Lung cancer-associated T cell repertoire as

potential biomarker for early detection of

stage I lung cancer
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panelMinLiabcdfChunliuZhangeShichaoDengaLiLiaShiqingLiuabdJingBaieYapingXueYanfangGuaneXuefengXiaeLunquanSuncgDavid
P.CarbonefChengpingHuabcg

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Abstract

Background

Early detection of lung cancer in asymptomatic patients remains challenging, especially for stage
I. Considering the substantial interaction with tumor immunogenicity, we hypothesized that lung
cancer-associated TCR (LC-aTCR) may serve as potential biomarker in early detection of stage I
lung cancer.

Methods

Individuals who received low-dose computed tomography (LDCT) screening were enrolled in
the study. Surgical tissues and peripheral blood specimens were collected and performed with
DNA-based T cell repertoire (TCR) sequencing. The motif-based algorithm was used to
deconstruct specific lung cancer-associated TCRs (LC-aTCRs).

Results

A total of 146 individuals participating in the real-world LDCT screening project were enrolled
in this study, including 52 patients with pathologically-confirmed stage I lung cancer and 94
non-cancer controls. We developed a motif-based algorithm to define 80 LC-aTCRs in the
 training cohort. Moreover, in the validation cohort, high sensitivity and specificity was showed
in stage I lung cancer with 72% and 91% respectively, and the AUC of the ROC curve was 0.91
(95% CI: 0.85 ∼ 0.96).

Conclusion

This work provides inspiration for stage I lung cancer detection by using blood TCR profiling
data. The combination of TCR-based assay and routine screening deserves further testing in
larger cohorts.

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Abbreviations

BPN
benign pulmonary nodules
CT
computed tomography
CTCs
circulating tumor cells
ctDNA
circulating tumor nucleic acids
PBMC
peripheral blood mononuclear cells
LC-aMotif
lung cancer-associated motif
LC-aTCR
lung cancer-associated T cell repertoire
LDCT
low-dose computed tomography
LUAD
lung adenocarcinoma
LUSC
lung squamous cell carcinoma
MOI
morisita overlap index
NLST
National Lung Screening Trial
NSCLC
non small cell lung cancer
TCR
T cell repertoire
TCRβ
T cell receptor β genes
TRB
T cell repertoire β chain

Keywords

Lung cancer
Lung cancer-associated TCRs
Biomarker
Early detection
Stage I

1. Introduction

Lung cancer is the most common cause of death from cancer, and 5-year survival in patients with
lung cancer varies depending on stage at diagnosis. Although the 5-year survival rate of stage
I lung cancer could reach as high as 68～92 %, only 20.8% of patients with stage I lung cancer
were diagnosed in China. Currently, LDCT screening is recommended for high-risk individuals
of early detection of stage I lung cancer. The National Lung Screening Trial (NLST)
demonstrated a 20% relative reduction in lung cancer mortality for annual screening over three
years with LDCT to chest radiography. Lung cancer mortality was reduced by 26% in men and
61% in women receiving LDCT screening in NELSON randomised-controlled population-based
screening trial. However, LDCT identifies a relatively high percentage of subjects
with pulmonary nodules (average ∼ 20%) and the high false-positive rate (96.4%) of LDCT
causing excessive medical care and unnecessary psychological burden. Therefore, a critical need
exists for an adjunctive test to help evaluate the malignancy potential and reduce the false-
positive rate.
Liquid biopsy is a non-invasive screening technique, and the screening results are quantifiable,
objective, and free from unnecessary radiation exposure compared to LCDT. This technique is
related to the detection and analysis of biomarkers from body fluids such as blood, urine and so
on, especially circulating tumor biomarkers including circulating tumor cells (CTCs) and
circulating tumor nucleic acids (ctDNA). Several studies have yielded promising results in early
screening of liver cancer, breast cancer, prostate cancer, colorectal cancer, as well as lung cancer,
however, the sensitivity was low for the early detection of lung cancer, especially for stage I lung
cancer with the sensitivity of <50%. This may be the result of low tumor burden for ctDNA
which was released into blood in only minute amounts in stage I lung cancer. However,
immune microenvironment changes may occur even at very low tumor burden. The activated
effector T cells traffic and infiltrate to the tumor bed by blood vessels and then kill the cancer
cells. Previous studies have reported that T cell repertoire(TCR) was potentially applied as
biomarkers in the treatment of cancer. However, few studies were related to early detection of
stage I lung cancer by using TCR profiling data.
In this study, we hypothesized that lung cancer-associated TCR(LC-aTCR) may be shared
among patients. Thus, we developed an algorithm based on GLIPH to select the LC-aTCRs, and
then we validated the potential of LC-aTCRs in non-invasive early detection of stage I lung
cancer.

2. Methods

2.1. Subject cohort and study design

A total of 146 individuals participating in the real-world LDCT screening project were enrolled

in this study and divided into two cohorts. Training Cohort: We collected tissues and blood
samples from 28 individuals, among them 14 pathologically-confirmed stage I lung cancer
patients and 14 patients with benign pulmonary nodules. Validation Cohort: We enrolled 118
individuals, composed of 38 pathologically-confirmed stage I lung cancer patients and 80 non-
cancer controls. Blood samples from these individuals were collected.

