A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfillment of the requirements for the degree of Master of Medicine in the branch of Internal Medicine / Medical Oncology. Johannesburg 1st September 2014 / Introduction: Tyrosine kinase inhibitors and EGFR mutations has changed the treatment approach to lung cancer globally. This retrospective study will look at factors associated with EGFR mutations and define the EGFR mutation rate in South Africa. Methods: Retrospective record review from NSCLC patients in South Africa who were tested for EGFR mutations at Lancet Laboratories during 1st September 2009 to 30th June 2012. Chi-squared test was used to determine association with categorical variables. Kaplan- Meier survival analysis was done for OS and PFS between EGFR mutation positive and negative patients. Cox proportional hazards were used for subgroup analysis. Treatment practices and response were described. Results: 170 lung cancer samples were evaluable for EGFR mutation and 37 were EGFR mutation positive (21.8%). There were 22 (59.5%) exon 19 deletions, 11 (29.7%) L858R mutations, two G719X mutations, one S768I mutation and one exon 20 insertion. The median age was 63 (range 27-85). There were more females (55.6%) than males (44.4%) sent for mutation testing. Most patients were whites (71%), followed by blacks (18.3%), and other race (10.7%). 85% of all NSCLC samples tested were adenocarcinoma. None of the squamous cell carcinoma tested was positive for EGFR mutation. Smoking status was inversely proportional to EGFR mutation status (p<0.001). Over 60% patients received chemotherapy first and second line and responses decreased with each line of chemotherapy. Median PFS and OS were not different between the EGFR mutation positive and negative groups (6.85 versus 6.8 months; HR 1.6; 95% CI 0.70-3.65; p=0.2543 and 11.5 versus 12.9 months; HR 0.70; 95% CI 0.28-1.75; p=0.44, respectively). On multivariate analysis, only non-white race was associated with decrease in OS (HR 6.66; 95% CI 2.31-19.19; p=0.0004). Conclusion: EGFR mutation rate in South African lung cancer patients was 21.8%. 89% of all EGFR mutations were either exon 19 deletions or L858R point mutations. Most EGFR mutations were associated with adenocarcinoma of the lung in non-smokers. These findings were consistent with current literature in western countries. Treatment practice remained chemotherapy based, with few patients receiving EGFR TKIs. Efforts should be made to prioritized targeted treatment approach in lung cancer in South Africa.

Background: Although palliative chemotherapy is the standard of care for patients diagnosed with stage IV NSCLC, patients with a small metastatic burden, “oligometastatic” disease, may benefit from definitive local therapy. Methods: We identified 186 patients (26% of Stage IV patients) prospectively enrolled in our institutional database from 2002-2012 with oligometastatic disease, which we defined as five or fewer distant metastatic lesions at diagnosis. Univariable and multivariable Cox proportional hazards models were used to identify patient and disease factors associated with improved survival. Using propensity score methods, we investigated the effect of definitive local therapy to the primary site on overall survival. Results: Median age at diagnosis was 61 years, 51% of patients were female, 12% had squamous histology, and 33% had N0-1 disease. On multivariable analysis, ECOG performance status ≥2 (hazard ratio [HR] 2.43), nodal status N2-3 (HR 2.16), squamous pathology, and metastases to multiple organs (HR 2.11) were associated with a greater hazard of death (all p<0.01). Number of metastatic lesions and size of primary were not significantly associated with overall survival. Definitive local therapy to the primary tumor was associated with prolonged survival (HR 0.65, p=0.043). Conclusions: Definitive local therapy to the primary tumor appears to be associated with improved survival in patients with oligometastatic NSCLC. Select patient and tumor characteristics, including good performance status, non-squamous histology, and limited nodal disease, may predict for improved survival in these patients.

Dissertation (Ph.D.) -- University of Texas Southwestern Medical Center at Dallas, 2008. / Vita. Bibliography: p. 174-213.

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2007. / Härtill 4 uppsatser.

