Abstract Cytochrome P450 2A6 (CYP2A6) is involved in the 7-hydroxylation of coumarin, C-oxidation of nicotine, and the metabolism of tobacco specific nitrosamines. Initially in 1995 Fernandez-Salguero et al. reported a genotyping method for three alleles: CYP2A6*1 (wild-type), CYP2A6*2 (variant 1), and CYP2A6*3 (variant 2). Later studies presented in this thesis indicated that the original genotyping method produces erroneous results for the CYP2A6*3 allele due to unspecific PCR conditions and previously unknown CYP2A6*1B allele. Furthermore, the CYP2A6*2 allele genotyping caused erroneous genotypes (CYP2A6*2/*2 was misclassified as CYP2A6*1/*2). In this work, new PCR based genotyping methods were developed for CYP2A6*2 and for several new alleles (CYP2A6*1B, CYP2A6*4A/*4D and CYP2A6*5). In population-based studies, the deletion alleles (pooled as CYP2A6*4) turned out to be more prevalent among Asians (15.1%) than Caucasians (0.5%). The frequencies of the other inactive alleles varied within 0–3% in both populations. Asians totally lacked the CYP2A6*2 allele, whereas Caucasians lacked the CYP2A6*5 allele. The frequencies of two wild-type alleles, CYP2A6*1A and CYP2A6*1B alleles were 66.5% and 30.0% in Caucasians, and 43.2% and 40.6% in Asians, respectively. Correlation studies between the phenotype, as tested by the administration of coumarin, and the genotype demonstrated that individuals with the CYP2A6*2/*2 genotype were totally defective, while CYP2A6*1/*2 subjects exhibited intermediate and CYP2A6*1/*1 subjects full capablility of producing 7-hydroxycoumarin. Upon phenotyping with nicotine, individuals with the CYP2A6*1/*2 or CYP2A6*1/*4 genotype were shown to have a lower enzyme activity (one fourth of the normal activity), compared to those with the CYP2A6*1/*1 genotype. Defective CYP2A6 activity has been hypothesised to reduce the risk of environmentally (especially tobacco smoke) induced diseases either by decreasing production of genotoxic metabolites or by preventing addiction to tobacco smoking. However, in our case-control studies on Spanish patients with liver cirrhosis (n = 83) and liver cancer (n = 90) and their controls (n = 237) no significant association between the CYP2A6 genotypes and disease proneness was found. The odds ratio (OR) for developing liver cancer was was 1.4 (95% confidence interval [CI] 0.5–3.7) for genotypes containing at least one CYP2A6*2 allele. For liver cancer the respective OR was 1.3 (95% CI 0.4–4.5). Similarly, no statistically association between CYP2A6 alleles and the risk of lung cancer was observed in our Finnish study population cinsisting of 177 cases and 1089 controls; the OR for combined CYP2A6 variant allele containing genotypes (CYP2A6*1/*2 and CYP2A6*1/*4) was 1.19 (95% CI 0.56–2.45). Our studies therefore do not indicate any major modifying role for the CYP2A6 genotypes in individual susceptibility to environmentally induced diseases.

Improved radiotherapy (RT) outcomes may be facilitated through monitoring of physiological processes implicated in radio-resistance such as proliferation. To this end, we studied 16 patients with non-small cell lung cancer with dynamic 3'-deoxy-3'-fluorothymidine (FLT) PET-CT before and after a week of radical RT. In absence of changes in primary tumour volume manually delineated on CT, RT induced a significant, moderately variable decrease in maximum and mean standard uptake values (SUVmax and SUVmean) of the order of 25%. Metastatic nodes showed a larger relative decrease in uptake approximating 40% associated with volumetric regression and only partially accountable by partial volume effect. Implementation of different segmentation approaches including manual delineation by a second operator and PET-based semi-automatic algorithms [two fixed thresholds, 2/3-cluster Fuzzy C-means (FCM-2, FCM-3) and 2/3-cluster fuzzy locally adaptive Bayesian algorithm (FLAB-2, FLAB-3)] yielded substantially different volumes and SUVs but consistent SUV responses. Reproducibility comparison favoured manual delineation, while thresholding delivered poor volumetric robustness and no apparent SUV reproducibility advantage over SUVmax or SUVpeak. FCM-2/FLAB-2 demonstrated intermediate reproducibility. In contrast to anatomical volumes, metabolic volumes exhibited significant increases with treatment, which for FLAB-2 correlated with changes of intratumoural uptake heterogeneity quantified by the coefficient of variation. Normal tissue analysis revealed an anterior-posterior gradient of lung uptake and an association of baseline marrow SUV with type/timing of neo-adjuvant chemotherapy. RT induced a dramatic (≈-76%), sharply demarcated marrow SUV decline in response to a minimum of 5Gy and a small (≈-20%), consistent decline in normal lung SUV. Kinetic analysis revealed a significant increase in the tumour delivery constant K1 (+32%) and a decrease in Ki/K1, larger (-36%) and more variable than the Ki (-26%) and SUV responses. Furthermore, despite baseline independence, we found a strong negative correlation between Ki/K1 and K1 at the response level. Kinetic analysis of the most uptake-avid tumour cluster extracted with FCM-3 yielded similar results with attenuated changes in delivery and retention. Overall, we found that RT induces early measurable changes in lung tumour FLT uptake. Spatial analysis indicated a variable dissociation of anatomical and metabolic volumes, while temporal analysis showed a variable antagonistic effect on delivery and phosphorylation, indicating that SUV analysis may misrepresent the magnitude and variability of RT anti-proliferative effect.