2.1.1. High-throughput sequencing of T-cell receptor β genes

T cell repertoire (TCR) was evaluated by T cell receptor β genes (TCRβ) sequencing in all
patients’ Peripheral blood mononuclear cells (PBMC). And for 28 patients including 14 non-
cancer patients and 14 patients with stage I lung cancer in training cohort were evaluated by T
cell receptor β genes (TCRβ) sequencing in both the resected tissues and peripheral blood
samples (Figure S1).
Multiplex PCR amplification of CDR3 of the TCR β chain (TRB) was conducted including
PCR1 and PCR2, inclusively and semi-quantitatively in TCR sequencing. To amplify all possible
V(D)J combinations, a set of 32 V forward and 13 J reverse primers was used to perform
multiplex PCR1 assays as follows: 1 cycle at 95° C for 15 min, 10 cycles of denaturation at 94°
C for 30 s, and 10 cycles of annealing at 60° C for 90 s and extension at 72° C for 30 s. In the
second round, PCR2 was performed using universal primers. Sequencing libraries were loaded
onto the Illumina XTen System, and reads of 100-bp fragments were obtained.
TCR sequencing was defined as the amino acids between the second cysteine of the V region and
the conserved phenylalanine of the J region, according to the ImMunoGeneTics (IMGT) V, D,
and J gene references. The CDR3 sequences were identified and assigned using the MiXCR
software package.
The similarity of inter-samples was evaluated by Morisita Overlap Index (MOI) which is a
measure of the similarity in the TCR between samples ranging from 0 to 1, taking into account
the specific rearrangements and their respective frequencies, with a MOI of 1 being an identical
T cell repertoire. Shannon’s entropy was calculated on the clonal abundance of all productive
TCR sequences. The normalized Shannon’s entropy was determined by dividing Shannon’s
entropy by the natural logarithm of the number of unique productive TCR
sequences. Clonality is defined as (1 - normalized entropy) with values ranging from 0 (most
diverse) to 1 (least diverse). Richness was a measure of T cell diversity of unique T cell
rearrangements. A diversity evenness score was calculated as the total frequency of top 50%
unique TCR.

2.1.2. Motif-Based algorithm for LC-aTCRs prediction

It has been reported that a 2-4aa motif located in the CDR3 region of the TCRβ chain plays an
important role in antigen recognition. To screen out the lung-cancer enriched TCR, we
developed a modified motif-based algorithm. Firstly, sample collection. In training cohort, 28
tissue samples from 14 patients with stage I lung cancer as case group and 14 patients with
benign pulmonary nodules (BPN) as control group was collected. Next, segmenting each
CDR3β sequence into motif. we excluded the first four and last single residue because of the
sequence conservation of CDR3β and then partitioned the remaining sequence into every
possible contiguous strip of motifs include 2-mer, 3-mer and 4-mer. Thirdly, screening lung
cancer-associated motif (LC-aMotif). We calculated the occurrences of every motif in case
group and control group. And the LC-aMotifs were got as RA. Fourthly, raw lung cancer-
associated TCRs (LC-aTCRs) selection. Every LC-aMotif was a part of CDR3β sequence and
associated with one or more CDR3β. By the linkage between LC-aMotif and CDR3β, LC-aTCRs
were identified. Finally, LC-aTCRs selection. To further reduce the false positives of LC-
aTCRs, the occurrence of raw LC-aTCRs in the two groups (case group and control group) was
calculated, and LC-aTCRs were screened by Fisher exact test (alternative = “greater”, p < 0.05)
(Fig. 2D).
M2-mer = F (p value ≤0.001 and countobservedcountexpected>1000)
M3-mer = F (p value≤0.001 and countobservedcountexpected>100)
M4-mer = F (p value ≤0.001 and countobservedcountexpected>10)
Pvalue indicates that the probability of this motif per 1000 in control group is higher than that
in the case group. Observed represents the the count of motif in case group, and expected
represents the count of motif in the control group.

2.1.3. The relationship between library size and LC-aTCRs detection

We sampled the blood TCR data in validation cohort without replacement. The number of
samples ranges from 100 K to 500 K with an interval of every 20 K. LC-aTCRs detection was
calculated as the total number and total proportion of LC-aTCRs in every sample. Pearson
correlation test and Pearson coefficient were used to evaluate the relationship between LC-
aTCRs detection and library size.Ntotal=∑i=0nCTCRβiFtotal=∑i=0nFTCRβiCTCRβi Is whether
each TCRβ appears in the sample, if it does, it is 1; if it does not, it is 0;FTCRβi Is the frequency
that each TCRβ appears in every blood sample

2.1.4. Machine learning
Logistic regression modeling and leave-one-out cross-validation procedure were used as machine
learning strategy. The frequency of every LC-aTCRs, the total number and proportion of LC-
aTCRs were applied as machine learning features. The machine learning features of blood in
training cohort was used for machine learning training. The machine learning features of
validation cohort were used as the independent set for machine learning validation (Figure S1).
Prediction model performance was evaluated by using the area under the curve (AUC) based on
the receiver operating characteristics (ROC) curves. Sensitivity and specificity of the model was
determined by an optimized cut-off value. Youden’s index was applied to evaluating cut-off
value optimization.

