EGFR inhibition in NSCLC: New findings\u2026. and opened questions?

The targeted inhibition of epidermal growth factor receptor (EGFR) has represented a milestone in the treatment of lung cancer. Several studies convincingly and consistently demonstrated a significant superiority of EGFR-TKIs over standard platinum-chemotherapy in EGFR-mutated NSCLC patients, leading to the sequential approval of gefitinib, erlotinib and afatinib as new standard first-line clinical treatment. To date we are witnessing a second revolution in the management of EGFR-positive NSCLC thanks to the development of new treatment strategies aiming to overcome acquired resistance to TKIs and ultimately improve patients\u2019 outcomes. In this review we summarize the most important recent findings regarding EGFR-inhibition in NSCLC, highlighting the current unsolved questions on the selection of the best TKI in first-line, which therapy can be combined with upfront EGFR-TKIs, how to overcome acquired resistance, and which are the clinical applications of liquid biopsy

Second-Line Treatment of Non-Small Cell Lung Cancer: Clinical, Pathological, and Molecular Aspects of Nintedanib

Lung carcinoma is the leading cause of death by cancer in the world. Nowadays, most patients will experience disease progression during or after first-line chemotherapy demonstrating the need for new, effective second-line treatments. The only approved second-line therapies for patients without targetable oncogenic drivers are docetaxel, gemcitabine, pemetrexed, and erlotinib and for patients with target-specific oncogenes afatinib, osimertinib, crizotinib, alectinib, and ceritinib. In recent years, evidence on the role of antiangiogenic agents have been established as important and effective therapeutic targets in non-small cell lung cancer (NSCLC). Nintedanib is a tyrosine kinase inhibitor targeting three angiogenesis-related transmembrane receptors (vascular endothelial growth factor, fibroblast growth factor, and platelet-derived growth factor). Several preclinical and clinical studies have proven the usefulness of nintedanib as an anticancer agent for NSCLC. The most important study was the phase III LUME-Lung 1 trial, which investigated the combination of nintedanib with docetaxel for second-line treatment in advanced NSCLC patients. The significant improvement in overall survival and the manageable safety profile led to the approval of this new treatment in Europe. This review focuses on the preclinical and clinical studies with nintedanib in NSCLC

Pathological characterization of tumor immune microenvironment (Time) in malignant pleural mesothelioma

SIMPLE SUMMARY: Tumor immune microenvironment is an important structural component of malignant pleural mesothelioma that contributes to disease growth support and progression. Its study and pathological characterization are important tools to find new biomarkers for advanced therapeutic strategies. ABSTRACT: Malignant pleural mesothelioma (MPM) is a rare and highly aggressive disease that arises from pleural mesothelial cells, characterized by a median survival of approximately 13–15 months after diagnosis. The primary cause of this disease is asbestos exposure and the main issues associated with it are late diagnosis and lack of effective therapies. Asbestos-induced cellular damage is associated with the generation of an inflammatory microenvironment that influences and supports tumor growth, possibly in association with patients’ genetic predisposition and tumor genomic profile. The chronic inflammatory response to asbestos fibers leads to a unique tumor immune microenvironment (TIME) composed of a heterogeneous mixture of stromal, endothelial, and immune cells, and relative composition and interaction among them is suggested to bear prognostic and therapeutic implications. TIME in MPM is known to be constituted by immunosuppressive cells, such as type 2 tumor-associated macrophages and T regulatory lymphocytes, plus the expression of several immunosuppressive factors, such as tumor-associated PD-L1. Several studies in recent years have contributed to achieve a greater understanding of the pathogenetic mechanisms in tumor development and pathobiology of TIME, that opens the way to new therapeutic strategies. The study of TIME is fundamental in identifying appropriate prognostic and predictive tissue biomarkers. In the present review, we summarize the current knowledge about the pathological characterization of TIME in MPM

PD-L1 expression as predictive biomarker in patients with NSCLC: A pooled analysis

none11Background: Clinical trials of immune checkpoints modulators, including both programmed cell death-1 (PD-1) and programmed cell death-ligand 1 (PD-L1) inhibitors, have recently shown promising activity and tolerable toxicity in pre-treated NSCLC patients. However the predictive role of PD-L1 expression is still controversial. This pooled analysis aims to clarify the association of clinical objective responses to anti PD-1/PD-L1 monoclonal antibodies (MoAbs) and tumor PD-L1 expression in pre-treated NSCLC patients. Methods: Data from published studies, that evaluated efficacy and safety of PD-1/PD-L1 inhibitors in pre-treated NSCLC patients, stratified by tumor PD-L1 expression status (immunohistochemistry, cut-off point 1%), were collected by searching in PubMed, Cochrane Library, American Society of Clinical Oncology, European Society of Medical Oncology and World Conference of Lung Cancer, meeting proceedings. Pooled Odds ratio (OR) and 95% confidence intervals (95% CIs) were calculated for the Overall Response Rate (ORR) (as evaluated by Response Evaluation Criteria in Solid Tumors, version 1.1), according to PD-L1 expression status. Results: A total of seven studies, with 914 patients, were eligible. Pooled analysis showed that patients with PD-L1 positive tumors (PD-L1 tumor cell staining ≥1%), had a significantly higher ORR, compared to patients with PD-L1 negative tumors (OR: 2.44; 95% CIs: 1.61-3.68). Conclusions: PD-L1 tumor over-expression seems to be associated with higher clinical activity of anti PD-1/PD-L1 MoAbs, in pre-treated NSCLC patients, suggesting a potential role of PD-L1 expression, IHC cut-off point 1%, as predictive biomarker for the selection of patients to treat with immune-checkpoint inhibitors.openPassiglia F.; Bronte G.; Bazan V.; Natoli C.; Rizzo S.; Galvano A.; Listi A.; Cicero G.; Rolfo C.; Santini D.; Russo A.Passiglia, F.; Bronte, G.; Bazan, V.; Natoli, C.; Rizzo, S.; Galvano, A.; Listi, A.; Cicero, G.; Rolfo, C.; Santini, D.; Russo, A

