Arrigo Capitanio

Spatial and temporal diversity in genomic instability processes defines lung cancer evolution

Spatial and temporal dissection of the genomic changes occurring during the evolution of human non–small cell lung cancer (NSCLC) may help elucidate the basis for its dismal prognosis. We sequenced 25 spatially distinct regions from seven operable NSCLCs and found evidence of branched evolution, with driver mutations arising before and after subclonal diversification. There was pronounced intratumor heterogeneity in copy number alterations, translocations, and mutations associated with APOBEC cytidine deaminase activity. Despite maintained carcinogen exposure, tumors from smokers showed a relative decrease in smoking-related mutations over time, accompanied by an increase in APOBEC-associated mutations. In tumors from former smokers, genome-doubling occurred within a smoking-signature context before subclonal diversification, which suggested that a long period of tumor latency had preceded clinical detection. The regionally separated driver mutations, coupled with the relentless and heterogeneous nature of the genome instability processes, are likely to confound treatment success in NSCLC. Different regions of a human lung tumor harbor different mutations, possibly explaining why the disease is so tough to treat. [Also see Perspective by Govindan] Space, time, and the lung cancer genome Lung cancer poses a formidable challenge to clinical oncologists. It is often detected at a late stage, and most therapies work for only a short time before the tumors resume their relentless growth. Two independent analyses of the human lung cancer genome may help explain why this disease is so resilient (see the Perspective by Govindan). Rather than take a single “snapshot” of the cancer genome, de Bruin et al. and Zhang et al. identified genomic alterations in spatially distinct regions of single lung tumors and used this information to infer the tumors evolutionary history. Each tumor showed tremendous spatial and temporal diversity in its mutational profiles. Thus, the efficacy of drugs may be short-lived because they destroy only a portion of the tumor. Science, this issue p. 251, p. 256; see also p. 169

Combination of endobronchial ultrasound-guided transbronchial needle aspiration with standard bronchoscopic techniques for the diagnosis of stage I and stage II pulmonary sarcoidosis

Background and objective:  Standard bronchoscopic techniques (transbronchial lung biopsy and endobronchial biopsy) provide a diagnosis in 70% of patients with pulmonary sarcoidosis. Previous data suggest that endobronchial ultrasound‐guided transbronchial needle aspiration (EBUS‐TBNA) has a high sensitivity in patients with sarcoidosis. The feasibility and utility of combining EBUS‐TBNA with standard bronchoscopic techniques is unknown. The aim of this study was to evaluate the feasibility, safety and efficacy of combined EBUS‐TBNA and standard bronchoscopic techniques in patients with suspected sarcoidosis and enlarged mediastinal or hilar lymphadenopathy.

Cell migration leads to spatially distinct but clonally related airway cancer precursors

Background Squamous cell carcinoma of the lung is a common cancer with 95% mortality at 5 years. These cancers arise from preinvasive lesions, which have a natural history of development progressing through increasing severity of dysplasia to carcinoma in situ (CIS), and in some cases, ending in transformation to invasive carcinoma. Synchronous preinvasive lesions identified at autopsy have been previously shown to be clonally related. Methods Using autofluorescence bronchoscopy that allows visual observation of preinvasive lesions within the upper airways, together with molecular profiling of biopsies using gene sequencing and loss-of-heterozygosity analysis from both preinvasive lesions and from intervening normal tissue, we have monitored individual lesions longitudinally and documented their visual, histological and molecular relationship. Results We demonstrate that rather than forming a contiguous field of abnormal tissue, clonal CIS lesions can develop at multiple anatomically discrete sites over time. Further, we demonstrate that patients with CIS in the trachea have invariably had previous lesions that have migrated proximally, and in one case, into the other lung over a period of 12 years. Conclusions Molecular information from these unique biopsies provides for the first time evidence that field cancerisation of the upper airways can occur through cell migration rather than via local contiguous cellular expansion as previously thought. Our findings urge a clinical strategy of ablating high-grade premalignant airway lesions with subsequent attentive surveillance for recurrence in the bronchial tree.

Randomized Prospective Biomarker Trial of ERCC1 for Comparing Platinum and Nonplatinum Therapy in Advanced Non-Small-Cell Lung Cancer: ERCC1 Trial (ET)