2.2. Statistical analysis

Comparisons of proportions and variables between different groups were performed with the
Mann-Whitney U test, paired or unpaired Wilcoxon rank sum test, as appropriate. All statistical
analyses were performed in the R statistical environment version 3.6.0. Statistical significance
was defined as p-value < 0.05.

2.3. Ethics approval

This study was approved by the Institutional Review Board (IRB) of Xiangya Hospital. Written
informed content was obtained from every patient. The study was conducted in accordance with
the Declaration of Helsinki.

3. Results

3.1. Subject characteristics

A total of 146 individuals participating in the real-world LDCT screening project were enrolled

in this study, including 52 patients with pathologically-confirmed stage I lung cancer and 94
non-cancer controls. Of 52 lung cancer patients, most of them were adenocarcinoma (LUAD)
(41/52, 78.8%), and the others were squamous cell carcinoma (LUSC) (11/52, 21.2%). 94 non-
cancer controls were age and sex matched with cancer patients. Detailed characteristics were
summarized in Table 1.
Table 1. Characteristics of all included participants.
 Training Cohort Validation Cohort
Motif-based algorithm Stage I prediction
building (n = 118)
(n = 28)
Case Control Case control
(n = 14) (n = 14) (n = 38) (n = 80)
Age, years median, (range) 58.5(49–70) 58.5(46–73) 60(43–80) 54.5(40–83)
Sex:
Male 10 9 15 45
Female 4 5 23 35
Smoking history:
Never 7 6 23 47
Ever/current 7 8 15 33
Pathology:
Ad 11 – 30 –
SCC 3 – 8 –
LCC 0 – 0 –
SCLC 0 – 0 –
Inflammatory – 9 – 9
Pseudotumor
Tuberculoma – 2 – 2
Mycosis – 2 – 1
Hamartoma – 0 – 1
Sclerosing alveolar cell – 1 – 0
tumor
Health – – – 67
Stage:
IA 14 – 30 –
IB 0 – 8 –

3.1.1. Higher similarity in patients with pulmonary nodules

To get the lung cancer-associated TCR(LC-aTCR), we hypothesized that LC-aTCRs might be
shared in different patients. To validation this hypothesis, we calculated the inter-sample
similarity by Morisita overlap index (MOI) which takes consideration of the composition as well
as the abundance of T cell rearrangements. MOI ranges from 0 to 1 with 1 indicating
identical TCR repertoires and 0 indicating completely distinct TCR repertoires between two
samples. To explore the inter-sample MOI, we integrated the blood TCR repertoire from all 146
patients of two cohorts. Firstly, we compared the relationship between stage I lung cancer group
and non-cancer control group. And we found that the inter-sample MOI in each group is very
low (Med.7.045E-06), indicating that specific TCR sequences are highly variable among
individuals. At the same time, we found that patients with stage I lung cancer were significantly
more similar in blood TCR repertoire than non-cancer control individuals (Med.1.48E-05 vs
5.85E-06, p < 0.0001, Wilcoxon test) (Fig. 1A). Taken together, T cells that the immune system
responds to lung cancer may be shared in patients. This was in line with our hypothesis that LC-
aTCRs may be shared among patients.

Fig. 1. The similarity (MOI) in every group. A. By Comparing the similarity in non-
cancer group and cancer group (patients with stage I lung cancer, green), higher MOI was
found in stage I cancer group. (non-parametric Wilcoxon test. ns: p > 0.05; * : p < 0.05;
**:p < 0.01; ***: p <= 0.001,****:p < 0.0001).
 Fig. 2. The motif-based algorithm of LC-aTCRs selection. A. The workflow of LC-
aTCRs’ selection in TCR repertoire of tissue samples in training cohort. B. The 80 LC-
aTCRs of WebLogo analysis. C. The LC-aMotif selection. The number of every motif in
each sample was calculated. And the occurrence in case and control group was
compared. D. The LC-aTCRs selection. LC-aTCRs were enriched by the linkage between
LC-aMotif and TCR sequence. To reduce false positives, Fisher’s exact test was
performed by the occurrence in case and control group.

3.1.2. Motif-based algorithm for LC-aTCRs prediction

Based on the above hypothesis, we want to screen LC-aTCRs which can be used as biomarkers
in non– invasive early detection of stage I lung cancer. The LC-aTCRs needed to meet several
requirements. Firstly, LC-aTCRs are tumor infiltrating lymphocytes (TILs). Thus, only patients
with available tissues in training cohort were enrolled in this part. Secondly, LC-aTCRs should
be well detected in early stage lung cancer. Thus, only patients in stage I were collected. Thirdly,
LC-aTCRs screening procedure should exclude TCRs associated with non-tumor-associated
pulmonary inflammation. Thus, we selected patients with BPN as control group. Finally, 14
tumor tissues of stage I lung cancer samples including 3 LUSC and 11 LUAD as case and 14
tissue samples of benign pulmonary nodule with matched age, sex, and smoking history as
control, including inflammatory pseudotumor, tuberculoma, mycosis and sclerosing alveolar
cell tumor were enrolled (Table1). Moreover, lung is directly exposed to the external
environment, there may be a risk of viral and bacterial infection. To exclude the TCRs associated
to pathogenic microorganism, we filtered the T cell repertoire in both case and control groups
through the VDJ database, which contained the anti-viral CDR3β sequences such as CDR3β
related to influenza A (Figure S2). And then, we calculated the the total number of k-mers
(k = 2,3,4) in 14 the lung cancer tissues, and got 41,414 motifs ranged from 1588 to 5269 per
sample (mean = 2958±1042). Furthermore, we selected LC-aMotifs by Motif-based algorithm
(Fig. 2A), and 356 motifs were obtained, ranging from 11 to 44 (mean = 27.5±11) (Fig. 2C).
6510 raw LC-aTCRs were identified by the linkage between motif and TCR sequences. Finally,
80 LC-aTCRs were enriched by Fisher’s exact test as in method protocol (Fig. 2B-D).