Yung, Kam Fai. / Thesis (M.Phil.)--Chinese University of Hong Kong, 2009. / Includes bibliographical references (leaves 107-129). / Abstracts in English and Chinese. / ABSTRACT --- p.ii / 摘要 --- p.iv / ACKNOWLEDGEMENTS --- p.vi / TABLE OF CONTENTS --- p.vii / PUBLICATION --- p.ix / LIST OF TABLES --- p.x / LIST OF FIGURES --- p.xi / LIST OF ABBREVIATIONS --- p.xii / Chapter SECTION I: --- BACKGROUND --- p.1 / Chapter CHAPTER 1: --- "The biology, diagnostics and management of lung cancer" --- p.2 / Chapter 1.1 --- "Basic biology, classification and diagnostics" --- p.2 / Chapter 1.1.1 --- Epidemiology and etiology of lung cancer --- p.2 / Chapter 1.1.2 --- Clinical Presentation and Diagnostics of Lung Cancer --- p.3 / Chapter 1.2 --- Treatment of lung cancer --- p.9 / Chapter 1.2.2 --- Radiotherapy --- p.10 / Chapter 1.2.3 --- Chemotherapy --- p.11 / Chapter CHAPTER 2: --- Epidermal Growth Factor Receptor Mutations in Lung Cancer --- p.13 / Chapter 2.1 --- The Epidermal Growth Factor Receptor --- p.13 / Chapter 2.2 --- Overexpression of EGFR in NSCLC --- p.14 / Chapter 2.3 --- The development of EGFR inhibitors --- p.15 / Chapter 2.3.1 --- Monoclonal Antibodies --- p.16 / Chapter 2.3.2 --- Small-molecule inhibitors --- p.17 / Chapter 2.3.2.1 --- Gefitinib --- p.17 / Chapter 2.3.2.2 --- Erlotinib --- p.19 / Chapter 2.3.2.3 --- Other small-molecule inhibitors --- p.20 / Chapter 2.4 --- Mutations of EGFR in NSCLC --- p.21 / Chapter 2.4.1 --- Activating Mutations conferring sensitivity to tyrosine kinase inhibitors --- p.21 / Chapter 2.4.2 --- Secondary mutations associated with resistance to tyrosine kinase inhibitors --- p.23 / Chapter 2.5 --- EGFR gene amplification --- p.24 / Chapter 2.6 --- Detection of EGFR mutations --- p.25 / Chapter 2.7 --- Aim of the thesis --- p.31 / Chapter SECTION II: --- DETECTION OF EGFR MUTATIONS IN TUMOR AND PLASMA SAMPLES BY MASS SPECTROMETRY AND DIGITAL PCR --- p.33 / Chapter CHAPTER 3: --- Detection of EGFR mutations by mass spectrometric methods --- p.34 / Chapter 3.1 --- Introduction --- p.34 / Chapter 3.1.1 --- Principles of Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) --- p.34 / Chapter 3.1.2 --- The MassARRAY Homogenous MassEXTEND (hME) assay --- p.35 / Chapter 3.1.3 --- The Single-Allele Base Extension Reaction (SABER) and the Allele-Specific Base Extension Reaction (ASBER) --- p.36 / Chapter 3.2 --- Materials and Methods --- p.36 / Chapter 3.2.1 --- The protocol for the detection of EGFR exon 21 point mutation by Mass Spectrometric Methods --- p.37 / Chapter 3.3 --- Results --- p.42 / Chapter 3.4 --- Discussion --- p.49 / Chapter CHAPTER 4: --- Evaluation of the detection limit and sensitivity of the digital PCR assays --- p.51 / Chapter 4.1 --- Introduction --- p.51 / Chapter 4.1.1 --- The theoretical basis of digital PCR quantification and the relationship with the Poisson distribution --- p.51 / Chapter 4.1.2 --- Assessment of Assay Detection Limit --- p.54 / Chapter 4.1.3 --- Comparing Digital PCR with sequencing after conformation sensitive gel electrophoresis (CSGE) --- p.59 / Chapter 4.2 --- Materials and Methods --- p.59 / Chapter 4.2.1 --- Design of digital PCR assay for the detection of EGFR exon21 L858R point mutation --- p.59 / Chapter 4.2.2 --- Design of digital PCR assay for the detection of EGFR exon19 deletion --- p.60 / Chapter 4.2.3 --- The protocols of digital PCR assays for EGFR mutation detection --- p.64 / Chapter 4.2.4 --- Single molecule detection test --- p.65 / Chapter 4.2.5 --- Artificial mixtures of mutant and wild-type DNA --- p.66 / Chapter 4.2.6 --- Sequencing after CSGE --- p.66 / Chapter 4.3 --- Results --- p.67 / Chapter 4.3.1 --- Results of the single molecule detection test and artificial mixture analysis --- p.67 / Chapter 4.3.2 --- Results of CSGE and sequencing compared with digital PCR --- p.73 / Chapter 4.4 --- Discussion --- p.75 / Chapter CHAPTER 5: --- Detection of EGFR mutations in prospectively collected tumor samples of NSCLC patients --- p.77 / Chapter 5.1 --- Introduction --- p.77 / Chapter 5.2 --- Materials and Methods --- p.78 / Chapter 5.2.1 --- Sample preparation and DNA extraction of tumor tissues --- p.78 / Chapter 5.3 --- Results --- p.79 / Chapter 5.4 --- Discussion --- p.82 / Chapter CHAPTER 6: --- Detection of EGFR mutations in prospectively collected plasma samples of NSCLC patients --- p.85 / Chapter 6.1 --- Introduction --- p.85 / Chapter 6.2 --- Materials and Methods --- p.87 / Chapter 6.2.1 --- Sample preparation and DNA extraction of plasma samples --- p.87 / Chapter 6.3 --- Results --- p.88 / Chapter 6.3.1 --- Digital PCR analysis of EGFR mutations in plasma samples of NSCLC patient --- p.88 / Chapter 6.3.2 --- Variations in plasma EGFR mutation concentration after TKI treatment --- p.93 / Chapter 6.4 --- Discussion --- p.96 / Chapter SECTION III: --- CONCLUDING REMARKS --- p.100 / Chapter CHAPTER 7: --- Conclusion and future perspectives --- p.101 / Chapter 7.1 --- Mass spectrometric analysis --- p.101 / Chapter 7.2 --- Microfluidics Digital PCR --- p.102 / Chapter 7.3 --- Future perspectives --- p.105 / References --- p.107

