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Introduction: HER2 mutations are reported to occur in 2%-5% of all cases of non-small cell lung cancer (NSCLC). The clinical outcomes in patients with HER2-mutant NSCLC treated with immune checkpoint inhibitors (ICIs) plus platinum-based chemotherapy as 1st line treatment still remain unclear., Methods: Using the large-scale clinico-genomic database of LC-SCRUM-Asia, the clinico-genomic characteristics and therapeutic outcomes of patients with HER2-mutant NSCLC were investigated., Results: Of the 15,251 patients with NSCLC enrolled in the LC-SCRUM-Asia database, tumor HER2 mutations were detected in 402 patients (2.6 %). The most common subtype of HER2 mutations was exon 20 in-frame insertions (79 %), followed in frequency by mutations in the tyrosine kinase domain other than Exon20ins (10 %) and mutations in extracellular domains (7 %). NSCLCs harboring HER2 mutations showed a higher tumor mutation burden (TMB) as compared with NSCLCs harboring EGFR mutations or ALK fusions (median: 4.22 vs. 2.54 and 2.52 mutation per megabase, respectively). Of the 402 patients, 268 patients had received platinum-based chemotherapy with ICIs (Chemo-ICI, n = 95) or without ICI (Chemo-alone, n = 173) as 1st line treatment. The progression-free survival (PFS) was significantly longer in the Chemo-ICI group as compared with the Chemo-alone group (median 8.5 vs. 6.3 months; HR [95 %CI]: 0.66 [0.50-0.88]; P < 0.005). Multivariate analysis identified use of ICIs in addition to platinum-based chemotherapy as an independent favorable prognostic factor for PFS. There was no significant difference in the overall survival between the patients of the Chemo-ICI and Chemo-alone groups (median 31.1 vs. 23.3 months; HR [95 %CI]: 0.80 [0.57-1.12], P = 0.20)., Conclusions: Addition of ICIs to platinum-based chemotherapy in 1st line treatment may improve the PFS in patients with HER2-mutant NSCLC. The relatively high TMB might be involved in the prolongation of the PFS in patients with HER2-mutant NSCLC receiving platinum-based chemotherapy with ICIs., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Hibiki Udagawa reports grants from Takeda Pharmaceutical Co., Ltd., Nippon Boehringer Ingelheim Co., Ltd., Amgen K.K., Taiho Pharmaceutical Co., Ltd. And MSD K.K. and honoraria for lectures from DAIICHI SANKYO COMPANY, LIMITED, CHUGAI PHARMACEUTICAL CO., LTD., Novartis Pharma K.K., Taiho Pharmaceutical Co. Ltd., Taiho Pharmaceutical Co. Ltd., and MSD K.K. outside the current study. Shingo Matsumoto reports grants from Merck, Chugai Pharmaceutical, MSD and Janssen Pharmaceutical and honoraria for lectures from Eli Lilly outside the current study. Hiroki Izumi reports grants from Amgen, Eisai, Takeda Pharmaceutical Co, Bristol-Myers Squibb Japan, Chugai, AstraZeneca, Ono Pharmaceutical Co, MSD and Merck outside the current study. Yuichiro Ohe reports grants from AstraZeneca, Chugai, Eli Lilly, Kirin, Sumitomo, Pfizer, Taiho, Novartis, Takeda, Daiichi-Sankyo and Janssen and honoraria for lectures from AstraZeneca, Chugai, Chugai, ONO, BMS, Boehringer Ingelheim, Bayer, Pfizer, MSD, Taiho, Nippon Kayaku, Kyowa Hakko Kirin, Eisai and Daiichi-Sankyo and payment for expert testimony from AstraZeneca, Chugai, ONO, BMS, Kyorin, Celltrion, Amgen, Nippon Kayaku, Boehringer Ingelheim, AnHeart Therapeutics Inc., PharmaMar outside the current study. Terufumi Kato reports grants from Abbvie, Amgen, Arrivent, AstraZeneca, Bayer, BeiGene, BluePrint, Bristol-Meyers Squibb, Chugai, Daiichi-Sankyo, Eli Lilly, Gilead, GlaxoSmithKline, Haihe, Janssen, Merck KGaA, MSD, Novartis, Pfizer, Regeneron and Takeda and honoraria for lectures from Amgen, AstraZeneca, BeiGene, Boehringer Ingelheim, Bristol-Meyers Squibb, Chugai, Daiichi-Sankyo, Eli Lilly, GlaxoSmithKline, Janssen, Merck KGaA, MSD, Novartis, Ono, Pfizer, Taiho, and Takeda and other from AstraZeneca, BeiGene, Chugai, Daiichi-Sankyo, Janssen, Merck KGaA, MSD, Novartis, Pfizer outside the current study. His spouse is an employer of Eli Lilly. Kazumi Nishino reports grants from ONO PHARMACEUTICAL CO., LTD., TAIHO PHARMACEUTICAL CO., LTD., MSD, AbbVie, DAIICHI SANKYO COMPANY, LIMITED, Amgen, Eisai Co., Ltd., Sanofi K.K., Janssen Pharmaceutical K.K., Novartis Pharmaceuticals, Pfizer, Eli Lilly Japan, Merck Biopharma Co., Ltd., Takeda Pharmaceutical Co.,Ltd., AstraZeneca, Merus NV, Gilead Sciences, CHUGAI PHARMACEUTICAL CO., LTD, Bayer Yakuhin, Ltd and AMGEN and honoraria for lectures from AstraZeneca, Nippon Boehringer Ingelheim, Eli Lilly Japan, MSD, Novartis Pharmaceuticals, Pfizer, Merck Biopharma Co., Ltd., Janssen Pharmaceutical K.K., Bristol Myers Squibb, Nippon Kayaku, ONO PHARMACEUTICAL CO., LTD., Takeda Pharmaceutical Co.,Ltd., CHUGAI PHARMACEUTICAL CO., LTD, AMGEN, DAIICHI SANKYO COMPANY, LIMITED, Nippon Boehringer Ingelheim Co., Ltd. outside the current study. Yuki Sato reports honoraria for lectures from AstraZeneca, MSD, Novartis, Chugai Pharmaceutical, Ono Pharmaceutical, Pfizer, Taiho Pharmaceutical, Nippon Kayaku, Bristol Myers Squibb, Eli Lilly, Takeda, Kyowa Kirin, Daiichi Sankyo and Boehringer Ingelheim outside the current study. Ryo Toyozawa reports grants from Abbvie, Amgen, AnHeart Therapeutics, Daiichi Sankyo, Eli Lilly Japan, MSD, Novartis Pharma, Pfizer Japan and Takeda Pharmaceutical and honoraria for lectures from AstraZeneca, Bristol-Myers Squibb, Chugai Pharmaceutical, Eli Lilly Japan, MSD, Nippon Kayaku, Ono Pharmaceutical, Pfizer Japan, Taiho Pharmaceutical, Takeda Pharmaceutical and Thermo Fisher Scientific outside the current study. Koichi Azuma reports honoraria for lectures from AstraZeneca K.K., Ono Pharmaceutical, Chugai Pharmaceutical, MSD, Bristol-Myers Squibb and Takeda Pharmaceutical outside the current study. Tetsuya Sakai reports grants from Amgen, GlaxoSmithKline K.K, Daiichi Sankyo and NEC and honoraria for lectures from AstraZeneca, Novartis, Thermo Fisher Scientific, Takeda, OLYMPUS, Taiho, Chugai, MSD, Merck, Daiichi Sankyo, RIKEN GENESIS and Amco outside the current study. Yuji Shibata reports grants from MSD, Blueprint Medicines Corporation and Novartis and honoraria for lectures from Pfizer, Bristol-Myers Squibb, AstraZeneca, Ono Pharmaceutical Co., Ltd., Chugai, Takeda, Merck and Eli Lilly Japan outside the current study. Kaname Nosaki reports grants from Takeda, AstraZeneca, MSD K.K, Abbvie, Chugai Pharma, Daiichi Sankyo/UCB Japan and AnHeart Therapeutics and honoraria for lectures from AstraZeneca, Chugai Pharma, Lilly, MSD, Pfizer, Taiho Pharmaceutical, Janssen, Ono Pharmaceutical, Takeda, Novartis and Merck outside the current study. Yoshitaka Zenke reports grants from AstraZeneca, Daiichi-Sankyo, Amgen, GSK, Roche, MSD and Merck and honoraria for lectures from AstraZenca, Lilly, Chugai, Ono, Bristol-Meyers Squibb, Takeda, Boheringer-Ingelheim, Taiho, MSD, Novartis, Pfizer, Nihon Kayaku, Kyowa Kirin and Amgen outside the current study. Shigeki Umemura reports grants from Taiho pharmaceutical, Lilly and MSD and honoraria for lectures from MSD, Chugai Pharmaceutical, Takeda, AstraZeneca and Daiichi sankyo outside the current study. Kiyotaka Yoh reports grants from Abbvie, Amgen, ArriVent Biopharma, AstraZeneca, Boehringer Ingelheim, Chugai Pharma, Daiichi sankyo, Lilly, MSD, Taiho and Takeda and consulting fees from Boehringer Ingelheim and Abbvie and honoraria for lectures from Amgen, AstraZeneca, Bristol-Myers Squibb, Chugai Pharma, Daiichi sankyo, Kyowa kirin, Lilly, MSD, Ono Pharmaceutical and Takeda outside the current study. Masahiro Seike reports grants from Chugai Pharmaceutical, Eli Lilly, Kyowa Hakko Kirin, Taiho Pharmaceutical and Nippon Kayaku and honoraria for lectures from AstraZeneca, Chugai Pharmaceutical, Eli Lilly, Bristol-Myers Squibb, Pfizer, Nippon Kayaku, Daiichi-Sankyo, Merck Biopharma, MSD K.K, Taiho Pharmaceutical, Ono Pharmaceutical, Nippon Boehringer Ingelheim, Takeda Pharmaceutical, Kyowa Hakko Kirin, Novartis and Amgen inc outside the current study. Koichi Goto reports grants from Amgen K.K., Astellas Pharma Inc., AstraZeneca K.K., Nippon Boehringer Ingelheim Co., Ltd., Bristol-Myers Squibb K.K., CHUGAI PHARMACEUTICAL CO., LTD., DAIICHI SANKYO COMPANY, LIMITED, Eisai Co., Ltd., Janssen Pharmaceutical K.K., Kyowa Kirin Co., Ltd., Merck Biopharma Co., Ltd., MEDICAL& BIOLOGICAL LABORATORIES CO., LTD., MSD K.K., Novartis Pharma K.K., ONO PHARMACEUTICAL CO., LTD., Pfizer R&D Japan G.K., Sumitomo Pharma Co., Ltd., Taiho Pharmaceutical Co., Ltd., Eli Lilly Japan K.K., Bayer Yakuhin, Ltd., Merus N.V. and Takeda Pharmaceutical Co., Ltd. for the present manuscript. Koichi Goto also reports grants from Amgen Inc., AbbVie GK, AnHeart Therapeutics Inc., Blueprint Medicines Corporation., Craif Inc., Guardant Health Asia, Middle East & Africa, Inc, Haihe Biopharma Co., Ltd., Ignyta,Inc., Life Technologies Japan Ltd., Loxo Oncology, Inc., Lunit Inc., Precision Medicine Asia Co., Ltd., RIKEN GENESIS CO., LTD., Spectrum Pharmaceuticals, Inc., Sysmex Corporation., Turning Point Therapeutics,Inc. and honoraria for lectures from Amgen K.K., Amoy Diagnosties Co.,Ltd., AstraZeneca K.K., Bayer U.S., Bristol-Myers Squibb K.K., CHUGAI PHARMACEUTICAL CO., LTD., DAIICHI SANKYO COMPANY, LIMITED, Eisai Co., Ltd., Eli Lilly Japan K.K., Guardant Health Japan Corp., iTeos Therapeutics Inc., Janssen Pharmaceutical K.K., Thermo Fisher Scientific K.K., Merck Biopharma Co., Ltd., Nippon Kayaku Co.,Ltd., Novartis Pharma K.K., ONO PHARMACEUTICAL CO., LTD., Pharma Mar, S.A., RIKEN GENESIS CO., LTD., Taiho Pharmaceutical Co., Ltd. And Takeda Pharmaceutical Co., Ltd. And other from Amgen Inc., Amgen K.K., AstraZeneca K.K., Bayer HealthCare Pharmaceuticals Inc., Bristol-Myers Squibb K.K., DAIICHI SANKYO COMPANY, LIMITED, Eli Lilly Japan K.K., GlaxoSmithKline K.K., Haihe Biopharma Co., Ltd., Janssen Pharmaceutical K.K. and SYNEOS HEALTH CLINICAL K.K. Other authors report no potential conflict of interest to disclose.., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Introduction: SCLC has been treated as a single entity resulting in limited survival improvement. Developing effective tools for guiding appropriate therapeutic strategies is crucial., Methods: A total of 1035 SCLCs were prospectively analyzed by a genomic screening platform: LC-SCRUM-Asia. Fresh frozen tumor samples were subjected to a next-generation sequencing system enabling the integrative analysis of cancer-related genes. A phase 2 trial of gedatolisib for SCLC with PI3K/AKT/mTOR pathway mutations was conducted based on this screening., Results: On the basis of the treatment outcomes and therapeutic targets, the following five distinct genetic subgroups were identified in SCLC: NSCLC-subgroup (genetic alterations associated with NSCLC, 8.5%); Hotspot-subgroup (targetable hotspot mutations common in tumors, 3.0%); PI3K-subgroup (PI3K/AKT/mTOR pathway mutations, 7.4%); MYC-subgroup (MYC family amplifications, 13.0%); and HME-subgroup (mutations in the histone-modifying enzymes, 17.6%). The NSCLC-subgroup (hazard ratio = 1.57; 95% confidence interval: 1.22-2.03) and MYC-subgroup (hazard ratio = 1.56; 95% confidence interval: 1.26-1.93) had significantly shorter progression-free survivals after first-line platinum-based treatment. The Hotspot-subgroup and MYC-subgroup were candidates for novel targeted therapies. The HME-subgroup had a favorable survival in patients who received programmed cell death (ligand) 1 inhibitor-based therapies (p = 0.005, log-rank test) regardless of some overlap with other subgroups. There were 15 patients enrolled into the phase 2 trial of gedatolisib in the PI3K-subgroup, and the overall response rate and the disease control rate were 6.7% and 20%, respectively. The MYC-subgroup or NSCLC-subgroup was associated with unfavorable clinical outcomes in this trial., Conclusions: Molecular classification of SCLC by genetic approach is beneficial for predicting the treatment outcomes and effectively guiding the clinical choices., Competing Interests: Disclosure Dr. Umemura reports receiving grants from Taiho Pharmaceutical and honoraria from Merck Sharp & Dohme and Chugai Pharmaceutical. Dr. Udagawa reports receiving grants from Takeda and Boehringer Ingelheim. Dr. Murakami reports receiving grants from Chugai Pharma, AstraZeneca, Takeda, Daiichi Sankyo, AbbVie, IQVIA, Taiho Pharmaceutical, and Bayer; receiving honoraria from Pfizer, Chugai Pharma, Daiichi Sankyo, AstraZeneca, Takeda, Amgen, Ono Pharmaceutical, Bristol-Myers Squibb Japan, Merck Sharp & Dohme, Novartis, Lilly Japan, Taiho Pharmaceutical, Eisai, and Nihonkayaku; and having participation on a data safety monitoring board or advisory board for Chugai Pharma, GAIA BioMedicine, Daiichi Sankyo, and Amgen. Dr. Daga reports receiving honoraria from AstraZeneca and Chugai Pharmaceutical. Dr. Toyozawa reports receiving grants from Pfizer, AbbVie, Amgen, AnHeart Therapeutics, Daiichi Sankyo, Eli Lilly Japan, Novartis Pharma, and Takeda Pharmaceutical and honoraria from Pfizer, AstraZeneca, Chugai Pharmaceutical, Eli Lilly Japan, Merck Sharp & Dohme, Nippon Boehringer Ingelheim, Novartis Pharma, Ono Pharmaceutical, Taiho Pharmaceutical, and Takeda Pharmaceutical. Dr. Kozuki reports receiving grants from Pfizer, Chugai Pharmaceutical Co., AstraZeneca, Eli Lilly Japan, Taiho Pharmaceutical Co., Bristol-Myers Squibb, Ono Pharmaceutical Co., Merck Sharp & Dohme, Kyowa Hakko Kirin, Merck Biopharma, Daiichi Sankyo, Amgen, AbbVie, Sanofi, Eisai, LabCorp Development Japan, IQVIA Services Japan, Gilead Sciences, and Bayer; consulting fees from Pfizer, Chugai Pharmaceutical Co., AstraZeneca, Ono Pharmaceutical Co., Daiichi Sankyo, Bayer, and AbbVie; and honoraria from Pfizer, Chugai Pharmaceutical Co., AstraZeneca, Eli Lilly Japan, Taiho Pharmaceutical Co., Bristol-Myers Squibb, Ono Pharmaceutical Co., Merck Sharp & Dohme, Kyowa Hakko Kirin, Nippon Boehringer Ingelheim, Merck Biopharma, Nippon Kayaku, Novartis, Daiichi Sankyo, Takeda Pharmaceutical Co., Bayer, Sawai, and Amgen. Dr. Sakakibara-Konishi reports receiving grants from Lilly. Dr. Ohe reports receiving grants from Pfizer, AstraZeneca, Chugai, Lilly, ONO, Bristol-Myers Squibb, Kyorin, Dainippon-Sumitomo, Taiho, Novartis, Takeda, Kissei, Daiichi Sankyo, Janssen, and Loxo; receiving payment for expert testimony from AstraZeneca, Chugai, ONO, Bristol-Myers Squibb, Kyorin, Celltrion, Amgen, Nippon Kayaku, Boehringer Ingelheim, and AnHeart Therapeutics Inc., and having leadership roles with JSMO, JLCS, and JCOG. Dr. Morise reports receiving grants from Boehringer Ingelheim and Eli Lilly; honoraria from Pfizer, Boehringer Ingelheim, Daiichi Sankyo, AstraZeneca, Eli Lilly, Chugai Pharmaceutical, Merck Sharp & Dohme, Ono Pharmaceutical, and Taiho Pharmaceutical; and other financial or nonfinancial interests from Pfizer, Chugai, AstraZeneca, Ono, Merck Serono, Kissei, Taiho, and Novartis. Dr. Kato reports receiving grants from Pfizer, AbbVie, Amgen, AstraZeneca, BeiGene, BluePrint, Chugai, Daiichi Sankyo, Eli Lilly, Haihe, Merck KGaA, Merck Sharp & Dohme, Novartis, Regeneron, Takeda, and TurningPoint; receiving honoraria from Pfizer, Amgen, AstraZeneca, BeiGene, Boehringer Ingelheim, Chugai, Daiichi Sankyo, Eli Lilly, GlaxoSmithKline, Janssen, Merck KGaA, Merck Sharp & Dohme, Novartis, Ono, Taiho, and Takeda; having participation on a data safety monitoring board or advisory board from Pfizer, AstraZeneca, BeiGene, Daiichi Sankyo, Janssen, Merck KGaA, Merck Sharp & Dohme, and Novartis; and receiving other financial or nonfinancial interests for Eli Lilly. Dr. Furuya reports receiving honoraria from Pfizer, Eli Lilly Japan, AstraZeneca, Boehringer Ingelheim Japan, Chugai, Bristol-Myers Squibb, Taiho, and Novartis. Dr. Nakachi reports receiving honoraria from AstraZeneca, Chugai Pharmaceutical, and Novartis Pharma. Dr. Nomura reports receiving grants from AstraZeneca and Amgen and honoraria from AstraZeneca, Chugai, Kyowa Hakko, JMDC, Byer, and Asahi-Kasei Pharma. Dr. Sato reports receiving grants from Taiho Pharmaceutical, Boehringer Ingelheim, Bayer, Chugai Pharma, Eisai, Ono Pharmaceutical, Takeda, Aspyrian Therapeutics, Pentax Medical Devices, and Daiichi Sankyo/UCB Japan. Dr. Ishii reports receiving grants from Daiichi Sankyo, Inc., Ono Pharmaceutical Co., Ltd., Noile-Immune Biotech, Takeda Pharmaceutical Company Limited, Sumitomo Dainippon Pharma Co., Ltd., Nihon Medi-Physics Co., Ltd., Indivumed GmbH, and H.U. Group Research Institute; consulting fees from Takeda Pharmaceutical Company Limited; and honoraria from Roche Diagnostics K.K., Chugai Pharmaceutical Co., Ltd., Novartis International AG, Eli Lilly Japan K.K., Takeda Pharmaceutical Company Limited, AstraZeneca, Riken Genesis Co., Ltd., and Merck Biopharma Japan. Dr. Kirita reports receiving consulting fees from Eli Lilly and honoraria from Pfizer, Merck Sharp & Dohme Oncology, Boehringer Ingelheim, Novartis, Takeda Pharmaceuticals, Boston Scientific, Chugai Pharma, ONO Pharma, Merk BioPharma, Thermo Fisher Scientific, AstraZeneca, Taiho Pharmaceuticals, Amgen, and Bristol-Myers Squibb. Dr. Sakai reports receiving grants from Amgen and Daiichi Sankyo and honoraria from AstraZeneca, Chugai, Novartis, Merck Sharp & Dohme, Thermo Fisher Scientific, and Merck. Dr. Shibata reports receiving grants from Merck Sharp & Dohme and Blueprint Medicines Corporation and honoraria from Pfizer, Chugai, Bristol-Myers Squibb, Takeda, AstraZeneca, Merck, Ono Pharmaceutical Co., Ltd., and Eli Lilly Japan. Dr. Izumi reports receiving grants from AbbVie, AstraZeneca, Amgen, Takeda, Eisai, and Ono Pharmaceutical; receiving honoraria from Takeda, Merck, Ono Pharmaceutical, Merck Sharp & Dohme, Chugai, and Bristol-Myers Squibb Japan; and having participation on a data safety monitoring board or advisory board for Amgen. Dr. Nosaki reports receiving grants from AbbVie, AnHeart Therapeutics, AstraZeneca, Chugai Pharma, Daiichi Sankyo, Merck Sharp & Dohme, and Takeda; receiving honoraria from Pfizer, AstraZeneca, Chugai Pharma, Lilly, Merck Sharp & Dohme, Taiho Pharmaceutical, Yansen Pharma, Ono, Takeda, Novartis, and Merck; and having participation on a data safety monitoring board or advisory board for Daiichi Sankyo/UCB/Japan and AbbVie. Dr. Zenke reports receiving grants from AstraZeneca, Merck Sharp & Dohme, Daiichi Sankyo, Amgen, GlaxoSmithKline, Roche, and Merck and honoraria from Pfizer, AstraZeneca, Lilly, Chugai, Ono, Bristol-Myers Squibb, Takeda, Boehringer Ingelheim, Taiho, Merck Sharp & Dohme, Novartis, Nihon Kayaku, Kyowa Kirin, and Amgen. Dr. Matsumoto reports receiving grants from Chugai Pharma, Janssen Pharmaceutical, and Merck Sharp & Dohme and honoraria from Eli Lilly, Merck Biopharma, Chugai Pharma, Novartis Pharma, Guardant Health, and AstraZeneca. Dr. Yoh reports receiving grants from Pfizer, AbbVie, Amgen, AstraZeneca, Boehringer Ingelheim, Chugai, Daiichi Sankyo, Lilly, Merck Sharp & Dohme, Taiho, and Takeda; receiving honoraria from AbbVie, Amgen, AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb, Chugai, Daiichi Sankyo, Janssen, Kyowa Kirin, Lilly, Merck Serono, Novartis, Ono, Otsuka, Taiho, and Takeda; and having participation on a data safety monitoring board or advisory board for Boehringer Ingelheim. Dr. Niho reports receiving grants from Chugai, Eli Lilly, Daiichi Sankyo, Boehringer Ingelheim, GlaxoSmithKline, Kyowa Kirin, Kyorin, Taiho, Nippon Kayaku, and Teijin; receiving consulting fees from Pfizer, AstraZeneca, and Daiichi Sankyo; and receiving honoraria from Pfizer, AstraZeneca, Amgen, Boehringer Ingelheim, Chugai, Daiichi Sankyo, Eisai, Eli Lilly, Kyorin, Kyowa Kirin, Merck Biopharma, Merck Sharp & Dohme, Nippon Kayaku, Novartis, Ono, and Takeda. Dr. Goto reports receiving grants from Pfizer, Amgen Inc., Amgen K.K., Amgen Astellas BioPharma K.K., AstraZeneca K.K., Bayer Yakuhin, Ltd., Boehringer Ingelheim Japan, Inc., Bristol-Myers Squibb K.K., Blueprint Medicines Corporation, Craif Inc., Daiichi Sankyo Co., Ltd., Eisai Co., Ltd., Eli Lilly Japan K.K., Haihe Biopharma Co., Ltd., Ignyta, Inc., Janssen Pharmaceutical K.K., Kissei Pharmaceutical Co., Ltd., Kyowa Kirin Co., Ltd., Life Technologies Japan Ltd., Loxo Oncology, Inc., LSI Medience Corporation, Medical & Biological Laboratories Co., Ltd., Merck Biopharma Co., Ltd., Merus N.V., Merck Sharp & Dohme K.K., Novartis Pharma K.K., Ono Pharmaceutical Co., Ltd., Precision Medicine Asia Co., Ltd., Riken Genesis Co., Ltd., Sumitomo Pharma Co., Ltd., Spectrum Pharmaceuticals, Inc., Sysmex Corporation, Taiho Pharmaceutical Co., Ltd., Takeda Pharmaceutical Co., Ltd., Turning Point Therapeutics, Inc., and Xcoo, Inc.; receiving honoraria from Amgen Inc., Amgen K.K., Amoy Diagnostics Co., Ltd., AstraZeneca K.K., Bayer HealthCare Pharmaceuticals Inc., Bayer Yakuhin, Ltd., Boehringer Ingelheim Japan, Inc., Blueprint Medicines Corporation, Daiichi Sankyo Co., Ltd., Eisai Co., Ltd., Eli Lilly Japan K.K., Guardant Health Inc., Haihe Biopharma Co., Ltd., Janssen Pharmaceutical K.K., Medpace Japan K.K., Merck Biopharma Co., Ltd., Nippon Kayaku Co., Ltd., Novartis Pharma K.K., Ono Pharmaceutical Co., Ltd., Otsuka Pharmaceutical Co., Ltd., Riken Genesis Co., Ltd., Taiho Pharmaceutical Co., Ltd., Takeda Pharmaceutical Co., Ltd., and Xcoo, Inc.; and having participation on a data safety monitoring board or advisory board for Amgen Inc., Amgen K.K., Daiichi Sankyo Co., Ltd., and Eli Lilly Japan K.K. The remaining authors declare no conflict of interest., (Copyright © 2024 International Association for the Study of Lung Cancer. Published by Elsevier Inc. All rights reserved.)