3.1.3. LC-aTCRs as a cancer predictor in training set

To explore the performance of 80 LC-aTCRs in stage I lung cancer, we calculated the

distribution of each LC-aTCR in the above 28 tissue TCR repertoires and the paired bloods. We
found that LC-aTCRs were mainly detected in stage I lung cancer patients (Figure S3A).
Additionally, the number and frequency of LC-aTCRs detected in stage I lung cancer group
(case group) were also significantly higher than non-cancer group (control group)(Med. 43.5 vs
0.5 and Med.0.005 vs 5.2E-05, p < 0.001 and p < 0.05, respectively, Wilcoxon test)(Figure S3B-
C). Moreover, the distribution of LC-aTCRs was also more prevalent in case group than control
group (Fig. 3A). And the total number and proportion of 80 LC-aTCRs were much higher in case
group than that in control group (Med.4 vs 27.5, and Med.0.003 vs 0.00027, p < 0.001 and
p < 0.01, respectively, Wilcoxon test) (Fig. 3B-C).
Fig. 3. The LC-aTCRs as cancer predictor in training cohort. A. The distribution of
80 LC-aTCRs in training cohort (blood TCR repertoires). Each square represents the
frequency of an LC-aTCR in a sample. The red for high frequency and the blue for low
frequency. B. By comparing the total frequency of 80 LC-aTCRs in every individual
between case group and control group, higher frequency in case group was
identified. C. Comparing the total number of 80 LC-aTCRs in every individual between
case group and control group, the same trend was observed as in LC-aTCRs
frequency. D. Logic regression model with leave-one-out validation was used to
distinguish stage I lung cancer patients from control group. The ROC curve of LC-aTCRs
as a cancer predictor in training cohort was showed. (non-parametric Wilcoxon test. ns:
p > 0.05; * : p < 0.05; **:p < 0.01; ***: p<= 0.001;****:p < 0.0001).
Of note, we estimated the relationship between LC-aTCRs detection and library size. By
comparing with other parameters which were indicators used to assess TCR repertoire diversity
like Shannon Index, we found that Shannon Index and other parameters were significant
correlated with library size (p < 0.05, Pearson correlation) (Figure S4A). In contract, there was
insignificant correlation between LC-aTCRs and library size (Figure S4B-C). This suggest that
LC-aTCRs were independent in library size and the LC-aTCRs may be potential as a non-
invasive screening tool for stage I lung cancer.
Our primary aim was to screen LC-aTCRs and develop a convenient and integrated diagnostic
model using blood TCR repertoire to distinguish patients in stage I lung cancer from non-cancer
individuals. Logistic regression was used to calculate AUC of the 80 LC-aTCRs in blood on the
cancer prediction in training set. The frequency and quantity of 80 LC-aTCRs in each blood were
used as model features. With leave-one-out cross validation, the AUC of ROC curve was 0.8
(95% CI: 0.61 ∼ 0.99) with 86% sensitivity and 79% specificity (Fig. 3D).

3.1.4. LC-aTCRs as cancer predictor with high sensitivity of stage I patients in the independent
validation cohort

To explore the robustness of LC-aTCRs detection and predictive performance of the marchine
learning model in stage I lung cancer, we collected 118 blood samples which contained 38 stage
I lung cancer patients and 80 age and sex matched non-lung cancer patients in validation cohort
(Table1, Figure S1). LC-aTCRs were obviously enriched in stage I lung cancer patients (Figure
S5A). And the number of LC-aTCRs was significantly higher in stage I lung cancer comparing
with non-cancer individuals (Med. 20 vs 3, p < 0.0001, Wilcoxon.test) (Fig. 4A). In addition, the
frequency of LC-aTCRs tended to have higher values in stage I lung cancer (Med. 0.0281 vs
0.0078, p < 0.0001, Wilcoxon.test) (Fig. 4B). By calculating the detection rate of different lung
cancer histopathological subtypes of LC-aTCRs, there was no significant difference between
LUSC and LUAD both in the number and proportion of LC-aTCRs (Med. 22 vs 20, p > 0.05 for
number and Med.0.06 vs 0.02, p > 0.05 for proportion, Wilcoxon.test) (Figure S5B-C). At the
same time, we also found that there was no significant difference between smoker and non-
smokers (Med.18 vs 21, p > 0.05 for number, Med.0.05 vs 0.02, p > 0.05 for proportion,
Wilcoxon.test) (Figure S5D-E), indicating that LC-aTCRs were independent of pathological
subtypes and smoking status, and very stable in the validation cohort. Furthermore, we verified
the early detection model in validation cohort. Of note, the AUC in this cohort was 0.91(95% CI:
0.85–0.96) with 91% specificity and 72% sensitivity (Fig. 4C). The sensitivity of pathological
subtypes was comparable with 73% in LUSC and 71% in LUAD, respectively. (Fig. 4D).

