Annelies Janssens

Immunotherapy: is a minor god yet in the pantheon of treatments for lung cancer?

Immunotherapy has been studied for many years in lung cancer without significant results, making the majority of oncologists quite skeptical about its possible application for non-small cell lung cancer treatment. However, the recent knowledge about immune escape and subsequent ‘cancer immunoediting’ has yielded the development of new strategies of cancer immunotherapy, heralding a new era of lung cancer treatment. Cancer vaccines, including both whole-cell and peptide vaccines have been tested both in early and advanced stages of non-small cell lung cancer. New immunomodulatory agents, including anti-CTLA4, anti-PD1/PDL1 monoclonal antibodies, have been investigated as monotherapy in metastatic lung cancer. To date, these treatments have shown impressive results of efficacy and tolerability in early clinical trials, leading to testing in several large, randomized Phase III trials. As these results will be confirmed, these drugs will be available in the near future, offering new exciting therapeutic options for lung cancer treatment.

Customizing systemic therapy in patients with advanced non-small cell lung cancer

Lung cancer is the leading cause of cancer deaths worldwide. Standard chemotherapy has been shown to improve quality of life and has a modest influence on overall survival. This modest improvement in survival is partly due to the choice of chemotherapy regimens that have been based on prognostic factors such as age, performance status and comorbidities of the patient. This underlines the importance of developing a more personalized therapy for patients with non-small cell lung cancer. Such an approach may reduce the variation in how individual patients respond to medications by tailoring therapies to their genetic profile. In this review we focus on several aspects of customized therapy, looking not only at patient characteristics but also to tumor histology and specific tumor biomarkers.

Routine implementation of EGFR mutation testing in clinical practice in Flanders: ‘HERMES’ project

Abstract Epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI) is the recommended first-line treatment in metastatic EGFR-mutation-positive non-small cell lung cancer (NSCLC) patients. Such a personalized treatment requires fast EGFR mutation testing. This study was performed to determine the turn around time (TAT) for EGFR mutation testing on tumour samples of NSCLC in the clinical care in the region of Antwerp (Belgium). The secondary aim was to determine the frequency of EGFR mutations in this Flemish population. Tumour tissue was prospectively obtained from lung cancer patients in participating hospitals and sent from the local pathology laboratory (lab) to two central laboratories (labs) where EGFR-mutation analysis was performed. Results were returned from the central labs to the clinicians and the local pathology lab. TAT was defined as the interval between the request from the oncologist and the result obtained by the oncologist. One hundred and seven specimens were analysed. The clinician got the result from the local lab in a median time of 10 days (3–37 days) and from the central lab in 9 days (3–29 days). We detected seven mutations (7%) in this study population, all occurring in tumours with an adenocarcinoma histology, four (57%) in men and five (71%) in (ex-)smokers. There were six exon 19 deletions and one L858R mutation. It is possible to implement EGFR-mutation testing with timely reporting of the EGFR-mutation status. EGFR-mutation occurs in 7% of Flemish patients with NSCLC. Patients with advanced non-squamous NSCLC should be tested for EGFR mutation regardless of their gender and smoking history.

Endobronchial lipomas: rare benign lung tumors, two case reports.

Endobronchial lipoma is a rare benign lung tumor. Here we present two cases. One case is the first report of the association of and endobronchial lipoma with a hilar lipoma. We discuss the epidemiology, difficulties in establishing the diagnosis, and the management of this rare condition.

Integrating early palliative care (EPC) in the management of lung cancer: The role of the thoracic oncologist

Early introduction of palliative care in the management of patients with metastatic lung cancer is recommended since it improves quality of life and improves survival rates. In many hospitals the focus of palliative teams is often on terminal care due to limited resources. How is Early palliative care (EPC) in this setting implemented in daily oncologic care? It seems obvious that thoracic oncologists will have to become involved in EPC for lung cancer patients. In this review we want to determine the assignments for the thoracic oncologist in EPC and to give some practical tools how we started EPC in collaboration with the palliative team.

Imaging of urgencies and emergencies in the lung cancer patient

Lung cancer patients often experience potentially life-threatening medical urgencies and emergencies, which may be a direct or indirect result of the underlying malignancy. This pictorial review addresses the most common thoracic, neurological and musculoskeletal medical emergencies in lung cancer patients, including superior vena cava syndrome, pulmonary embolism, spontaneous pneumothorax, cardiac tamponade, massive haemoptysis, central airway obstruction, oesophagorespiratory fistula, malignant spinal cord compression, carcinomatous meningitis, cerebral herniation and pathological fracture. Emphasis is placed on imaging findings, the role of different imaging techniques and a brief discussion of epidemiology, pathophysiology and therapeutic options. Since early diagnosis is important for adequate patient management and prognosis, radiologists have a crucial role in recognising and communicating these urgencies and emergencies.Teaching points• Multiplanar multidetector computed tomography is the imaging examination of choice for thoracic urgencies and emergencies.• Magnetic resonance imaging is the imaging modality of choice for investigating central nervous system emergencies.• Urgencies and emergencies can be the initial manifestation of lung cancer.• Radiologists have a crucial role in recognising and in communicating these urgencies/emergencies.

