Philip W. Carrott

Non-coding RNA LINC00857 is predictive of poor patient survival and promotes tumor progression via cell cycle regulation in lung cancer

We employed next generation RNA sequencing analysis to reveal dysregulated long non-coding RNAs (lncRNAs) in lung cancer utilizing 461 lung adenocarcinomas (LUAD) and 156 normal lung tissues from 3 separate institutions. We identified 281 lncRNAs with significant differential-expression between LUAD and normal lung tissue. LINC00857, a top deregulated lncRNAs, was overexpressed in tumors and significantly associated with poor survival in LUAD. knockdown of LINC00857 with siRNAs decreased tumor cell proliferation, colony formation, migration and invasion in vitro, as well as tumor growth in vivo. Overexpression of LINC00857 increased cancer cell proliferation, colony formation and invasion. Mechanistic analyses indicated that LINC00857 mediates tumor progression via cell cycle regulation. Our study highlights the diagnostic/prognostic potential of LINC00857 in LUAD besides delineating the functional and mechanistic aspects of its aberrant disease specific expression and potentially using as a new therapeutic target.

Teaching video-assisted thoracic surgery (VATS) lobectomy

Video-assisted thoracic surgery (VATS) lobectomy has become the standard of care for early stage lung cancer throughout the world. Teaching this complex procedure requires adequate case volume, adequate instrumentation, a committed operating room team and baseline experience with open lobectomy. We outline what key maneuvers and steps are required to teach and learn VATS lobectomy. This is most easily performed as part of a thoracic surgery training program, but with adequate commitment and proctoring, there is no reason experienced open surgeons cannot become proficient VATS surgeons. We provide videos showing the key portions of a subcarinal lymph node dissection, posterior hilar dissection of the right upper lobe, fissureless right middle lobectomy, and fissureless left lower lobectomy. These videos highlight what we feel are important principals in VATS lobectomy, i.e., N2 and N1 lymph node dissection, fissureless techniques, and progressive responsibility of the learner. Current literature in simulation of VATS lobectomy is also outlined as this will be the future of teaching in VATS lobectomy.

MAP3K3 expression in tumor cells and tumor-infiltrating lymphocytes is correlated with favorable patient survival in lung cancer

MAP3K3 is involved in both the immune response and in tumor progression. Its potential biological role in vitro in lung cancer cell lines and the association of mRNA/protein expression patterns with clinical outcome of primary lung tumors were investigated in this study. Silencing MAP3K3 using siRNA in lung cancer cell lines resulted in decreased cell proliferation, migration and invasion. These effects were associated with down-regulation of the JNK, p38, AKT, and GSK3β pathways as determined using phospho-protein and gene expression array analyses. However, MAP3K3 mRNA and protein overexpression in primary lung tumors correlated significantly with favorable patient survival. Gene cluster and pathway analyses of primary tumor datasets indicated that genes positively-correlated with MAP3K3 are significantly involved in immune response rather than the cell cycle regulators observed using in vitro analyses. These results indicate that although MAP3K3 overexpression has an oncogenic role in vitro, in primary lung adenocarcinomas it correlates with an active immune response in the tumor environment that correlates with improved patient survival. MAP3K3 may potentially not only serve as diagnostic/prognostic markers for patients with lung cancer but also provide an indicator for future investigations into immunomodulatory therapies for lung cancer.

Poor Prognosis Indicated by Venous Circulating Tumor Cell Clusters in Early-Stage Lung Cancers

Early detection of metastasis can be aided by circulating tumor cells (CTC), which also show potential to predict early relapse. Because of the limited CTC numbers in peripheral blood in early stages, we investigated CTCs in pulmonary vein blood accessed during surgical resection of tumors. Pulmonary vein (PV) and peripheral vein (Pe) blood specimens from patients with lung cancer were drawn during the perioperative period and assessed for CTC burden using a microfluidic device. From 108 blood samples analyzed from 36 patients, PV had significantly higher number of CTCs compared with preoperative Pe (P < 0.0001) and intraoperative Pe (P < 0.001) blood. CTC clusters with large number of CTCs were observed in 50% of patients, with PV often revealing larger clusters. Long-term surveillance indicated that presence of clusters in preoperative Pe blood predicted a trend toward poor prognosis. Gene expression analysis by RT-qPCR revealed enrichment of p53 signaling and extracellular matrix involvement in PV and Pe samples. Ki67 expression was detected in 62.5% of PV samples and 59.2% of Pe samples, with the majority (72.7%) of patients positive for Ki67 expression in PV having single CTCs as opposed to clusters. Gene ontology analysis revealed enrichment of cell migration and immune-related pathways in CTC clusters, suggesting survival advantage of clusters in circulation. Clusters display characteristics of therapeutic resistance, indicating the aggressive nature of these cells. Thus, CTCs isolated from early stages of lung cancer are predictive of poor prognosis and can be interrogated to determine biomarkers predictive of recurrence. Cancer Res; 77(18); 5194-206. ©2017 AACR.