Purpose Retrospective studies indicate that expression of excision repair cross complementing group 1 (ERCC1) protein is associated with platinum resistance and survival in non-small-cell lung cancer (NSCLC). We conducted the first randomized trial, to our knowledge, to evaluate ERCC1 prospectively and to assess the superiority of nonplatinum therapy over platinum doublet therapy for ERCC1-positive NSCLC as well as noninferiority for ERCC1-negative NSCLC. Patients and Methods This trial had a marker-by-treatment interaction phase III design, with ERCC1 (8F1 antibody) status as a randomization stratification factor. Chemonaïve patients with NSCLC (stage IIIB and IV) were eligible. Patients with squamous histology were randomly assigned to cisplatin and gemcitabine or paclitaxel and gemcitabine; nonsquamous patients received cisplatin and pemetrexed or paclitaxel and pemetrexed. Primary end point was overall survival (OS). We also evaluated an antibody specific for XPF (clone 3F2). The target hazard ratio (HR) for patients with ERCC1-positive NSCLC was ≤ 0.78. Results Of patients, 648 were recruited (177 squamous, 471 nonsquamous). ERCC1-positive rates were 54.5% and 76.7% in nonsquamous and squamous patients, respectively, and the corresponding XPF-positive rates were 70.5% and 68.5%. Accrual stopped early in 2012 for squamous patients because OS for nonplatinum therapy was inferior to platinum therapy (median OS, 7.6 months [paclitaxel and gemcitabine] v 10.7 months [cisplatin and gemcitabine]; HR, 1.46; P = .02). Accrual for nonsquamous patients halted in 2013. Median OS was 8.0 (paclitaxel and pemetrexed) versus 9.6 (cisplatin and pemetrexed) months for ERCC1-positive patients (HR, 1.11; 95% CI, 0.85 to 1.44), and 10.3 (paclitaxel and pemetrexed) versus 11.6 (cisplatin and pemetrexed) months for ERCC1-negative patients (HR, 0.99; 95% CI, 0.73 to 1.33; interaction P = .64). OS HR was 1.09 (95% CI, 0.83 to 1.44) for XPF-positive patients, and 1.39 (95% CI, 0.90 to 2.15) for XPF-negative patients (interaction P = .35). Neither ERCC1 nor XPF were prognostic: among nonsquamous patients, OS HRs for positive versus negative were ERCC1, 1.11 ( P = .32), and XPF, 1.08 ( P = .55). Conclusion Superior outcomes were observed for patients with squamous histology who received platinum therapy compared with nonplatinum chemotherapy; however, selecting chemotherapy by using commercially available ERCC1 or XPF antibodies did not confer any extra survival benefit.

Abstract C32: PTEN and p53 expression in endometrial cancer correlated with clinicopathological phenotype.

p53 overexpression and loss of PTEN expression have been implicated in the pathogenesis of endometrial cancer. Our aim was to correlate expression levels of these proteins with clinicopathological parameters to characterise their utility as biomarkers. Immunohistochemistry was done on 49 cases of formalin fixed paraffin embedded endometrial cancer tissue for p53 and 47 for PTEN expression. For p53 staining the Hue Saturation and Intensity mathematical model was used to evaluate different degrees of positivity of the immunohistochemical stain. The quick score was used for p53 and immunoreactive score for PTEN was done to score immunoreactivity. For PTEN, average percentage of positive cells and intensity was evaluated and the immunoreactive score was calculated. Both these scoring methods incorporated percentage of positive cells and staining intensity. Univariate Cox regression analysis for cause specific survival showed a hazard ratio of 9.2 for p53 overexpression (P<0.05). High levels of P53 were significantly associated with histologic type, grade, LVI and recurrent disease. There was no significant association between PTEN expression and clinicopathological features but it was noted that the 8 patients who relapsed were PTEN negative. Cause specific survival could not be assessed for PTEN expression due to the lack of events in this group. PTEN and p53 (n=46) combined analysis failed to demonstrate a significant association on prognostic features in this group. ![Figure][1] Overexpression of P53 has a negative effect on disease specific survival and was associated with poor prognostic features. We did not demonstrate a significant association with clinicopathological features assessed and PTEN expression. However of the 8 patients who relapsed all were PTEN negative and 7 were p53 positive. Dual assessment of p53 and PTEN warrants further investigation as a prognostic indicator. Citation Information: Mol Cancer Ther 2013;12(11 Suppl):C32. Citation Format: Bihani Kularatne, Arrigo Capitanio, Rupali Arora, Philippa Jones, Andre Lopes, Jennifer Paterson, Rebecca Kristeleit. PTEN and p53 expression in endometrial cancer correlated with clinicopathological phenotype. [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2013 Oct 19-23; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2013;12(11 Suppl):Abstract nr C32. [1]: pending:yes

Pulmonary mass in a 19-year-old male

A 19-year-old student who had never smoked presented with a 6-month history of cough, wheeze, sputum production and generalised fatigue. His exercise tolerance was unaffected and he continued to play rugby competitively. He had a history of childhood asthma and received treatment with inhaled salbutamol with no effect. A chest x-ray revealed a round density at the base of the right lung. A CT chest was performed (figure 1) and subsequently a 68Ga-DOTATATE (1,4,7,10-tetraazacyclododecane-N,N′,N″,N‴-tetraacetic acid-d-Phe(1),Tyr(3)-octreotate) PET-CT (positron emission tomography-CT) was arranged, demonstrating that the mass had a maximum standardised uptake value of 6.6 (figure 2). He was referred for a right lower lobectomy. Histological evaluation of the lobectomy …