Introduction: Pembrolizumab is a programmed death-ligand 1 inhibitor that was initially indicated for monotherapy in patients with advanced lung cancer. The Japanese Lung Cancer Society conducted an observational study on pembrolizumab using confirmative data obtained through postmarketing all-case surveillance (PMACS), which was performed by a pharmaceutical company under the Japanese law in 2017., Methods: This multicenter observational study was conducted by the Japanese Lung Cancer Society using PMACS data with the newly created central registration system regarding patients with NSCLC who received pembrolizumab monotherapy between February 1, 2017 and June 30, 2017; a new database was created by adding the clinical information regarding prognosis for 3 years after therapy to the existing data collected by PMACS., Results: A total of 300 patients from 43 facilities were enrolled in this study. The median overall survival and progression-free survival after pembrolizumab initiation were 558 and 188 days, respectively. Moreover, the 1- and 3-year survival rates were 58.9% and 33.7%, respectively. Results of multivariate analysis revealed performance status ( p < 0.0001), histology ( p = 0.0118), previous chemotherapy ( p = 0.0007), programmed death-ligand 1 expression status ( p = 0.0195), and previous steroid use ( p = 0.0460) as significant factors that affected overall survival. The toxicity profile was similar to that previously reported., Conclusions: In this first attempt to use PMACS data, we successfully collected clinical information and found the real-world efficacy and safety of pembrolizumab., (© 2022 The Authors.)