Small Cell Lung Cancer (SCLC) is a very aggressive neuroendocrine tumour of the lung, which demonstrates a 5 year survival of only 10% for extensive stage disease (20-30% for limited stage), with only modest improvement over the last few decades. Identification of new molecular diagnostic and therapeutic targets is thus imperative. Previous efforts in identifying molecular changes in SCLC by gene expression profiling using microarrays have facilitated disease classification but yielded very limited information on SCLC biology. Previous DNA studies have been successful in identifying several loci important to SCLC. However the low resolution of conventional chromosomal Comparative Genomic Hybridization (CGH) has limited the findings to large chromosomal regions with only a few specific candidate genes discovered to date. Thus, to further understand the biological behaviour of SCLC, better methods for studying the genomic alterations in SCLC are necessary. This thesis highlights the development of array CGH technology for the high resolution dissection of aneuploidy in cancer genomes and the application of this new technology to the study of SCLC. I present the development of the first whole genome CGH array which offered unprecedented resolution in the profiling of cancer genomes allowing fine mapping of genes in a single experiment. Through application of DNA based analysis in conjunction with integrated expression analysis and comparison of SCLC to less aggressive non-small cell lung tumours I have identified novel patterns of pathway disruption specific to SCLC. This included alteration to Wnt pathway members and striking patterns of cell cycle activation through predominantly downstream disruption of signalling pathways including direct activation of the E2F transcription factors, which are normally repressed by the Rb gene. Analysis of targets of the E2F/Rb pathway identified EZH2 as being specifically hyper-activated in SCLC, compared to NSCLC. EZH2 is a polycomb group gene involved in the control of many cellular functions including targeted DNA methylation and escape from senescence in hematopoietic stem cells. Taken together these results suggest that in SCLC, downstream disruption may replace multiple upstream alterations leading to activation independent of a specific mitogenic pathway, and that EZH2 represents a potentially important therapeutic target. / Medicine, Faculty of / Pathology and Laboratory Medicine, Department of / Graduate

Lung cancer is the most common cause of cancer-related deaths in the United States. Prevention and early detection of lung cancer are imperative in decreasing lung cancer mortality. Screening for lung cancer with low-dose computed tomography (LDCT) decreases lung cancer by 20%. Several organizations introduced lung cancer screening (LCS) guidelines in 2013, including Centers for Medicare and Medicaid (CMS) and the United States Preventive Services Task Force. However, LCS participation for eligible patients remains low, due in part to the complexity of the LCS process. The goal of this practice improvement project was to increase the knowledge of rural primary care providers regarding LCS guidelines and the related CMS requirements and to increase their confidence in initiating shared decision-making (SDM) discussions. An educational intervention consisting of a LCS educational session and a toolkit was implemented in two rural clinics. Providers at both clinics reported a benefit to the educational intervention. Pre-, immediate post-, and two-month post-education surveys were collected to evaluate the impact of the educational intervention, including provider knowledge of LCS guidelines and CMS requirements, and confidence in SDM. Project results demonstrated an increased knowledge of LCS guidelines and CMS requirements with the greatest knowledge at immediate post-education and a high level of knowledge remaining at two months post-education. A small, nonsignificant, increase in provider confidence in initiating SDM discussions occurred. At both clinics, data collected through chart audit demonstrated an improvement in documentation needed to determine LCS eligibility and increased the percentage of patients identified at high risk for lung cancer and thus, eligible for LCS. At one clinic these changes were significant. The data were further examined for SDM discussions and referrals for LDCT or to specialist for LCS with one clinic increasing SDM documentation and LDCT referrals post-education. In conclusion, although further research is needed in implementation processes of LCS, specifically in consistent documentation to improve determination of LCS eligibility of patients, this practice improvement project found education increased provider knowledge and ability to complete requirements needed to improve LDCT screenings for lung cancer.