Overexpression of FAM83H-AS1 indicates poor patient survival and knockdown impairs cell proliferation and invasion via MET/EGFR signaling in lung cancer

Whole transcriptome analyses of next generation RNA sequencing (RNA-Seq) data from human cancer samples reveled thousands of uncharacterized non-coding RNAs including long non-coding RNA (lncRNA). Recent studies indicated that lncRNAs are emerging as crucial regulators in cancer processes and potentially useful as biomarkers for cancer diagnosis and prognosis. To delineate dysregulated lncRNAs in lung cancer, we analyzed RNA-Seq data from 461 lung adenocarcinomas (LUAD) and 156 normal lung tissues. FAM83H-AS1, one of the top dysregulated lncRNAs, was found to be overexpressed in tumors relative to normal lung and significantly associated with worse patient survival in LUAD. We verified this diagnostic/prognostic potential in an independent cohort of LUAD by qRT-PCR. Cell proliferation, migration and invasion were decreased after FAM83H-AS1 knockdown using siRNAs in lung cancer cells. Flow cytometry analysis indicated the cell cycle was arrested at the G2 phase after FAM83H-AS1 knockdown. Mechanistically, we found that MET/EGFR signaling was regulated by FAM83H-AS1. Our study indicated that FAM83H-AS1 plays an important role in lung tumor progression and may be potentially used as diagnostic/prognostic marker. Further characterization of this lncRNA may provide a novel therapeutic target impacting MET/EGFR signaling.

18F-FDG PET intensity correlates with a hypoxic gene signature and other oncogenic abnormalities in operable non-small cell lung cancer

Background 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) is critical for staging non-small-cell lung cancer (NSCLC). While PET intensity carries prognostic significance, the genetic abnormalities associated with increased intensity remain unspecified. Methods NSCLC samples (N = 34) from 1999 to 2011 for which PET data were available were identified from a prospectively collected tumor bank. PET intensity was classified as mild, moderate, or intense based on SUVmax measurement or radiology report. Associations between genome-wide expression (RNAseq) and PET intensity were determined. Associations with overall survival were then validated in two external NSCLC cohorts. Results Overall survival was significantly worse in patients with PET-intense (N = 11) versus mild (N = 10) tumors (p = 0.039). Glycolytic gene expression patterns were markedly similar between intense and mild tumors. Gene ontology analysis demonstrated significant enhancement of cell-cycle and proliferative processes in FDG-intense tumors (p<0.001). Gene set enrichment analysis (GSEA) suggested associations between PET-intensity and canonical oncogenic signaling pathways including MYC, NF-κB, and HIF-1. Using an external cohort of 25 tumors with PET and genomic profiling data, common genes and gene sets were validated for additional study (P<0.05). Of these common gene sets, 20% were associated with hypoxia or HIF-1 signaling. While HIF-1 expression did not correlate with poor survival in the NSCLC validation cohort (N = 442), established targets of hypoxia signaling (PLAUR, ADM, CA9) were significantly associated with poor overall survival. Conclusions PET-intensity is associated with a variety of oncogenic alterations in operable NSCLC. Adjuvant targeting of these pathways may improve survival among patients with PET-intense tumors.