Yearly, 22, 200 Canadians are diagnosed with lung cancer, with 80-85% of the cases being non-small cell lung cancer (NSCLC). With diagnoses being predominantly in the advanced stages, prognosis is poor and quality of life (QoL) becomes the focus of treatment. The main symptom cachexia, issues a loss of strength and impacts on an important aspect of QoL, physical function. Physical function is predominately assessed subjectively. Lately performance-based measures are gaining in popularity. One performance measure, the chair rise test, has not been validated in the NSCLC population and was the objective of this study. / Subjects completed the chair rise test, 6MWT, hand grip, and the SF-36 pre and post chemotherapy. Evidence for construct and discriminant validity but not predictive validity was provided for the chair rise test. The 60-second chair rise may be too strenuous for persons with severe disability but a standardized timed-based chair rise test is needed.

Diss. (sammanfattning) Stockholm : Karol. inst., 2003. / Härtill 5 uppsatser.

No description available.

Thesis (M.S.)--University of Florida, 2004. / Typescript. Title from title page of source document. Document formatted into pages; contains 52 pages. Includes Vita. Includes bibliographical references.

<p>Hemioterapija koja se koristi za lečenje karcinoma utiče i na kardiovaskularni sistem. Ciljevi&nbsp; istraživanja&nbsp; su: u tvrditi uticaj kardiotoksičnosti&nbsp; na&nbsp; reživljavanje&nbsp; bolesnika&nbsp; sa uznapredovalim stadijumom NSCLC; utvrditi učestalost pojave kardiotoksičnosti kod bolesnika koji su lečeni hemioterapijom prve linije (gemcitabin/cisplatin i paclitaxel/carboplatin) sa i bez prethodnih kardiovaskularnih oboljenja i utvrditi učestalost pojave kardiotoksičnosti u toku primene protokola docetaxel/cisplatin kao hemioterapije druge linije, u odnosu na primenu protokola gemcitabin/ cisplatin i paclitaxel/carboplatin, kao terapije prve linije. Istraživanjem je obuhvaćeno 270 bolesnika sa citolo&scaron;ki ili patohistolo&scaron;ki dokazanim NSCLC kliničkog stadiju ma III i IV.&nbsp; Dobijeni su rezultati koji ukazuju da je preživljavanje bolesnika u III i IV stadijumu NSCLC koji su imali pojavu kardiotoksičnosti tokom hemioterapije prve i druge linije kraće u odnosu na bolesnike bez pojave kardiotoksičnosti, sa statističkom značajno&scaron;ću nakon prvog, drugog, četvrtog ciklusa hemioterapije i nakon &scaron;est meseci (p=0.004, p=0.020, p=0.030 i p&lt;0.0005. respektivno). Kardiotoksičnost kod bolesnika u III i IV stadijumu NSCLC koji su primali hemioterapiju prve linije prema protokolu gemcitabin/cisplatin se če&scaron;će javila ukoliko su imali prethodne kardiovaskularne bolesti, ali statistička značajnost nije utvrđena. Kardiotoksičnost kod bolesnika u III i IV stadijumu NSCLC koji su primali hemioterapiju prve linije prema protokolu paclita xel/carboplatin se če&scaron;će javila ukoliko su imali prethodne kardiovaskularne bolesti, a statistička značajnost utvrđena prilikom prvog kontrolnog pregleda