A majority of mesothelioma specimens were defective of p14 and p16 expression due to deletion of the INK4A/ARF region, and the p53 pathway was consequently inactivated by elevated MDM2 functions which facilitated p53 degradaton. We investigated a role of p53 elevation by MDM2 inhibitors, nutlin-3a and RG7112, in cytotoxicity of replication-competent adenoviruses (Ad) lacking the p53-binding E1B55kDa gene (Ad-delE1B). We found that a growth inhibition by p53-activating Ad-delE1B was irrelevant to p53 expression in the infected cells, but combination of Ad-delE1B and the MDM2 inhibitor produced synergistic inhibitory effects on mesothelioma with the wild-type but not mutated p53 genotype. The combination augmented p53 phosphorylation, activated apoptotic but not autophagic pathway, and enhanced DNA damage signals through ATM-Chk2 phosphorylation. The MDM2 inhibitors facilitated production of the Ad progenies through augmented expression of nuclear factor I (NFI), one of the transcriptional factors involved in Ad replications. Knocking down of p53 with siRNA did not increase the progeny production or the NFI expression. We also demonstrated anti-tumor effects by the combination of Ad-delE1B and the MDM2 inhibitors in an orthotopic animal model. These data collectively indicated that upregulation of wild-type p53 expression contributed to cytotoxicity by E1B55kDa-defective replicative Ad through NFI induction and suggested that replication-competent Ad together with augmented p53 levels was a therapeutic strategy for p53 wild-type mesothelioma.

