were excluded if they had squamous cell carcinoma; hemoptysis; symptomatic or hemorrhagic brain metastases; history of abdominal fistula, gastrointestinal perforation or intra-abdominal abscess; and myocardial infarction or stroke within 6 months prior to enrollment. For six 28-day cycles, patients received: paclitaxel 90 mg/m[2] (days 1, 8, and 15), pemetrexed 500 mg/m[2] (days 1 and 15), and bevacizumab 10 mg/kg (days 1 and 15). Patients with response or stable disease continued pemetrexed and bevacizumab every 14 days until progression or unacceptable toxicity. Patients were evaluated on days 1, 8 and 15 of each 28-day cycle. To assess response, CT scans were performed after cycles 1 and 2, and every 2 cycles thereafter. ORR was the primary endpoint.

Results
Forty-four patients were enrolled: 50% women, median age of 59 years (range, 31 to 77), 89% with Karnofsky performance status ≥80%. Mutation status was known in 38 patients (KRAS, n=16; ALK, n=3; BRAF V600E, n =2; Her2 insertion/PIK3CA, n=1; EGFR Exon 20 insertion, n=1; none, n=15). The ORR was 52% (95% CI, 37-68), with 23 partial responses and no complete responses. The median overall survival and progression-free survival were 17 months (95% CI, 12-33) and 8 months (95% CI, 6-12), respectively. Grade 3/4 toxicities included fatigue (33%); elevated liver function tests (15%); leukopenia (9%); hoarseness (7%); nausea (7%); and anemia (7%). Two patients died on study of respiratory failure, possibly related to therapy. No bleeding events were noted.

Conclusion
The “non-platinum” containing regimen of paclitaxel, pemetrexed and bevacizumab is an effective first-line treatment for patients with advanced NSCLCs, regardless of mutational status. Long survival was observed, with acceptable toxicities. This regimen warrants further study.

Background
A post hoc analysis of NSCLC patients (pts) aged ≥70 y in the pivotal E4599 trial found increased adverse events (AEs) and numerically decreased overall survival (OS) benefit associated with bevacizumab (BEV) compared with pts <70 y. We evaluated the efficacy and safety of BEV by age in pts in a pooled dataset from the E4599 and PointBreak (PB) trials.

Methods
Pts randomized to the PC (paclitaxel and carboplatin ) + BEV arms of E4599 and PB received P 200 mg/m[2], C AUC 6, and BEV 15 mg/kg q3w for 6 (E4599) or 4 (PB) cycles; Eligible pts received maintenance BEV alone q3w until disease progression or unacceptable toxicity. OS, progression-free survival (PFS), overall response rate (ORR), disease control rate (DCR), and safety were assessed in pts grouped according to age (<65 y, 65–74 y, 70–74 y, <75 y, and ≥75 y). Pt-level data from the PC + BEV arms of E4599 and PB were pooled and compared with data from pts in the PC-alone arm of E4599.

Results
PB and E4599 randomized 467 pts and 434 pts to PC + BEV, respectively, while 444 were randomized to receive PC alone on E4599. Baseline characteristics were balanced between age groups. OS and PFS hazard ratios (HRs) and increases in grade ≥3 AEs for the pooled pt cohort relative to E4599 PC-alone arm are shown (Table). Outcomes were similar in pts <70 y and ≥70 y, and data from the pooled population were similar to those seen in each individual trial (data not shown). ORR for pts <75 y was 39% with PC + BEV vs 26% with PC (P<.01). For pts ≥75 y, ORR was 33% vs 30% (P=.71). DCR in pts <75 y was 70% with PC + BEV vs 53% with PC (P<.01). For pts ≥75 y, DCR was 60% vs 67% (P=.37).

Conclusion
In a pooled exploratory analysis of pt data from E4599 and PB, the statistically significant benefit associated with the addition of BEV to PC appeared consistent across all age groups <75y, while pts ≥75 y receiving PC + BEV had no statistically significant survival benefit. Pts receiving PC + BEV had an increase in grade ≥3 AEs compared with pts receiving PC-alone in all age groups.

PB + E4599	<65 y n=735	65–74 y n=453	70–74 y n=203	<75 y n=1188	≥75 y n=157
HR for OS 95% CI P	0.75 0.62–0.89 <.01	0.80 0.64–1.00 .05	0.68 0.48–0.96 .03	0.78 0.68–0.89 <.01	1.05 0.70–1.57 .83
HR for PFS 95% CI P	0.71 0.60–0.85 <.01	0.62 0.49–0.78 <.01	0.68 0.48–0.96 .03	0.69 0.60–0.79 <.01	0.95 0.62–1.44 .80
E4599	n=499	n=277	n=129	n=776	n=102
Δ Grade ≥3 AEs,[a ]% P	13 <.01	21 <.01	23 <.01	15 <.01	25 <.01

[a]Relative to PC-alone arm.

Background
Bevacizumab, a monoclonal antibody that inhibits angiogenesis via the vascular endothelial growth factor (VEGF) pathway, has proven efficacy in extending overall survival (OS) (Sandler et al, 2006) and progression-free survival (PFS) (Sandler et al, 2006; Reck et al, 2009) when added to platinum-doublet chemotherapy as first-line treatment for advanced non-squamous NSCLC. These pivotal studies included mainly Caucasian patients, however subgroup analyses in Asian patients also reported efficacy of the first-line Bv+CP regimen (Reck et al, 2009). The BEYOND study was initiated to confirm efficacy in a Chinese population.

Methods
Patients aged ≥18 years with histologically or cytologically confirmed, locally advanced, metastatic or recurrent advanced non-squamous NSCLC and an ECOG performance status of 0–1 were randomised 1:1 to receive CP (paclitaxel 175mg/m[2] i.v. and carboplatin AUC6 i.v. on day 1 of each 3-week cycle for up to 6 cycles), plus either Pl or Bv 15mg/kg i.v. on day 1 of each cycle, until progression, unacceptable toxicity, withdrawal of patient consent or death. Patients had no prior treatment for advanced NSCLC. Patients were stratified by gender, smoking status and age. The primary endpoint was PFS in the intent-to-treat (ITT) population; secondary endpoints included objective response rate (ORR), OS, exploratory biomarkers and safety. Collection of blood samples for biomarker analyses was mandatory (at baseline, every two cycles during treatment, at progression, and 4–6 weeks post-progression); tissue samples were optional.

Results
276 patients were randomised into the study, 138 to each arm. Baseline characteristics were similar in both treatment groups. PFS was prolonged with Bv+CP versus Pl+CP: hazard ratio 0.40 (95% CI 0.29–0.54); median 9.2 versus 6.5 months; p<0.0001 (ITT population). ORR was also improved with the addition of Bv to CP: 54.4% versus 26.3% with Pl+CP. Disease control rate was 94.4% versus 88.7% with Bv+CP and Pl+CP, respectively. Median duration of response was 8.0 months with Bv+CP versus 5.3 months with Pl+CP. OS data are not yet mature. Safety data were similar to previous studies of Bv+CP in NSCLC; no new safety signals were observed. Treatment discontinuation due to adverse events was 18.4% (Bv+CP) and 15.0% (Pl+CP). Treatment-related deaths were low in both arms (Bv+CP: 2.2%; Pl+CP: 0.0%). Detailed safety data and biomarker analyses will be reported.

Conclusion
This study confirms that the addition of bevacizumab to first-line platinum-based chemotherapy appears to provide similar PFS benefits in Chinese patients with advanced non-squamous NSCLC compared with global populations. No new safety concerns were reported.

Abstract not provided