kod bolesnika u III stadijumu (p=0.037). Kod bolesnika u III i IV stadijumu NSCLC koji su primali hemioterapiju prve linije prema protokolima gemcitabin/cisplatin paclitaxel / carboplatin kardiotoksičnost se če&scaron;će javila ukoliko su imali prethodna kardiovaskularna oboljenja, ali je statistička značajnost ustanovljena samo pri prvom kontrolnom pregledu , (p=0.022). Kod bolesnika koji su primali hemioterapiju druge linije kardiotoksičnost značajno če&scaron;će javila u toku prvog ciklusa hemioterapije (p=0.049) u odnosu&nbsp; na&nbsp; bolesnike&nbsp; koji&nbsp; su&nbsp; primali hemioterapiju&nbsp; prve&nbsp; linije.&nbsp; Kod bolesnika koji su imali prethodne kardiovaskularne bolesti u toku druge linije hemioterapije kardiotoksičnost se statistički značajno če&scaron;će javila u odnosu na prvu liniju hemioterapije u toku četvrtog ciklusa hemioterapije (p=0.020). Uspostavljanje ravnoteže između efektivnosti hemioterapije i rizika od o&scaron;tećenja kardiovaskularnog sistema zahteva blisku saradnju onkologa i kardiologa , sa ciljem kreiranja individualne terapije za svakog bolesnika.</p> / <p>Lung&nbsp; cancer&nbsp; chemotherapy&nbsp; affects&nbsp; the&nbsp; cardiovascular&nbsp; system&nbsp; as&nbsp; well. The research&nbsp; objectives&nbsp; were&nbsp; to&nbsp; establish:&nbsp; the&nbsp; effects&nbsp; of&nbsp; cardiotoxicity&nbsp; on&nbsp; the survival of advanced NSCLC patients;&nbsp; the frequency of cardiotoxicity in the patients&nbsp; treated&nbsp; with&nbsp; the&nbsp; first - line&nbsp; chemotherapy&nbsp; (gemcitabine/cisplatin&nbsp; and paclitaxel/carboplatin),&nbsp;&nbsp; with&nbsp;&nbsp; or&nbsp;&nbsp; without&nbsp;&nbsp; the&nbsp;&nbsp; history&nbsp;&nbsp; of&nbsp;&nbsp; cardiovascular comorbidities, and the frequency of cardiotoxicity registered in the course of the&nbsp; second - line&nbsp; chemotherapy&nbsp; with docetaxel/cisplatin,&nbsp; as&nbsp; compared&nbsp; to&nbsp; the first - line chemotherapy&nbsp; with gemcitabine/cisplatin and paclitaxel/carboplatin.&nbsp;&nbsp;&nbsp; The&nbsp;&nbsp;&nbsp; investigation&nbsp;&nbsp;&nbsp; included&nbsp;&nbsp;&nbsp; 270&nbsp;&nbsp;&nbsp; patients&nbsp;&nbsp;&nbsp; with citologically&nbsp; or histopathologically&nbsp; confirmed&nbsp; NSCLC&nbsp; at&nbsp; the&nbsp; clinical&nbsp; stages III&nbsp; and&nbsp; IV. The&nbsp; obtained&nbsp; research&nbsp; results&nbsp; suggest&nbsp; the&nbsp; patients&nbsp; with&nbsp; stage&nbsp; III and IV NSCLC who developed&nbsp; cardiotoxicity in the course of&nbsp; the first &ndash; and second - line&nbsp;&nbsp; chemotherapy&nbsp;&nbsp; had&nbsp;&nbsp; a&nbsp;&nbsp; shorter&nbsp;&nbsp; survival&nbsp;&nbsp; than&nbsp;&nbsp; those&nbsp;&nbsp; without cardiotoxicity,&nbsp; with&nbsp; the&nbsp; statistical&nbsp; significance&nbsp; registered&nbsp; after&nbsp; the&nbsp; first, second,&nbsp; and&nbsp; fourth&nbsp; chemotherapy&nbsp; course,&nbsp; as&nbsp; well&nbsp; as&nbsp; six&nbsp; months&nbsp;&nbsp;&nbsp; later (p=0.004,&nbsp; p=0.020,&nbsp; p=0.030&nbsp; and&nbsp; p&lt;0.0005&nbsp; respectively). Stage&nbsp; III&nbsp; and&nbsp; IV