Objectives: The aim of this study was to assess the clinical value of [ 11 C]4DST uptake in patients with lung nodules, including benign and malignant tumors, and to assess the correlation between [ 11 C]4DST uptake and proliferative activity of tumors in comparison with [ 18 F]FDG uptake., Methods: Twenty-six patients (22 males and 4 females, mean age of 65.5-year-old) were analyzed in this prospective study. Patients underwent [ 11 C]4DST and [ 18 F]FDG PET/CT imaging on the same day. Diagnosis of each lung nodule was confirmed by histopathological examination of tissue specimens at surgery, or during clinical follow-up after the PET/CT studies. To assess the utility of the semi-quantitative evaluation method, the SUV max was calculated of [ 11 C]4DST and [ 18 F]FDG uptake by the lesion. Proliferative activities of each tumor as indicated by the immunohistochemical Ki-67 index was also estimated using surgical specimens of patients. Then the relationship between the SUV max of both PET/CT and the Ki-67 index was examined. Furthermore, the relationship between the uptake of [ 11 C]4DST or [ 18 F]FDG and the histopathological findings, the clinical stage, and the clinical outcome of patients were also assessed., Results: There was a positive linear relationship between the SUV max of [ 11 C]4DST images and the Ki-67 index (Correlation coefficients = 0.68). The SUV max of [ 11 C]4DST in the 26 lung nodules were 1.65 ± 0.40 for benign lesions, 3.09 ± 0.83 for adenocarcinomas (P < 0.001 between benign and adenocarcinoma), and 2.92 ± 0.58 for SqCCs (P < 0.001 between benign and SqCC). Whereas, the SUVmax of [ 18 F]FDG were 2.38 ± 2.27 for benign lesions, 6.63 ± 4.24 for adenocarcinomas (n.s.), and 7.52 ± 2.84 for SqCCs (n.s.). The relationship between TNM tumor stage and the SUV max of [ 11 C]4DST were 2.54 ± 0.37 for T1, 3.48 ± 0.57 for T2, and 4.17 ± 0.72 for T3 (P < 0.005 between T1 and T2, and P < 0.001 between T1 and T3). In comparison with the TNM pathological stage, SUVmax of [ 11 C]4DST were 2.63 ± 0.49 for stage I, 3.36 ± 0.23 for stage II, 3.40 ± 1.12 for stage III, and 4.65 for stage IV (P < 0.05 between stages I and II). In comparison of the clinical outcome, the SUV max of [ 11 C]4DST were 2.72 ± 0.56 for the no recurrence (No Rec.) group, 3.10 ± 0.33 for the recurrence-free with adjuvant chemotherapy after the surgery (the No Rec. Adjv. CTx. group) and 4.66 ± 0.02 for the recurrence group (Rec. group) (P < 0.001 between the No Rec and Rec. groups, and P < 0.005 between the No Rec. Adjv. CTx. and Rec. groups)., Conclusions: PET/CT with [ 11 C]4DST is as feasible for imaging of lung tumors as [ 18 F]FDG PET/CT. For diagnosing lung tumors, [ 11 C]4DST PET is useful in distinguishing benign nodules from malignancies. [ 11 C]4DST uptake in lung carcinomas is correlated with the proliferative activity of tumors, indicating a promising noninvasive PET imaging of DNA synthesis in malignant lung tumors.