Disease-Specific Diets in Surgical Diseases

Purpose of ReviewDietary recommendations for common surgical diseases vary widely amongst healthcare centers and is mainly dependent upon provider experience and practice patterns. Despite frequently prescribed nutrition regimens, there is a paucity of quality evidence to support many of these recommendations. We present data for several common surgical diseases including dietary recommendations post-esophagectomy, post-Nissen fundoplication, and post-colectomy. We will also discuss the evidence in diverticulitis, inflammatory bowel disease, dumping syndrome, and short bowel syndrome.Recent FindingsDietary consistency may make a difference in post-esophageal surgery diets. Other past dietary recommendations in diseases such as diverticulitis may not make as much difference. Dumping syndrome and Short bowel syndrome have some newer interventions in timing of oral intake and some medications.SummaryDiet may make less difference overall in many routine small and large intestinal diseases, although surgical diseases with altered anatomy, such as gastric bypass or short bowel syndrome, there are definite dietary interventions that will modify the patient’s disease process for the better. More research is needed in many diseases with regard to routine diets.

Clinical Significance of Skeletal Muscle Loss Following Lung Resection for Cancer: Recovery and Sarcopenia are Linked to Cancer Outcomes

Early-stage lung cancer has a low but real rate of recurrence and metastatic disease in the order of 10–20 %. Dr. Takamori and colleagues from Kyushu University have identified skeletal muscle loss following resection as a predictor of cancer-specific outcomes in lung cancer following resection. The relation of muscle mass and other physiologic markers seen on computed tomography (CT) scans has recently become a significant predictor of outcomes in a number of disease states and surgical populations. The field has been developed as ‘morphomics’ to identify these morphological characteristics of patients. Thus far, transplant patient outcomes and surgical outcomes have been reliably linked to patient morphomic factors such as psoas muscle area, and density of visceral and truncal fat, or dorsal muscle density in abdominal and thoracic CT scans. Cancer-specific outcomes have been shown in prior studies in adrenocortical cancers. The link between patient physiology and outcomes makes sense, but now linking the likelihood of cancerspecific outcomes to a patient’s physiologic or morphomic status makes a further leap in the value of assessing these very specific factors, particularly in early-stage lung cancer. The authors nicely show a relationship between muscle loss and poorer respiratory status with disease-free and overall survival. These important factors should be followed and studied in future patients and disease states to better identify those patients who may benefit from close follow-up or perhaps postoperative nutritional intervention or physiotherapy. The value in any new finding that can influence clinical course is how it can be applied to clinical care. These patients will typically have routine surveillance CT scans for recurrent or metastatic cancer. The morphomic data can also be relatively easily surveilled, and the subset of patients at risk might benefit from closer follow-up or enrollment in physical therapy or nutritional rehabilitation programs. These data may suggest to the treating physician which patients may benefit from adjuvant therapy, although these patients with significant sarcopenia would not be good candidates for high-morbidity treatments. Alternatively, those with significant sarcopenia on preoperative or pretreatment CT scans may have their treatment plans altered by either avoiding surgery altogether or avoiding minimal resection strategies such as wedge resection or segementectomy. This also makes sense on a physiologic level, but one that I think is poorly understood and also difficult to discern, i.e. what makes a patient sarcopenic or predisposed to poor physiologic health and recurrent cancer? Is it nutrition? Patient conditioning, or immune status? In all likelihood, it is a combination of factors, as well as genetic and cancer-specific factors. Morphomics and CT scan variables are likely some of the most objective and specific metrics in medicine, and will do much to quantify a patient’s real health status. Continuing to work to identify these relevant health factors and acting on them may produce gains in identifying health risks, when outward signs of disease are more subtle. I congratulate the authors on nicely outlining this link, even in early-stage disease.Early-stage lung cancer has a low but real rate of recurrence and metastatic disease in the order of 10–20 %. Dr. Takamori and colleagues from Kyushu University have identified skeletal muscle loss following resection as a predictor of cancer-specific outcomes in lung cancer following resection. The relation of muscle mass and other physiologic markers seen on computed tomography (CT) scans has recently become a significant predictor of outcomes in a number of disease states and surgical populations. The field has been developed as ‘morphomics’ to identify these morphological characteristics of patients. Thus far, transplant patient outcomes and surgical outcomes have been reliably linked to patient morphomic factors such as psoas muscle area, and density of visceral and truncal fat, or dorsal muscle density in abdominal and thoracic CT scans. Cancer-specific outcomes have been shown in prior studies in adrenocortical cancers. The link between patient physiology and outcomes makes sense, but now linking the likelihood of cancerspecific outcomes to a patient’s physiologic or morphomic status makes a further leap in the value of assessing these very specific factors, particularly in early-stage lung cancer. The authors nicely show a relationship between muscle loss and poorer respiratory status with disease-free and overall survival. These important factors should be followed and studied in future patients and disease states to better identify those patients who may benefit from close follow-up or perhaps postoperative nutritional intervention or physiotherapy. The value in any new finding that can influence clinical course is how it can be applied to clinical care. These patients will typically have routine surveillance CT scans for recurrent or metastatic cancer. The morphomic data can also be relatively easily surveilled, and the subset of patients at risk might benefit from closer follow-up or enrollment in physical therapy or nutritional rehabilitation programs. These data may suggest to the treating physician which patients may benefit from adjuvant therapy, although these patients with significant sarcopenia would not be good candidates for high-morbidity treatments. Alternatively, those with significant sarcopenia on preoperative or pretreatment CT scans may have their treatment plans altered by either avoiding surgery altogether or avoiding minimal resection strategies such as wedge resection or segementectomy. This also makes sense on a physiologic level, but one that I think is poorly understood and also difficult to discern, i.e. what makes a patient sarcopenic or predisposed to poor physiologic health and recurrent cancer? Is it nutrition? Patient conditioning, or immune status? In all likelihood, it is a combination of factors, as well as genetic and cancer-specific factors. Morphomics and CT scan variables are likely some of the most objective and specific metrics in medicine, and will do much to quantify a patient’s real health status. Continuing to work to identify these relevant health factors and acting on them may produce gains in identifying health risks, when outward signs of disease are more subtle. I congratulate the authors on nicely outlining this link, even in early-stage disease.