Lung cancer surpasses all other causes of cancer-related deaths worldwide. Gene-expression microarrays have shown that differences in the cytologically normal bronchial airway can distinguish between patients with and without lung cancer. In research reported here, we have used microRNA expression in bronchial epithelium and gene expression in nasal epithelium to advance biological understanding of the lung-cancer "field of injury" and develop new biomarkers for lung cancer diagnosis. MicroRNAs are known to mediate the airway response to tobacco smoke exposure but their role in the lung-cancer-associated field of injury was previously unknown. Microarrays can measure microRNA expression; however, they are probe-based and limited to detecting annotated microRNAs. MicroRNA sequencing, on the other hand, allows the identification of novel microRNAs that may play important biological roles. We have used microRNA sequencing to discover novel microRNAs in the bronchial epithelium. One of the predicted microRNAs, now known as miR-4423, is associated with lung cancer and airway development. This finding demonstrates for the first time a microRNA expression change associated with the lung-cancer field of injury and microRNA mediation of gene expression changes within that field. The National Lung Screening Trial showed that screening high-risk smokers using CT scans decreases lung-cancer-associated mortality. Nodules were detected in over 20% of participants; however, the overwhelming majority of screening-detected nodules were non-malignant. We therefore need biomarkers to determine which screening-detected nodules are benign and do not require further invasive testing. Given that the lung-cancer-associated field of injury extends to the bronchial epithelium, our group hypothesized that the field of injury may extend farther up in the airway. Using gene expression microarrays, we have identified a nasal epithelium gene-expression signature associated with lung cancer. Using samples from the bronchial epithelium and the nasal epithelium, we have established that there is a common lung-cancer-associated gene-expression signature throughout the airway. In addition, we have developed a nasal epithelium gene-expression biomarker for lung cancer together with a clinico-genomic classifier that includes both clinical factors and gene expression. Our data suggests that gene expression profiling in nasal epithelium might serve as a non-invasive approach for lung cancer diagnosis and screening

<div>Prostate cancer (PCa) is the second leading cause of cancer related deaths in American men. In this study, I identify two combinational therapeutics to treat PCa – the combination of enzalutamide and simvastatin, and the combination of GSK126 and metformin, both of which strongly suppress PCa cell growth in vitro and in vivo via inhibiting androgen receptor (AR), an important oncogenic driver for the PCa progression. Simvastatin leads to more AR degradation when combined with enzalutamide. For the combination of GSK126 and metformin, the interaction between enhance of zeste homolog2 (EZH2) and AR is interrupted by GSK126, re-sensitizing EZH2 to metformin. Meanwhile, GSK126 inhibits EZH2’s activity. </div><div><br></div><div>Polo-like kinase 1 (PLK1), a cell cycle regulator, is usually overexpressed in non-small-cell lung cancer (NSCLC). Here, we report that PLK1 overexpression promotes the development of Kras^G12D and Trp53^fl/fl (KP)-driven lung adenocarcinoma (LADC). KP mice harboring transgenic PLK1 (KPPI) display heavier tumor burden, poorer tumor differentiation, and lower survival than KP mice. Mechanistically, PLK1 overexpression enhances the activity of MAPK pathway, via upregulating RET expression in a kinase-dependent manner. Supporting our findings, PLK1 knockout in KP mice reduces RET gene expression, inhibits MAPK pathway activity, and strongly delays LADC development. Therefore, these data reveal that PLK1 functions as an oncogene in KP-driven LADC.</div><div> </div><div><br></div>

Lung cancer is the leading cause of cancer related deaths in the United States, with an estimated 158, 040 deaths in 2015, accounting for 27% of all cancer deaths. Recent research has identified several important molecular driver oncogenes, including epidermal growth factor receptor (EGFR). EGFR is encoded by exons 18-21, each of which harbor specific mutations within the tyrosine kinase domain. These mutations can drive cell growth, proliferation, and survival, resulting in the formation of non-small cell lung cancer. The development of EGFR tyrosine kinase inhibitors, allows the targeting of these specific mutations without the toxicity normally associated with standard chemotherapy. Unfortunately, inevitably resistance to therapy manifests, requiring a change in therapy and adding complexity to treatment decision making for clinicians and patients alike. Through a comprehensive examination of current literature, this review will establish a standard for first line, targeted treatment for specific genetic mutations within the EGFR gene, as well as address treatment options once resistance to first-line therapy inevitably develops.