A majority of mesothelioma had the wild-type p53 genotype but was defective of p53 functions primarily due to a genetic defect in INK4A/ARF region. We examined a growth suppressive activity of CP-31398 which was developed to restore the p53 functions irrespective of the genotype in mesothelioma with wild-type or mutated p53. CP-31398 up-regulated p53 levels in cells with wild-type p53 genotype but induced cell growth suppression in a p53-independent manner. In contrasts, nutlin-3a, an MDM2 inhibitor, increased p53 and p21 levels in mesothelioma with the wild-type p53 genotype and produced growth suppressive effects. We investigated a combinatory effect of CP-31398 and nutlin-2a and found the combination produced synergistic growth inhibition in mesothelioma with the wild-type p53 but not with mutated p53. Western blot analysis showed that the combination increased p53 and the phosphorylation levels greater than treatments with the single agent, augmented cleavages of PARP and caspase-3, and decreased phosphorylated FAK levels. Combination of CP-31398 and defactinib, a FAK inhibitor, also achieved synergistic inhibitory effects and increased p53 with FAK dephosphorylation levels greater than the single treatment. These data indicated that a p53-activating CP-31398 achieved growth inhibitory effects in combination with a MDM2 or a FAK inhibitor and suggested a possible reciprocal pathway between p53 elevation and FAK inactivation.

Pemetrexed (PEM) inhibits DNA and RNA synthesis and is currently one of the first-line agents for mesothelioma. PEM suppresses the activities of several enzymes involved in purine and pyrimidine synthesis, and elevated activity of these enzymes in tumors is often linked with resistance to PEM. The agent also stimulates AMP-activated protein kinase (AMPK) and consequently influences the mammalian target of rapamycin complex 1 (mTORC1) pathways. Nevertheless, it remains unclear whether PEM resistance is linked to the AMPK or mTORC1 pathways. Here, we established two independent PEM-resistant mesothelioma cell lines in which expression of the PEM-target enzymes was not elevated, and found that levels of phosphorylated AMPK and p70S6K and, to a lesser extent, levels of phosphorylated AKT and p53, were increased in these cells as compared with the respective parent cells. PEM stimulation also augmented phosphorylation of AMPK, p70S6K, AKT and p53 in most cases. An AMPK activator increased phosphorylation and PEM resistance in parental cells, and the inhibitor decreased the resistance of PEM-resistant cells. In contrast, inhibitors for p70S6K and AKT did not influence PEM resistance; furthermore, increased levels of endogenous p53 did not affect PEM sensitivity. These data collectively indicate that constitutive activation of AMPK is associated with PEM resistance, and that this is unconnected with elevated DNA and RNA synthesis., (© 2019 The Authors. Published by FEBS Press and John Wiley & Sons Ltd.)

Introduction: The East Asia S-1 Trial in Lung Cancer (EAST-LC) was a randomized phase III study conducted in East Asia that demonstrated the non-inferiority of S-1 to docetaxel in previously treated patients with advanced non-small cell lung cancer (NSCLC). Here, we reported the results of the Japanese subgroup treated with docetaxel 60 mg/m 2 , the standard dosage in Japan., Patients and Methods: Patients were randomized 1:1 to receive either S-1 or docetaxel. The primary endpoint was overall survival (OS); the secondary endpoints included progression-free survival (PFS), response rate (RR), quality of life (QOL), and safety., Results: Patient characteristics in the Japanese subgroup (n = 724) were similar to those in the overall EAST-LC population. Median OS was 13.4 months in the S-1 group and 12.6 months in the docetaxel group. In pemetrexed-pretreated patients, OS with S-1 was similar to that with docetaxel. Median PFS was 2.9 and 3.0 months in the S-1 and docetaxel groups, respectively. RR was 9.4% and 10.3% in the S-1 and docetaxel groups, respectively. The QOL of patients treated with S-1 was better compared with that of patients treated with docetaxel. Decreased appetite and diarrhea were more common in the S-1 group, whereas the frequency of neutropenia and febrile neutropenia was markedly higher in the docetaxel group., Conclusions: This Japanese subgroup analysis showed that S-1 had similar efficacy to docetaxel in patients with previously treated advanced NSCLC. These results are similar to those of the overall EAST-LC population.