RAS as a positive predictive biomarker: focus on lung and colorectal cancer patients

Rat sarcoma (RAS) oncogenes have intensively been investigated during the last decades. Taking into account all human tumours, Kirsten Rat Sarcoma Viral Oncogene Homolog (KRAS) gene is the most frequently mutated (about 22%) among the three isoforms, followed by Neuroblastoma RAS Viral Oncogene Homolog (NRAS) (8%) and Harvey Rat Sarcoma Viral Oncogene Homolog (HRAS) (3%). In the last years, careful attention has been paid on KRAS and NRAS gene mutations in non–small-cell lung cancer (NSCLC) and colorectal cancer (CRC) patients because of their prognostic and predictive roles. In particular, a large body of literature data has been generated investigating clinical outcomes of targeted treatments in NSCLC and CRC KRAS- and NRAS-mutated patients. The latest evidences are here reviewed, providing also an overview of the real-world RAS mutation testing practice across different Italian laboratories. On this basis, we propose a knowledge-based system, www.rasatlas.com, to support the healthcare personnel in the management of patients featuring RAS gene mutations in the landscape of precision oncology

The role of microRNAs in driving EGFR-TKI resistance in NSCLC cell lines

Background: the inhibition of EGFR kinase activity by tyrosine kinase inhibitors (EGFR-TKIs), such as gefitinib and erlotinib, can result in improved response and prolonged progression-free survival (PFS) in NSCLC patients harboring sensitizing exon 19del and exon 21 L858R mutations. Unfortunately, almost all patients will develop resistance to EGFR-TKI, in particular T790M is the most frequent mutation. Nowadays, new methods are urgently needed for a rapid, cost-effective and non-invasive identification of biomarkers as a valuable tool for obtaining the genetic follow-up data during the course of the disease. Circulating microRNAs might represent a new precious biomarker for patients\u2019 monitoring. The study aimed to verify the association between microRNAs expression and EGFR mutational status in adenocarcinoma wt and EGFR-TKI sensitive mutated (del19) cells. Methods: EGFR wt and mutated adenocarcinoma cells (A549, HCC827), were cultured in RPMI1640 and incubated at 37C in 5% CO2. Cell viability before treatment was evaluated by MTT assay and then cells were treated with Erlotinib at growing concentration. MicroRNAs were extracted by using miRNeasy mini kit (QIAGEN). Nucleic acids quantity and quality was evaluated through the NanoDrop ND-2100 Bioanalyzer whereas integrity through the 2100 Bioanalyzer. MicroRNAs after retrotranscription were profiled through TaqMan Array Human MicroRNA Cards v2.0. Results: microRNAs extracted from A549 (wild-type) and HCC827 (del19) were profiled and differential expression analyzed at basal conditions (no treatment) using the wt cell as control. The miRNAs analysis highlighted that among the up-regulated microRNAs (miR-7, miR-18a, miR-106b, miR-200b, miR-505, miR-625), the miR-7 expression levels were 10 times higher, whereas among the down-regulated miRNAs (let-7f, miR-10b, miR-192, miR-193, miR-194, miR-767, miR-801), let-7f was 12 times lower. This signature may represent a valid start point for studying variations of the aforementioned miRNAs levels during TKIs treatment in order to demonstrate their involvement in inducing resistance. Conclusions: to outline molecular mechanisms responsible for resistance onset as consequence of TKIs treatment, the hypotetical role of miRNAs has been studied. The preliminary data, obtained so far only in cultured cell lines at basal conditions, would acquire higher relevance, if their involvement may be confirmed also in TKI-treated cells

The prognostic role of KRAS and BRAF in patients undergoing surgical resection of colorectal cancer liver metastasis: a systematic review and meta-analysis