Signet Rings Around the World

Esophageal and gastric adenocarcinoma of signet ring subtype is aggressive and portends a poor prognosis. This subtype of an already aggressive cancer metastasizes widely and can progress quickly. Hart and colleagues outline an unusual and specific metastasis following resection of signet ring esophageal adenocarcinoma. More frequent surveillance for resected patients may help identify metastases early.

Abstract 1581: A study of pulmonary and peripheral vein blood as sources of circulating tumor cells in early lung cancer

Proceedings: AACR 106th Annual Meeting 2015; April 18-22, 2015; Philadelphia, PA Lung cancer is one of the most prevalent cancers world-wide. It is usually diagnosed at an advanced stage with low survival rates. Early detection and intervention can have a profound impact in improving survival. Circulating tumor cells (CTCs), or cells shed by the tumor into the blood circulation, offer a less invasive method of tumor biopsy. Surgical lobectomy for early stage lung cancers provides access to the pulmonary vein (PV) draining the affected lobe, and is presumably an enriched source of CTCs shed by the primary lung tumor. Analyzing peripheral (Pe) and pulmonary vein (PV) blood combined could potentially shed light onto optimal markers and disease progression. We hypothesize that blood from the pulmonary vein has a higher abundance of CTCs than peripheral blood, thereby providing a larger yield of CTCs from early lung cancer patients for downstream analysis. A cohort of greater than 30 lung cancer patients was enrolled in a pilot study. PV and Pe blood specimens from these patients were obtained at different time points in the perioperative time period, and were processed through a high-throughput microfluidic device, the OncoBean Chip that isolates CTCs by immuno-affinity based capture. A higher number of PV CTCs were detected than from Pe. In addition, rare CTC clusters were observed in the PV blood in some cases, which were further characterized for protein expression. Gene expression analysis was performed for comparison of CTCs obtained from these two different sources. Evaluating different CTC sources along the venous drainage of a tumor could potentially offer an insight into CTC biology and spread of the disease. Citation Format: Vasudha Murlidhar, Rishindra M. Reddy, Ebrahim Azizi, Lili Zhao, Svetlana Grabauskiene, Zhuo Zhang, Nithya Ramnath, Jules Lin, Andrew C. Chang, Philip W. Carrott, William R. Lynch, Mark B. Orringer, Max S. Wicha, Nallasivam Palanisamy, David G. Beer, Sunitha Nagrath. A study of pulmonary and peripheral vein blood as sources of circulating tumor cells in early lung cancer. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 1581. doi:10.1158/1538-7445.AM2015-1581