Abstract Introduction & Background: One of the most common and debilitating side effects of cancer is fatigue. Fatigue is a general feeling of tiredness or weakness that can greatly impact a patient’s quality of life. It can have a profound impact on a patient’s ability to perform day to day activities and cause emotional distress leading to anxiety and depression. In recent years, there has been an increase in research to look at the effectiveness of non-pharmacological interventions on improving cancer patients’ fatigue. Purpose Statement: The purpose of our research is to look at the effectiveness of different types of non-pharmacological interventions on improving fatigue in lung cancer patients. Literature Review: The ETSU Library Database was used to locate the articles reviewed for this research. Only articles that were peer reviewed, open access, and available online were used. Articles that were published in 2016 or before were eliminated in the search to ensure the research’s relevancy. A total of five articles were selected to be reviewed. Findings: Progressive muscle relaxation therapy, physical therapies such as acupressure, acupuncture, and transcutaneous electrical acupoint stimulation, psychological intervention using the PERMA framework, and light exercise and balance programs consisting of walking in place showed an improvement in cancer patients’ level of fatigue. Conclusions: Non-pharmacological interventions for fatigue, compared to traditional pharmacological treatments, prove to have fewer adverse side-effects and risks for the patient. Therefore, these interventions are a safer and effective option in managing the distressing symptoms like fatigue that many lung cancer patients face while undergoing treatment.

Lung cancer is a disease with a high mortality rate for the U.S. Black population. There had been considerable research done on different population demographics, necessary to achieve the Healthy People 2020 overarching goals to eliminate health disparities, gain health equity and maintain quality health. Yet, the African-born Black (AFBB) population has been understudied for nonsmall cell lung cancer (NSCLC). This study sought to determine whether within race differences in stage at diagnosis and treatment of NSCLC exists between AFBB and American-born Blacks (AMBB) populations in the United States. The study data is secondary data collected as part of the National Cancer Institute's Surveillance Epidemiologic and End Result (SEER) Program from 2004-2011. Athough no significant difference was found between AFBB (n = 119) and AMBB (n = 238) relative to NSCLC stage at diagnosis, differences in treatments were found. The proportion of AFBB patients with early stage (I and II) NSCLC who underwent surgery differed significantly from that of AMBB (p < 0.05); AFBB patients were more likely to receive surgical therapy. The proportion of AFBB patients with stages I-IV of the disease who received radiation treatment also differed significantly from that of AMBB patients (p < 0.05); the latter were more likely to receive radiation therapy. Results from logistic regression analysis indicate that AFBB patients were more likely to receive surgical treatment while AMBB patients were more likely to receive radiation treatment. This study outcome can inform other NSCLC research to provide better insights to the cause of the treatment differences within the race from differing birth places, and efficient planning, evaluation of control programs and management of the disease.

Common presenting symptoms of Lung cancer are cough, hemoptysis, chest pain, dyspnea, pleurisy. Dysphagia is a very uncommon presenting feature of Lung cancer. Incidence of Dysphagia in Lung cancer is unclear from Literature. Causes of Dysphagia in case of Lung cancer are Anatomically classified as Oropharyngeal and Esophageal. Causes of oropharyngeal dysphagia are oral candidiasis, oropharyngeal Metastasis of Lung cancer. Causes of esophageal dysphagia are Cervical or Mediastinal Lymphadenopathy, Motor dysfunction because of Brain stem Metastasis, Lambert eaton syndrome, Esophageal candidiasis, Radiation esophagitis. Here by we present an Unusual presentation of an aggressive disease, poorly differentiated SCLC presenting as Mid esophageal dysphagia secondary to extrinsic esophageal compression. 65 year old female with past medical history of Diabetes, Hypertension presented with complaints of worsening sub sternal chest pain radiating to back since last 2 days and progressive dysphagia. Pt underwent Left heart catheterization revealing non obstructive coronary artery disease. Modified Barium swallow showed stasis of contrast in mid esophagus, Endoscopy showed extrinsic compression of the proximal esophagus, normal mucosa. Computerized tomography of chest was done for further evaluation, revealing extensive left cervical, mediastinal, left hilar lymphadenopathy causing extrinsic compression of the esophagus and encasement of the left hilar structures. Further evaluation through Bronchoscopic biopsy of her left upper lobe mass reveals poorly differentiated small cell carcinoma. Staging was performed revealing limited stage disease. Started on concurrent chemotherapy with cisplatin, etoposide and radiation. As SCLC is highly responsive to chemotherapy and radiotherapy sensitive patient got symptomatic relief by the end of first cycle. SCLC is an aggressive lung cancer. As it is a micro metastatic disease in nature at presentation, it’s management is entirely different from Non SCLC. SCLC being an aggressive disease can cause dysphagia in 1-2% during the disease course. SCLC presenting as dysphagia is almost never reported in the literature. Our patient presented with severe dysphagia, described it as “a tennis ball sitting in her food pipe”. Fortunately she presented to the Emergency room with dysphagia and associated chest pain, we were able to make early diagnosis of SCLC, initiate treatment. Delay in the diagnosis lead to rapid progression of disease and poor prognosis. Through our case we wanted to convey that it is very important to obtain meticulous history, keeping broad differentials, which can help improve prognosis. Because not always the presenting features are from the organ of involvement it could be from the contiguous spread or compression.