Background: Clinical trials investigated the potential role of both KRAS and BRAF mutations, as prognostic biomarkers, in colorectal cancer (CRC) patients who underwent surgical treatment of liver metastasis (CLM), showing conflicting results. This meta-analysis aims to review all the studies reporting survival outcomes (recurrence free survival (RFS), and/or overall survival (OS)) of patients undergoing resection of CLM, stratified according to KRAS and/or BRAF mutation status. Materials and Methods: Data from all published studies reporting survival outcomes (RFS and/or OS) of CRC patients who received resection of CLM, stratified by KRAS and/or BRAF mutation status were collected by searching in PubMed, Cochrane Library, American Society of Clinical Oncology and European Society of Medical Oncology meeting proceedings. Pooled hazard ratios (HRs) and 95% confidence intervals (95% CIs) were calculated for both the OS and/or RFS. Results: Seven eligible trials (1403 patients) were included. Pooled analysis showed that KRAS mutations predicted a significant worse both RFS (HR: 1.65; 95% CI: 1.23 \u2013 2.21) and OS (HR: 1.86; 95% CI: 1.51 \u2013 2.30) in patients who underwent surgical resection of CLM. BRAF mutations were also associated with a significant worse OS (HR: 3.90; 95% CI: 1.96 \u2013 7.73) in this subgroup of patients. Conclusion: This meta-analysis suggests both KRAS and BRAF mutations as negative prognostic biomarkers associated with worse survival outcomes in patients undergoing hepatic resection of CLM. Such evidences support the introduction of new treatment decision models, taking into account the tumor molecular profile in order to individualize both systemic and loco-regional treatment strategies

CALR MUTATIONS IN SICILIAN ESSENTIAL THROMBOCYTHEMIA AND MYELOFIBROSIS PATIENTS.

Background. Essential thrombocythemia (ET) and primary myelofibrosis (MF) are myeloproliferative neoplasms characterized by the overproduction of mature cells such as platelets (ET) or early bone marrow fibrosis due to scarring induced by highly proliferating myeloid progenitors and pathological stimulation of local fibroblasts (MF). Somatic mutations in CALR gene have recently identified in the majority of JAK2-V617F and MPL negative ET and MF patients. In this study we evaluated the frequency and type of CALR mutations and their clinical and hematological features. Methods. A total of 54 patients, 29 ET and 25 MF patient, was included in this study. All patients were JAK2 V617F and MPL negative. We registered clinical and hematological characteristics of patients i.e. age, hemoglobin level, white blood cell count, platelet count, International Prognostic Scoring System (IPSS), risk of thrombosis. Samples were collected from peripheral blood and DNA was extracted by using the QIAamp DNA mini kit (QIAGEN); CALR mutations were analyzed by direct sequencing method. Results. CALR mutations were present in 20.4 % of patients (4 ET; 7 MF). Four types of CALR mutations were detected; type 1 (p.L367fs*46) was isolated in 6 MF patient, type 2 (p.K385fs*47) was isolated in 3 ET patient; we also found 2 deletion mutations (p.E371fs*49 and D373fs*47), which are less common deletions, in the remaining patients. Patients carrying CALR mutations were younger (mediane age: 50 vs 65; p=0.2) than CALR negative patients. Furthermore, they did not show thrombosis and IPSS high risk. Conclusions. Our observations are in agreement with the findings of literature. We can assert an improved outcome of CALR mutated patients and we can also speculate a possible protective role of CARL mutations given the absence of thrombosis events and of IPSS high risk. However, the cohort of patients with myeloproliferative disease need to be implemented to draw final conclusion

Critical Transition in Tissue Homeostasis Accompanies Murine Lung Senescence

BACKGROUND: Respiratory dysfunction is a major contributor to morbidity and mortality in aged populations. The susceptibility to pulmonary insults is attributed to "low pulmonary reserve", ostensibly reflecting a combination of age-related musculoskeletal, immunologic and intrinsic pulmonary dysfunction. METHODS/PRINCIPAL FINDINGS: Using a murine model of the aging lung, senescent DBA/2 mice, we correlated a longitudinal survey of airspace size and injury measures with a transcriptome from the aging lung at 2, 4, 8, 12, 16 and 20 months of age. Morphometric analysis demonstrated a nonlinear pattern of airspace caliber enlargement with a critical transition occurring between 8 and 12 months of age marked by an initial increase in oxidative stress, cell death and elastase activation which is soon followed by inflammatory cell infiltration, immune complex deposition and the onset of airspace enlargement. The temporally correlative transcriptome showed exuberant induction of immunoglobulin genes coincident with airspace enlargement. Immunohistochemistry, ELISA analysis and flow cytometry demonstrated increased immunoglobulin deposition in the lung associated with a contemporaneous increase in activated B-cells expressing high levels of TLR4 (toll receptor 4) and CD86 and macrophages during midlife. These midlife changes culminate in progressive airspace enlargement during late life stages. CONCLUSION/SIGNIFICANCE: Our findings establish that a tissue-specific aging program is evident during a presenescent interval which involves early oxidative stress, cell death and elastase activation, followed by B lymphocyte and macrophage expansion/activation. This sequence heralds the progression to overt airspace enlargement in the aged lung. These signature events, during middle age, indicate that early stages of the aging immune system may have important correlates in the maintenance of tissue morphology. We further show that time-course analyses of aging models, when informed by structural surveys, can reveal nonintuitive signatures of organ-specific aging pathology