Fig. 4. LC-aTCRs as a cancer predictor in the independent validation cohort. A-

B. The LC-aTCRs were more enriched in stage I group both in number and
frequency. C. We verified the model in the validation cohort. The AUC of the ROC curve
was 0.91 with 91% specificity and 72% sensitivity. D. The early detection model has
high performance in stage I lung cancer with 72% sensitivity. Comparable sensitivity in
LUSC and LUAD was shown with 73% and 71%, respectively. (non-
parametric Wilcoxon test. ns: p > 0.05; *: p < 0.05; **: p < 0.01; ***:
p ≤ 0.001,****:p < 0.0001).
4. Discussion

Early detection of lung cancer is the most effective way to reduce deaths from lung
cancer. Liquid biopsy approaches represent a promising strategy for disease surveillance in lung
cancer, free from unnecessary radiation exposure compared to LCDT. However, limitation of
liquid biopsies was showed in early detection of stage I lung cancer with lower
sensitivity. TCR sequencing has shown great potential in disease diagnosis. According to
previous studies that TCR diversity in the peripheral blood of lung cancer patients is different
compared with healthy people, TCR profiling data was applied for LC-aTCRs selection and
early-detection of stage I lung cancer in our study. We developed a motif-based algorithm and
selected LC-aTCRs of stage I lung cancer. With the combination of LC-aTCR features, we
aimed to set up an early detection model in stage I patients that would not only show appropriate
sensitivity and specificity in the training cohort, but also have comparable diagnostic value in
independent populations.
Lung cancer is characterized by the accumulation of a large number of somatic genetic
alterations, and these alterations result in many potential neoantigens by presentation of novel
peptides bound to major histocompatibility class I (MHCI) molecules on the surface of cancer
cells. DCs present the captured antigens on MHCI and MHCII molecules to T cells, resulting in
the priming and activation of effector T cell responses against the cancer-specific antigens in
lymph node. Tumor-associated T cells follow the circulatory system into the peripheral blood.
And then, T cells can be captured by TCR sequencing of peripheral blood. TCR sequencing
reflects the characteristics of the immune repertoire and TCR is highly diverse in the population.
This was in line with the previous study. However, the higher inter-sample similarity in stage I
lung cancer validated the assumption that common mutations in the lung cancer would stimulate
similar anti-tumor T-cell clones expanding. Therefore, we developed a motif-based algorithm to
screen LC-aTCRs.
Our study highlighted that LC-aTCRs in peripheral blood was a potential alternative strategy
which had higher sensitivity and specificity than other liquid biopsy methods in stage I lung
cancer. Furthermore, our strategy could distinguish stage I lung cancer from non-cancer
individuals with high sensitivity of 72% and specificity of 91%. In addition, the sensitivity was
stable in pathological subtypes, 73% in LUSC and 71% in LUAD respectively. To our
knowledge, this is the first study of TCR sequencing as a candidate biomarker for early detection
of stage I lung cancer. Limitations of our study include testing in a small sample size research,
lack of patients with ethnicities beyond Asian, and the bias of real-world cohorts. Since the study
focused on biomarkers for stage I NSCLC, we didn’t enrolled patients with stage II, III, IV
cancers in the study. Future efforts should focus on validating the LC-aTCRs in prospective
cohorts, which are designed to screen for larger numbers of individuals with early stage NSCLC
and on extending the study beyond Asian patients.

Funding

This work was supported by Natural Science Foundation of China (81903020), China
Postdoctoral Science Foundation (2019M652812), and National Multidisciplinary Cooperative
Diagnosis and Treatment Capacity Building Project for Major Diseases (Lung Cancer, z027002).

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal
relationships that could have appeared to influence the work reported in this paper.

References

W. Chen, R. Zheng, P.D. Baade, et al. Cancer statistics in China, 2015. CA: A Cancer J.
Clin. 66 2016 115-132.
Kimberly D. Miller, Rebecca L. Siegel, Chun Chieh Lin, et al. Cancer treatment and
survivorship statistics, 2016. CA Cancer J. Clin. 66 2016 271-289.

Peter Goldstraw, Kari Chansky, John Crowley, et al. The IASLC Lung Cancer Staging
Project:Proposals for Revision of the TNM Stage Groupings in the Forthcoming (Eighth)
Edition of the TNM Classification for Lung Cancer, J. Thorac. Oncol. 11 39-51.