A 61-year-old female patient with right-sided pleuritic chest pain and fatigue

A 61-yr-old Caucasian female patient was investigated because of right-sided pleuritic chest pain. The patient had a 2-month history of chronic, nonproductive cough, extreme fatigue, night sweats and reduced exercise tolerance. Initially, the patient was treated with antibiotics for presumed pneumonia. She had smoked for >20 pack-yrs and her medical history included parotidectomy for Warthin tumour, resection of a benign cyst in the left breast and varicectomy. Physical examination showed no clinical signs of respiratory distress. Sinus rhythm was present with a heart rate of 88 bpm and blood pressure of 135/80 mmHg. Cardiopulmonary auscultation revealed no significant abnormalities and there was no hepatomegaly or limb oedema. No lymphadenopathy was found in the neck, supraclavicular, axillary or inguinal regions. The laboratory results showed an elevated C-reactive protein of 5.02 mg·dL−1. Low haemoglobin and haematocrit values were in keeping with anaemia. Studies of coagulability were all within normal ranges. Arterial blood gas analysis while breathing ambient air showed an arterial oxygen tension of 66 mm Hg, carbon dioxide arterial tension of 40 mmHg, pH of 7.43 and arterial oxygen saturation of 94%. Pulmonary function tests revealed a mild restrictive defect with a reduced diffusing capacity. A chest radiograph (fig. 1⇓) and computed tomography (CT) scans (figs 2⇓ and 3⇓) were performed and the patient underwent bronchoscopy and mediastinoscopy. Bronchoscopy revealed no endobronchial involvement. Subsequent biopsies were all found to be negative. Fig. 1— Chest radiograph. Fig. 2— Axial contrast-enhanced chest computed tomography scan. Extensive soft tissue mass in the right pulmonary artery, extending in different side branches, is indicated by the arrows. Fig. 3— Axial contrast-enhanced chest computed tomography scan. a) Mediastinal window and b) lung window. Two peripherally located wedge-shaped focal consolidations areas at the right lung base are indicated by the arrows. All accessible lymph nodes in the superior mediastinum and the region of the right mainstem bronchus …

FEV1 AS A PROGNOSTIC FACTOR FOR SURVIVAL IN STAGE III NSCLC PATIENTS TREATED WITH CHEMORADIATION: MULTIVARIATE ANALYSIS OF CHERNOS TRIAL

PURPOSE: Data from the recent HOG 01–24 trial suggest that survival of stage III NSCLC patients (pts) treated with chemoradiotherapy (CRT) is correlated with the FEV1. In this multivariate analysis we evaluated the prognostic value of FEV1 and/or DLCO in pts treated with CRT in the Chernos trial. METHODS: Patients (PS 0–2) with unresectable stage III NSCLC were treated with 3 cycles of induction chemotherapy (carboplatin AUC 5 on d1 and gemcitabine 1200 mg/m2 on d1 and d8 Q3 wks) followed by conventional radiotherapy (2.0 Gy/fraction, 5 fractions a week, up to a total dose of 60 Gy) with concurrent weekly cisplatin (30 mg/m2). The primary endpoint was overall survival at 2 years. In an exploratory analysis the effect of FEV1 and/or DLCO on survival was investigated. RESULTS: Between 02/2003 and 11/2005, 45 pts were enrolled. The demographics were as follows: 76%/24% male/female, median age 62 y (range 41–81 y), 73%/27% performance status (PS) 0–1/2, 26%/74% FEV1 ≥70%/<70%, 76%/24% cN0–2/cN3 disease, 42%/58% squamous/non-squamous. No treatment-related deaths were observed. The median progression free (PFS) and overall survival (OS) are 11.1 m and 20.4 m. The 1-, 2and 3-yr OS rates are 62%, 38% and 17%. In univariate analysis there was a favourable association for PFS with cN0–2 (p .07), DLCO ≥55% (p .02), and for both PFS and OS with FEV1 ≥70% (HR .22; p <.01 and HR .37; p< .01 resp.). There was no survival difference according to gender, histology and PS. In multivariate analysis, only FEV1 ≥70% was independently associated with better PFS and OS. CONCLUSION: In our series of pts with unresectable stage III NSCLC treated with CRT FEV1 ≥70% is an independent favourable prognostic factor. CLINICAL IMPLICATIONS: Our data confirm the prognostic value of FEV1 in pts with stage III NSCLC, indicating that FEV1 is an important factor when interpreting results from different CRT trials, when selecting CRT treatment for individual pts or when designing new trials comparing different CRT regimens. DISCLOSURE: Paul Germonpre, No Financial Disclosure Information; No Product/Research Disclosure Information Tuesday, October 28, 2008