Restoration of p53 functions is one of the therapeutic strategies for esophageal carcinoma which is often defective of the p53 pathway. We examined effects of CP-31398 which potentially increased expression of wild-type p53 or converted mutated p53 to the wild-type. We used 9 kinds of human squamous esophageal carcinoma cells with different p53 genotypes and examined expression of p53 and the related molecules in CP-31398-treated cells. Cisplatin, a DNA damaging agent, induced cleavages of PARP and caspase-3 without increase of p53 levels, indicating that the p53 down-stream pathway was disrupted in these cells. CP-31398 induced growth retardation but the cytotoxic effects were irrelevant to p53 genotype. CP-31398 influenced expression of p53 and the downstream molecules in a cell-dependent manner, but constantly increased p21 expression at the transcriptional level with decreased YY1 expression. Knockdown experiments with siRNA demonstrated that the CP-31398-mediated p21 up-regulation was unrelated with p53 expression but was associated with YY1 expression. We also showed that CP-31398-induced cell cycle changes including increase of G2/M populations was attributable to the up-regulated p21. These data collectively indicated that CP-31398 augmented endogenous p21 levels and induced cell cycle changes through regulation of YY1, and that YY1 was a novel target of CP-31398 in p53 dysfunctional cells., Competing Interests: None.

The mechanisms underlying anaplastic lymphoma kinase (ALK) resistance have not been well investigated in clinical practice. We herein report the case of a lung cancer patient with carcinomatous meningitis who had an ALK I1171T resistance mutation revealed by direct DNA sequencing of the cerebrospinal fluid after treatment with cytotoxic chemotherapy, crizotinib, and alectinib. I1171T is considered to be sensitive to ceritinib. Although ceritinib was not effective initially, we chose ceritinib again after whole-brain radiotherapy and ventriculoperitoneal shunting. Although the response duration was short, spinal magnetic resonance imaging revealed a marked response. The identification of an acquired ALK resistance mutation will aid in choosing the optimum sequence therapy.

Heat shock protein 90 (HSP90) inhibitors suppressed MDM4 functions which mediated p53 ubiquitination, and blocked a chaperon function which influenced expression of the client proteins. We examined cytotoxic effects of the inhibitors, 17-allylamino-17-demetheoxygeldanamycin (17-AAG) and 17-dimethylaminoethylamino-17-demethoxy-geldanamycin (17-DMAG), on mesothelioma and investigated combinatory effects of the inhibitors and adenoviruses expressing the wild-type p53 gene (Ad-p53). A majority of mesothelioma lacks p14 and p16 expression, which leads to defective p53 pathway despite bearing the wild-type p53 genotype. The HSP90 inhibitors up-regulated endogenous wild-type p53 expression and induced cell death. Furthermore, the inhibitors increased the endogenous p53 levels that were induced by cisplatin. Nevertheless, the HSP90 inhibitors suppressed Ad-p53-induced exogenous p53 expression primarily at a posttranscriptional level and inhibited the Ad-p53-mediated cell death. HSP90 inhibitors suppressed ubiquitination processes which were involved in p53 degradation, but a proteasome inhibitor, MG-132, prevented the HSP90 inhibitors-induced p53 down-regulation. In contrast, an inhibitor for HSP70 with a chaperon function, pifithrin-μ, did not produce the p53 down-regulation. The HSP90 inhibitors did not suppress expression of Ad receptor molecules but rather increased expression of green fluorescence protein transduced by the same Ad vector. These data collectively indicated that an HSP90 inhibitor possessed a divalent action on p53 expression, as an activator for endogenous wild-type p53 through inhibited ubiquitination and a negative regulator of exogenously over-expressed p53 through the proteasome pathway., Competing Interests: CONFLICTS OF INTEREST The authors declare that there is no conflict of interests in this research. We obtained a grant from Nichias Corporation. It is not a pharmaceutical company but a company making industrial products for building, automobiles and pipes (see http://www.nichias.co.jp/). The grant is as a kind of their mécénat activities, corporate social contributions, which is aimed to assist for medical research for intractable cancer treatments. We are thereby irrelevant to any employment, consultancy, patents or products in development or marketed products to the company. All the authors agree to publish the data included in the manuscript.

Background: Pemetrexed (PEM) is an anti-cancer agent targeting DNA and RNA synthesis, and clinically in use for mesothelioma and non-small cell lung carcinoma. A mechanism of resistance to PEM is associated with elevated activities of several enzymes involved in nucleic acid metabolism., Methods: We established two kinds of PEM-resistant mesothelioma cells which did not show any increase of the relevant enzyme activities. We screened genes enhanced in the PEM-resistant cells with a microarray analysis and confirmed the expression levels with Western blot analysis. A possible involvement of the candidates in the PEM-resistance was examined with a WST assay after knocking down the expression with si-RNA. We also analyzed a mechanism of the up-regulated expression with agents influencing AMP-activated protein kinase (AMPK) and p53., Results: We found that expression of cardiac ankyrin repeat protein (CARP) was elevated in the PEM-resistant cells with a microarray and Western blot analysis. Down-regulation of CARP expression with si-RNA did not however influence the PEM resistance. Parent and PEM-resistant cells treated with PEM increased expression of CARP, AMPK, p53 and histone H2AX. The CARP up-regulation was however irrelevant to the p53 genotypes and not induced by an AMPK activator. Augmented p53 levels with nutlin-3a, an inhibitor for p53 degradation, and DNA damages were not always associated with the enhanced CARP expression., Conclusions: These data collectively suggest that up-regulated CARP expression is a potential marker for development of PEM-resistance in mesothelioma and that the PEM-mediated enhanced expression is not directly linked with immediate cellular responses to PEM.

Background: Genetically modified adenoviruses (Ad) with preferential replications in tumor cells have been examined for a possible clinical applicability as an anti-cancer agent. A simple method to detect viral and cellular proteins is valuable to monitor the viral infections and to predict the Ad-mediated cytotoxicity., Methods: We used type 5 Ad in which the expression of E1A gene was activated by 5'-regulatory sequences of genes that were augmented in the expression in human tumors. The Ad were further modified to have the fiber-knob region replaced with that derived from type 35 Ad. We infected human mesothelioma cells with the fiber-replaced Ad, and sequentially examined cytotoxic processes together with an expression level of the viral E1A, hexon, and cellular cleaved caspase-3 with image cytometric and Western blot analyses., Results: The replication-competent Ad produced cytotoxicity on mesothelioma cells. The infected cells expressed E1A and hexon 24 h after the infection and then showed cleavage of caspase-3, all of which were detected with image cytometry and Western blot analysis. Image cytometry furthermore demonstrated that increased Ad doses did not enhance an expression level of E1A and hexon in an individual cell and that caspase-3-cleaved cells were found more frequently in hexon-positive cells than in E1A-positive cells. Image cytometry thus detected these molecular changes in a sensitive manner and at a single cell level. We also showed that an image cytometric technique detected expression changes of other host cell proteins, cyclin-E and phosphorylated histone H3 at a single cell level., Conclusions: Image cytometry is a concise procedure to detect expression changes of Ad and host cell proteins at a single cell level, and is useful to analyze molecular events after the infection.