M. Oudkerk, A. Devaraj, R. Vliegenthart, T. Henzler, H. Prosch, C.P. Heussel, G. Bastarr
ika, N. Sverzellati, M. Mascalchi, S. Delorme, D.R. Baldwin, M.E. Callister, N. Becker, 
M.A. Heuvelmans, W. Rzyman, M.V. Infante, U. Pastorino, J.H. Pedersen, E. Paci, S.W. 
Duffy, H. de Koning, J.K. Field

European position statement on lung cancer screening

Lancet Oncol., 18 (12) (2017), pp. e754-e766
Team TNLSTR

Reduced lung-cancer mortality with low-dose computed tomographic screening

N. Engl. J. Med., 365 (365) (2011), pp. 95-409
Google Scholar
[6]
H. De Koning, C. Van Der Aalst, K. Ten Haaf, M. Oudkerk

PL02.05 effects of volume CT lung cancer screening: mortality results of the

NELSON randomised-controlled population based trial
J. Thorac. Oncol., 13 (10) (2018), p. S185, 10.1016/j.jtho.2018.08.012
ArticleDownload PDFGoogle Scholar

J.K. Field, M.W. Marcus, M. Oudkerk

Risk assessment in relation to the detection of small pulmonary nodules

Transl. Lung Cancer Res., 6 (1) (2017), pp. 35-41
 View PDF
CrossRefView Record in ScopusGoogle Scholar

L.A. Diaz, A. Bardelli

Liquid biopsies: genotyping circulating tumor DNA

J. Clin. Oncol., 32 (6) (2014), pp. 579-586
 View PDF
View Record in ScopusGoogle Scholar

S. Leroy, J. Benzaquen, A. Mazzetta, S. Marchand-Adam, B. Padovani, D. Israel-Biet, C. 
Pison, P. Chanez, J. Cadranel, J. Mazières, V. Jounieaux, C. Cohen, V. Hofman, M. Ilie, 
P. Hofman, C.H. Marquette

Circulating tumour cells as a potential screening tool for lung cancer (the AIR
study): protocol of a prospective multicentre cohort study in France
BMJ Open, 7 (12) (2017), p. e018884, 10.1136/bmjopen-2017-018884
 View PDF
CrossRefView Record in ScopusGoogle Scholar

A.A. Chaudhuri, J.J. Chabon, A.F. Lovejoy, A.M. Newman, H. Stehr, T.D. Azad, M.S. K
hodadoust, M.S. Esfahani, C.L. Liu, L.i. Zhou, F. Scherer, D.M. Kurtz, C. Say, J.N. Carte
r, D.J. Merriott, J.C. Dudley, M.S. Binkley, L. Modlin, S.K. Padda, M.F. Gensheimer, R.
B. West, J.B. Shrager, J.W. Neal, H.A. Wakelee, B.W. Loo, A.A. Alizadeh, M. Diehn

Early detection of molecular residual disease in localized lung cancer by circulating

tumor DNA profiling
Cancer Discov., 7 (12) (2017), pp. 1394-1403
 View PDF
View Record in ScopusGoogle Scholar
C. Qu, Y. Wang, P. Wang, K. Chen, M. Wang, H. Zeng, J. Lu, Q. Song, B.H. Diplas, D.a
. Tan, C. Fan, Q. Guo, Z. Zhu, H. Yin, L. Jiang, X. Chen, H. Zhao, H. He, Y. Wang, G. L
i, X. Bi, X. Zhao, T. Chen, H. Tang, C. Lv, D. Wang, W. Chen, J. Zhou, H. Zhao, J. Cai, 
X. Wang, S. Wang, H. Yan, Y.-X. Zeng, W.K. Cavenee, Y. Jiao

Detection of early-stage hepatocellular carcinoma in asymptomatic HBsAg-

seropositive individuals by liquid biopsy
Proc. Natl. Acad. Sci. USA, 116 (13) (2019), pp. 6308-6312
 View PDF
CrossRefView Record in ScopusGoogle Scholar

E.A. Klein, M.V. Seiden, E. Hubbell, et al.
Multi-cancer detection of early-stage cancers with simultaneous tissue localization
using a plasma cfDNA-based targeted methylation assay
ESMO (2019)
Google Scholar

M.C. Liu, E. Klein, E. Hubbell, T. Maddala, A.M. Aravanis, J.F. Beausang, D. Filippova, 
S. Gross, A. Jamshidi, K. Kurtzman, L. Shen, N. Zhang, O. Venn, J. Yecies, S. Patel, D.
A. Smith, T. Yeatman, M. Seiden, A.-R. Hartman, G. Oxnard

Plasma cell-free DNA (cfDNA) assays for early multi-cancer detection: The
circulating cell-free genome atlas (CCGA) study
Ann. Oncol., 29 (2018), p. viii14, 10.1093/annonc/mdy269.048
ArticleDownload PDFView Record in ScopusGoogle Scholar

C. Abbosh, N.J. Birkbak, G.A. Wilson, M. Jamal-Hanjani, T. Constantin, R. Salari, J. Le
Quesne, D.A. Moore, S. Veeriah, R. Rosenthal, T. Marafioti, E. Kirkizlar, T.B.K. Watkin
s, N. McGranahan, S. Ward, L. Martinson, J. Riley, F. Fraioli, M. Al
Bakir, E. Grönroos, F. Zambrana, R. Endozo, W.L. Bi, F.M. Fennessy, N. Sponer, D. Joh
nson, J. Laycock, S. Shafi, J. Czyzewska-Khan, A. Rowan, T. Chambers, N. Matthews, S
. Turajlic, C. Hiley, S.M. Lee, M.D. Forster, T. Ahmad, M. Falzon, E. Borg, D. Lawrence
, M. Hayward, S. Kolvekar, N. Panagiotopoulos, S.M. Janes, R. Thakrar, A. Ahmed, F. B
lackhall, Y. Summers, D. Hafez, A. Naik, A. Ganguly, S. Kareht, R. Shah, L. Joseph, A. 
Marie
Quinn, P.A. Crosbie, B. Naidu, G. Middleton, G. Langman, S. Trotter, M. Nicolson, H. R
emmen, K. Kerr, M. Chetty, L. Gomersall, D.A. Fennell, A. Nakas, S. Rathinam, G. Ana
nd, S. Khan, P. Russell, V. Ezhil, B. Ismail, M. Irvin-Sellers, V. Prakash, J.F. Lester, M. 
Kornaszewska, R. Attanoos, H. Adams, H. Davies, D. Oukrif, A.U. Akarca, J.A. Hartley, 
H.L. Lowe, S. Lock, N. Iles, H. Bell, Y. Ngai, G. Elgar, Z. Szallasi, R.F. Schwarz, J. Herr
ero, A. Stewart, S.A. Quezada, K.S. Peggs, P. Van
Loo, C. Dive, C.J. Lin, M. Rabinowitz, H.J.W.L. Aerts, A. Hackshaw, J.A. Shaw, B.G. Zi
mmermann, C. Swanton