NSCLC&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; patients&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; receiving&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; the&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; first - line&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; chemotherapy&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; with gemcitabine/cisplatin developed cardiotoxicity more frequently if they had a former history of cardiovascular diseases, but with no statistical significance registered. Stage&nbsp; III and IV NSCLC patients on the&nbsp; first - line&nbsp; chemotherapy protocol&nbsp;&nbsp;&nbsp; with&nbsp;&nbsp;&nbsp; paclitaxel/carboplatin&nbsp;&nbsp;&nbsp; developed&nbsp;&nbsp;&nbsp; cardiotoxicity&nbsp;&nbsp;&nbsp; more frequently&nbsp; if&nbsp; they&nbsp; had&nbsp; a&nbsp; former&nbsp; history&nbsp; of&nbsp; cardiovascular&nbsp; diseases,&nbsp; and&nbsp; the&nbsp; statistical significance was registered at the first control examination in stage III&nbsp; NSCLC&nbsp; patients&nbsp; (p=0.037).&nbsp; Stage III&nbsp; and&nbsp; IV&nbsp; NSCLC&nbsp; patients&nbsp; receiving the&nbsp;&nbsp; first-line&nbsp;&nbsp; chemotherapy&nbsp;&nbsp; protocols&nbsp;&nbsp; with&nbsp;&nbsp; gemcitabine/cisplatin&nbsp;&nbsp; and paclitaxel/carboplatin&nbsp; developed&nbsp; cardiotoxicity&nbsp; more&nbsp; frequently&nbsp; if&nbsp; they&nbsp; had former cardiovascular diseases, but the statistical significance was registered at&nbsp;&nbsp; the&nbsp;&nbsp; first&nbsp;&nbsp; control&nbsp;&nbsp; examination&nbsp;&nbsp; only, one&nbsp;&nbsp; month&nbsp;&nbsp; after&nbsp;&nbsp; chemotherapy application (p=0.022). The&nbsp; patients receiving the&nbsp; second - line&nbsp; chemotherapy developed&nbsp; cardiotoxicity&nbsp; much&nbsp; more&nbsp; often&nbsp; during&nbsp; the&nbsp; first&nbsp; chemotherapy course (p=0.049),&nbsp;&nbsp; as&nbsp;&nbsp; compared&nbsp;&nbsp; to&nbsp;&nbsp; the&nbsp;&nbsp; patiens&nbsp;&nbsp; receiving&nbsp;&nbsp; the&nbsp;&nbsp; first - line chemotherapy.&nbsp; Among&nbsp; the&nbsp; patients&nbsp; with&nbsp; a&nbsp; former&nbsp; history&nbsp; of&nbsp; cardiovascular diseases,&nbsp;&nbsp;&nbsp; those&nbsp;&nbsp;&nbsp; receiving&nbsp;&nbsp;&nbsp; the&nbsp;&nbsp;&nbsp; second &ndash; line&nbsp;&nbsp;&nbsp; chemotherapy&nbsp;&nbsp;&nbsp; developed cardiotoxicity&nbsp; during&nbsp; the&nbsp; fourth&nbsp; chemotherapy&nbsp; course&nbsp; significanly&nbsp; more freequently&nbsp;&nbsp; than&nbsp;&nbsp; the&nbsp;&nbsp; patients&nbsp;&nbsp; on&nbsp;&nbsp; the&nbsp;&nbsp; same&nbsp;&nbsp; course&nbsp;&nbsp; of&nbsp;&nbsp; the&nbsp;&nbsp; first-line chemotherapy&nbsp; (p=0.020). To&nbsp; achieve&nbsp; the&nbsp; balance&nbsp; between&nbsp; chemotherapy efficacy&nbsp; and&nbsp; the&nbsp; risk&nbsp; of&nbsp; the&nbsp; cardiovascular&nbsp; system&nbsp; damage&nbsp; requires&nbsp; a&nbsp; close cooperation of an oncologist and a cardiologist, aimed at designing a unique, individual therapy for each patient.</p>