Background: Replication-competent adenoviruses (Ad) produced cytotoxic effects on infected tumors and have been examined for the clinical applicability. A biomarkers to predict the cytotoxicity is valuable in a clinical setting., Methods: We constructed type 5 Ad (Ad5) of which the expression of E1A gene was activated by a 5' regulatory sequences of survivin, midkine or cyclooxygenase-2, which were highly expressed in human tumors. We also produced the same replication-competent Ad of which the fiber-knob region was replaced by that of Ad35 (AdF35). The cytotoxicity was examined by a colorimetric assay with human tumor cell lines, 4 kinds of pancreatic, 9 esophageal carcinoma and 5 mesothelioma. Ad infectivity and Ad-mediated gene expression were examined with replication-incompetent Ad5 and AdF35 which expressed the green fluorescence protein gene. Expression of cellular receptors for Ad5 and AdF35 was also examined with flow cytometry. A transcriptional activity of the regulatory sequences was investigated with a luciferase assay in the tumor cells. We then investigated a possible correlation between Ad-mediated cytotoxicity and the infectivity/gene expression, the transcriptional activity or the p53 genotype., Results: We found that the cytotoxicity was greater with AdF35 than with Ad5 vectors, but was not correlated with the Ad infectivity/gene expression irrespective of the fiber-knob region or the E1A-activating transcriptional activity. In contrast, replication-competent Ad produced greater cytotoxicity in p53 mutated than in wild-type esophageal carcinoma cells, suggesting a possible association between the cytotoxicity and the p53 genotype., Conclusions: Sensitivity to Ad-mediated cytotoxic activity was linked with the p53 genotype but was not lineally correlated with the infectivity/gene expression or the E1A expression.

Background: It is not uncommon for patients with lung cancer to receive supportive care alone. However, the clinical characteristics of these patients have not been fully studied. We conducted a retrospective study to identify the clinical characteristics of definitive lung cancer patients treated with supportive care alone., Methods: We retrospectively analyzed the percentage of and reasons for definitive lung cancer patients treated with supportive care alone at a regional cancer center. We also investigated the histological diagnostic approaches, palliative therapy types, primary treatment locations after hospital consultation, and places of death., Results: A total of 1,223 patients were histologically diagnosed as having lung cancer between 2011 and 2014. Of these, 160 (13%) patients were treated with supportive care alone. The primary reason for treatment with supportive care alone was a poor performance status (PS) in almost half of the patients. Overall, 40% of the patients received supportive care at home, and 17% were admitted to a palliative care unit (PCU). Death occurred at home for 17% of the patients and in the PCU for 42% of the patients., Conclusion: This study revealed that 13% of histologically proven lung cancer patients were treated with supportive care alone, mostly because of a poor PS. Only 40% of these patients received home care, suggesting the need for a more accessible home care system for patients and their families.

Background: Mesothelioma is resistant to conventional treatments and is often defective in p53 pathways. We then examined anti-tumor effects of metformin, an agent for type 2 diabetes, and combinatory effects of metformin and nutlin-3a, an inhibitor for ubiquitin-mediated p53 degradation, on human mesothelioma., Methods: We examined the effects with a colorimetric assay and cell cycle analyses, and investigated molecular events in cells treated with metformin and/or nutlin-3a with Western blot analyses. An involvement of p53 was tested with siRNA for p53., Results: Metformin suppressed cell growth of 9 kinds of mesothelioma including immortalized cells of mesothelium origin irrespective of the p53 functional status, whereas susceptibility to nutlin-3a was partly dependent on the p53 genotype. We investigated combinatory effects of metformin and nutlin-3a on, nutlin-3a sensitive MSTO-211H and NCI-H28 cells and insensitive EHMES-10 cells, all of which had the wild-type p53 gene. Knockdown of p53 expression with the siRNA demonstrated that susceptibility of MSTO-211H and NCI-H28 cells to nutlin-3a was p53-dependent, whereas that of EHMES-10 cells was not. Nevertheless, all the cells treated with both agents produced additive or synergistic growth inhibitory effects. Cell cycle analyses also showed that the combination increased sub-G1 fractions greater than metformin or nutlin-3a alone in MSTO-211H and EHMES-10 cells. Western blot analyses showed that metformin inhibited downstream pathways of the mammalian target of rapamycin (mTOR) but did not activate the p53 pathways, whereas nutlin-3a phosphorylated p53 and suppressed mTOR pathways. Cleaved caspase-3 and conversion of LC3A/B were also detected but it was dependent on cells and treatments. The combination of both agents in MSTO-211H cells rather suppressed the p53 pathways that were activated by nutrin-3a treatments, whereas the combination rather augmented the p53 actions in NCI-H28 and EHMES-10 cells., Conclusion: These data collectively indicated a possible interactions between mTOR and p53 pathways, and the combinatory effects were attributable to differential mechanisms induced by a cross-talk between the pathways.

Background: Approximately 80 % of mesothelioma specimens have the wild-type p53 gene, whereas they contain homozygous deletions in the INK4A/ARF locus that encodes p14 (ARF) and the 16 (INK4A) genes. Consequently, the majority of mesothelioma is defective of the p53 pathways. We examined whether zoledronic acid (ZOL), a third generation bisphosphonate, and adenoviruses with a deletion of the E1B-55kD gene (Ad-delE1B55), which augments p53 levels in the infected tumors, could produce combinatory anti-tumor effects on human mesothelioma cells bearing the wild-type p53 gene., Methods: Cytotoxicity of ZOL and Ad-delE1B55 was assessed with a WST assay. Cell cycle changes were tested with flow cytometry. Expression levels of relevant molecules were examined with western blot analysis to investigate a possible mechanism of cytotoxicity. Furthermore, the expressions of Ad receptors on target cells and infectivity were estimated with flow cytometry. Viral replication was assayed with the tissue culture infection dose method., Results: A combinatory use of ZOL and Ad-delE1B55 suppressed cell growth and increased sub-G1 or S-phase populations compared with a single agent, depending on cells tested. The combinatory treatment up-regulated p53 levels and subsequently enhanced the cleavage of caspase-3, 8, 9 and poly (ADP-ribose) polymerase, but expression of molecules involved in autophagy pathways were inconsistent. ZOL-treated cells also increased Ad infectivity with a dose-dependent manner and augmented Ad replication although the expression levels of integrin molecules, one of the Ad receptors, were down-regulated., Conclusions: These findings indicated that ZOL and Ad-delE1B55 achieved combinatory anti-tumor effects through augmented apoptotic pathways or increased viral replication.