Phylogenetic ctDNA analysis depicts early-stage lung cancer evolution

Nature, 545 (7655) (2017), pp. 446-451
 View PDF
CrossRefView Record in ScopusGoogle Scholar

C. Mascaux, M. Angelova, A. Vasaturo, J. Beane, K. Hijazi, G. Anthoine, B. Buttard, F. 
Rothe, K. Willard-Gallo, A. Haller, V. Ninane, A. Burny, J.-P. Sculier, A. Spira, J. Galon

Immune evasion before tumour invasion in early lung squamous carcinogenesis

Nature, 571 (7766) (2019), pp. 570-575
 View PDF
CrossRefView Record in ScopusGoogle Scholar
[16]
K. Krysan, L.M. Tran, B.S. Grimes, et al. The immune contexture associates with the
genomic landscape in lung adenomatous premalignancy, Cancer Res. 79 2019 5022-
5033.
Google Scholar
[17]
D. Chen, I. Mellman

Oncology meets immunology: the cancer-immunity cycle

Immunity, 39 (1) (2013), pp. 1-10
ArticleDownload PDFCrossRefView Record in ScopusGoogle Scholar
[18]
S.A. Hogan, A. Courtier, P.F. Cheng, N.F. Jaberg-Bentele, S.M. Goldinger, M. Manuel, S
. Perez, N. Plantier, J.-F. Mouret, T.D.L. Nguyen-Kim, M.I.G. Raaijmakers, P. Kvistborg
, N. Pasqual, J.B.A.G. Haanen, R. Dummer, M.P. Levesque

Peripheral blood TCR repertoire profiling may facilitate patient stratification for
immunotherapy against melanoma
Cancer Immunol. Res., 7 (1) (2019), pp. 77-85
 View PDF
CrossRefView Record in ScopusGoogle Scholar
[19]
M.A. Postow, M. Manuel, P. Wong, J. Yuan, Z. Dong, C. Liu, S. Perez, I. Tanneau, M. N
oel, A. Courtier, N. Pasqual, J.D. Wolchok

Peripheral T cell receptor diversity is associated with clinical outcomes following

ipilimumab treatment in metastatic melanoma
J. Immunother. Cancer, 3 (1) (2015), 10.1186/s40425-015-0070-4
Google Scholar
[20]
D.B. Page, J. Yuan, D. Redmond, Y.H. Wen, J.C. Durack, R. Emerson, S. Solomon, Z. D
ong, P. Wong, C. Comstock, A. Diab, J. Sung, M. Maybody, E. Morris, E. Brogi, M. Mor
row, V. Sacchini, O. Elemento, H. Robins, S. Patil, J.P. Allison, J.D. Wolchok, C. Hudis, 
L. Norton, H.L. McArthur
Deep sequencing of T-cell receptor DNA as a biomarker of clonally expanded TILs
in breast cancer after immunotherapy
Cancer Immunol. Res., 4 (10) (2016), pp. 835-844
 View PDF
View Record in ScopusGoogle Scholar
[21]
D.A. Bolotin, S. Poslavsky, I. Mitrophanov, M. Shugay, I.Z. Mamedov, E.V. Putintseva, 
D.M. Chudakov

MiXCR: software for comprehensive adaptive immunity profiling

Nat. Methods, 12 (5) (2015), pp. 380-381
 View PDF
CrossRefView Record in ScopusGoogle Scholar
[22]
L.i. Zhang, J. Cham, A. Paciorek, J. Trager, N. Sheikh, L. Fong

3D: diversity, dynamics, differential testing - a proposed pipeline for analysis of

next-generation sequencing T cell repertoire data
BMC Bioinformatics, 18 (1) (2017), 10.1186/s12859-017-1544-9
Google Scholar
[23]
J. Glanville, H. Huang, A. Nau, O. Hatton, L.E. Wagar, F. Rubelt, X. Ji, A. Han, S.M. Kr
ams, C. Pettus, N. Haas, C.S.L. Arlehamn, A. Sette, S.D. Boyd, T.J. Scriba, O.M. Martin
ez, M.M. Davis