Objective: The aim of this study was to analyze the spectral features of the radiofrequency of lymph nodes during endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and to determine its diagnostic value for detecting metastatic nodes in patients with lung cancer., Methods: Ultrasound spectrums of lymph nodes during EBUS-TBNA were retrospectively analyzed. A linear regression of frequency spectrum and the ultrasonic spectral parameters midband-fit, slope, and intercept were calculated. Mean values for these parameters within lymph nodes were computed. The cutoff values for each parameter for distinguishing metastatic vs benign lymph nodes were first determined within the training set; these cutoff values were then applied to the testing set for validation., Results: Overall, 362 lymph nodes (112 metastatic, 250 benign) were analyzed as the training set, and 284 lymph nodes (74 metastatic, 210 benign) were evaluated as the testing set. In the training set, all of the parameters showed a significant difference between metastatic and benign lymph nodes (P < .001). The metastatic nodes tended to show low midband-fit, high slope, and low intercept. When midband-fit and intercept were combined, the diagnostic accuracy was maximized in the training set. In the testing set, the combination of intercept and slope produced the highest diagnostic accuracy, with the following outcomes: sensitivity, 79.7%; specificity, 84.3%; diagnostic accuracy, 83.1%; positive predictive value, 64.1%; and negative predictive value, 92.2%., Conclusions: Metastatic lymph nodes possess unique ultrasonic spectrum features, and spectrum analysis can be used as a novel diagnostic tool for differentiating between benign and malignant nodes in patients with lung cancer., (Copyright © 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Background: The third generation of bisphosphonates is clinically in use for patients of osteoporosis or malignancy-linked hypercalcemia. The agents can also produce anti-tumor effects on bone metastasis of several types of tumors. We recently found that one of the agents achieved cytotoxicity to mesothelioma in vitro and in an orthotopic animal model. Mesothelioma is resistant to a number of chemotherapeutic agents, and suppression of local tumor growth is beneficial to the patients since metastasis to extra-thoracic organs is relatively infrequent until a late stage., Methods/design: We demonstrated in an orthotopic mouse model that an intrapleural but not intravenous injection of zoledronic acid, one of the third generation bisphosphonates, at a clinically equivalent dose suppressed the tumor growth. Nevertheless, a high concentration of zoledronic acid administrated in the pleural cavity produced pleural adhesion. We also showed that zoledronic acid produced synergistic cytotoxic effects with cisplatin, the first-line chemotherapeutic agent for mesothelioma. We then planned to conduct a phase I clinical study to investigate any adverse effects and a possible clinical benefits produced by an intrapleural administration of zoledronic acid to mesothelioma patients who became resistant to the first-line chemotherapeutic agents. The clinical trial is a dose escalation study starting with 0.4, 1, 4, 8 and 16 mg per person since safety of administration of zoledronic acid into the pleural cavity remains unknown. Each dose group consists of three persons and the protocol allows to repeat administration of the same dose into the pleural cavity at a 4-weeks interval., Discussion: We will conduct a possible combinatory study of intrapleural administration of zoledronic acid and systemic administration of the first-line agent to a chemotherapy-naïve patient based on the maximum tolerance dose of zoledronic acid determined by the present clinical trial. We propose that administration of bisphosphonates in a closed cavity is a treatment strategy for tumors developed in the cavity probably through the direct cytotoxic activity., Trial Registration: UMIN clinical trials registry, Japan. Register ID: UMIN8093.

Pancreatic carcinoma is relatively resistant to chemotherapy and cell death induced by replication of adenoviruses (Ad) can be one of the therapeutic options. Transduction efficacy of conventional type 5 Ad (Ad5) is however low and the cytotoxic mechanism by replication-competent Ad was not well understood. We constructed replication-competent Ad5 of which the E1A promoter region was replaced with a transcriptional regulatory region of the midkine, the survivin or the cyclooxygenase-2 gene, all of which were expressed at a high level in human tumors. We also prepared replication-competent Ad5 that were activated with the same region but had the type 35 Ad-derived fiber-knob region (AdF35) to convert the major cellular receptor for Ad infection from the coxsackie adenovirus receptor to CD46 molecules. Replication-competent AdF35 that were activated with the exogenous region produced cytotoxic effects on human pancreatic carcinoma cells greater than the corresponding Ad5 bearing with the same regulatory region. Cells infected with the AdF35 showed cytopathic effects and increased sub-G1 fractions. Caspase-9, less significantly caspase-8 and poly (ADP-ribose) polymerase, but not caspase-3 was cleaved and expression of molecules involved in autophagy and caspase-independent cell death pathways remained unchanged. Nevertheless, H2A histone family member X molecules were phosphorylated, and N-acetyl-L-cystein, an inhibitor for reactive oxygen species, suppressed the AdF35-mediated cytotoxicity. These data indicated a novel mechanism of Ad-mediated cell death and suggest a possible clinical application of the fiber-knob modified Ad.

Type 5 adenoviruses expressing mda-7 gene (Ad-mda-7) induced cell death in various kinds of human tumors, but pancreatic carcinoma cells were relatively resistant to Ad-mda-7-mediated cytotoxicity. We then examined whether infection of Ad-mda-7 together with replication-competent Ad produced combinatory cytotoxic effects. We prepared replication-competent Ad, defective of the E1B55kDa gene or activated by a transcriptional regulatory region of the midkine or the survivin gene of which the expression was up-regulated in human tumors. Type 5 Ad bearing the exogenous regulatory region were further modified by replacing the fiber-knob region with that of type 35 Ad. Pancreatic carcinoma cells were infected with replication-incompetent Ad-mda-7 and the replication-competent Ad. Combinatory effects were examined with the CalcuSyn software and cell cycle analyses. Ad-mda-7 and the replication-competent Ad achieved cytotoxicity to pancreatic carcinoma. A combinatory use of Ad-mda-7 and either Ad defective of the E1B55kDa gene or Ad activated by the regulatory region produced synergistic cytotoxic effects. Cell cycle analyses demonstrated that the combination increased sub-G1 populations. These data collectively suggest that expression of MDA-7 augments cytotoxicity of replication-competent Ad and achieves adjuvant effects on Ad-mediated cell death.

Background: The brain is a frequent site of metastases from non-small-cell lung cancer (NSCLC). We analyzed the frequency of brain metastases (BMs) from NSCLC in the era of magnetic resonance images, and evaluated the correlation between epidermal growth factor receptor (EGFR) mutations and BMs among East Asian patients., Methods: Frequency, number, and size of BMs, and survival of 1,127 NSCLC patients were retrospectively reviewed. Mutation status of EGFR was evaluated in all cases, and its association with BMs was statistically evaluated., Results: EGFR mutations were found for 331 cases (29.4 %). BM was the cause of primary symptoms for 52 patients (4.6 %), and found before initiation of treatment for 102 other patients (9.1 %); In addition to these 154 patients, 107 patients (9.5 %) developed BMs, giving a total of 261 patients (23.2 %) who developed BMs from 1,127 with NSCLC. BM frequency was higher among EGFR-mutated cases (31.4 %) than EGFR-wild cases (19.7 %; odds ratio: 1.86; 95 % confidence interval (CI) 1.39-2.49; P < 0.001). BMs from EGFR-mutated NSCLC were small, but often became disseminated. EGFR mutations accounted for 39.9 % of BMs, but patient survival after BMs was significantly longer for EGFR-mutated cases than for EGFR-wild cases (hazard ratio: 2.23; 95 % CI 1.62-3.10; P < 0.001)., Conclusions: Patients with EGFR-mutated NSCLC were more likely to develop BMs, but apparently also survived longer after BMs.

Purpose: To evaluate a 3-drug combination of carboplatin, docetaxel and bevacizumab as a front-line chemotherapy for patients with advanced non-squamous non-small cell carcinoma (NSCLC), a single arm phase II study was conducted., Methods: Patients with stage IIIB/IV or postoperative recurrent non-squamous NSCLC were treated with carboplatin (targeted area under the curve of 6 mg h/L), docetaxel (60 mg/m(2)), and bevacizumab (15 mg/kg) on day 1, repeated every 3 weeks for 4 to 6 cycles, followed by maintenance with bevacizumab every 3 weeks until disease progression or occurrence of predefined toxicity. The planned patient number was 40, and the primary endpoint was progression free survival (PFS) as assessed by independent reviewers., Results: One patient refused the treatment after enrollment; thus, 39 patients were treated and analyzed. The 3-drug therapy was delivered for a median of 4 cycles, and 54 % of the patients proceeded to the maintenance therapy for a median of 4 cycles. The overall response rate was 74.4 % (29/39), with a 95 % confidence interval (CI) of 60.0 to 88.7 %. The median PFS and overall survival (OS) were 6.2 months (95 % CI, 4.8-8.5 months) and 22.4 months (95 % CI, 11.3-26.2 months), respectively. Toxicities of grade 3 or higher included neutropenia in 71.8 %, febrile neutropenia in 23.1 %, and hypertension in 38.5 % of the patients, but they were transient and manageable., Conclusion: The primary endpoint was met. The regimen yielded promising results with an excellent overall response rate, PFS, and OS for chemotherapy-naïve patients with advanced non-squamous NSCLC. Further studies are warranted.