Identifying specificity groups in the T cell receptor repertoire

Nature, 547 (7661) (2017), pp. 94-98
 View PDF
CrossRefView Record in ScopusGoogle Scholar
[24]
M. Shugay, D.V. Bagaev, I.V. Zvyagin, et al. VDJdb: a curated database of T-cell
receptor sequences with known antigen specificity, Nucleic Acids Res. 46 2018 D419-
D27.
Google Scholar
[25]
R.O. Emerson, W.S. DeWitt, M. Vignali, J. Gravley, J.K. Hu, E.J. Osborne, C. Desmarais
, M. Klinger, C.S. Carlson, J.A. Hansen, M. Rieder, H.S. Robins

Immunosequencing identifies signatures of cytomegalovirus exposure history and

HLA-mediated effects on the T cell repertoire
Nat. Genet., 49 (5) (2017), pp. 659-665
 View PDF
CrossRefView Record in ScopusGoogle Scholar
[26]
J.F. Beausang, A.J. Wheeler, N.H. Chan, V.R. Hanft, F.M. Dirbas, S.S. Jeffrey, S.R. Qua
ke
 T cell receptor sequencing of early-stage breast cancer tumors identifies altered
clonal structure of the T cell repertoire
Proc. Natl. Acad. Sci., 114 (48) (2017), pp. E10409-E10417
 View PDF
CrossRefView Record in ScopusGoogle Scholar
[27]
Y.-Y. Liu, Q.-F. Yang, J.-S. Yang, R.-B. Cao, J.-Y. Liang, Y.-T. Liu, Y.-L. Zeng, S. Che
n, X.-F. Xia, K. Zhang, L. Liu

Characteristics and prognostic significance of profiling the peripheral blood T-cell

receptor repertoire in patients with advanced lung cancer
Int. J. Cancer, 145 (5) (2019), pp. 1423-1431
 View PDF
CrossRefView Record in ScopusGoogle Scholar
[28]
S.K. Wculek, F.J. Cueto, A.M. Mujal, I. Melero, M.F. Krummel, D. Sancho

Dendritic cells in cancer immunology and immunotherapy

Nat. Rev. Immunol., 20 (1) (2020), pp. 7-24

REACTION
a. Personal standpoint or idea about the article
 Early detection of lung cancer in asymptomatic patients remains
challenging, especially for stage I. Considering the substantial
interaction with tumor immunogenicity, we hypothesized that lung
cancer-associated TCR (LC-aTCR) may serve as potential biomarker in
early detection of stage I lung cancer.

b. Implication

Nursing Practice

Do's and don'ts include: 

 Rest when you are tired. Don’t worry if you are extremely tired (fatigued). Fatigue and
weakness are normal for a few weeks after having a lung removed.
 Limit your activity to short walks. Gradually increase your pace and distance as you feel
able.
 Don't do any strenuous activities, such as mowing the lawn, using a vacuum cleaner, or
playing sports.
 Listen to your body. If an activity causes pain, stop. Breathing may cause some pain at
the cut (incision) site. This is normal.
 Don’t drive until you are free of pain and no longer taking opioid pain medicine. This
may take 2 to 4 weeks.
 Don't sit with your legs down for long periods.
 Don’t lift anything heavier than 10 pounds (4.5 kg) until your healthcare providers says it
is OK to do so. 

Nursing Education
Lung cancer is cancer that begins in the lungs, the two organs found in the chest that help you
breathe.
The lungs are made up of areas called lobes. The right lung has three lobes; the left lung has two,
so there's room for the heart. When you breathe, air goes through your nose, down your windpipe
(trachea), and into the lungs where it spreads through tubes called bronchi. Most lung cancer
begins in the cells that line these tubes.
There are two main types of lung cancer:

 Non-small cell lung cancer (NSCLC) is the most common type of lung cancer.
 Small cell lung cancer makes up about 20% of all lung cancer cases.

If the lung cancer is made up of both types, it is called mixed small cell/large cell cancer.
If the cancer started somewhere else in the body and spread to the lungs, it is called metastatic
cancer to the lung.

Nursing Research

Introduction
Lung cancer or bronchogenic carcinoma refers to tumors originating in the lung parenchyma or
within bronchi. It is one of the leading causes of cancer-related deaths in the United States. Since
1987, lung cancer is responsible for more deaths in women than breast cancer. It is estimated that
there are 225,000 new cases of lung cancer in the United States annually and approximately
160,000 die because of lung cancer. It is interesting to note that at the beginning of the 20th
century, lung cancer was a relatively rare disease. Its dramatic rise in later decades is mostly
attributable to the increase in smoking among both males and females

Etiology
Smoking is the most common cause of lung cancer. It is estimated that 90% of the cases of lung
cancer are attributable to smoking. The risk is highest in males who smoke. The risk is further
compounded with exposure to other carcinogens, such as asbestos. There is no correlation
between lung cancer and the number of packs smoked per year due to the complex interplay
between smoking and environmental and genetic factors. The risk of lung cancer by passive
smoking increases by 20% to 30%. Other factors include radiation for non-lung cancer treatment,
especially non-Hodgkins lymphoma and breast cancer. Exposure to metals, such as chromium,
nickel, and arsenic, and polycyclic aromatic hydrocarbons also is associated with lung cancer.
Lung diseases like idiopathic pulmonary fibrosis increase risk of lung cancer independent of
smoking

Epidemiology
Lung cancer is the most commonly diagnosed cancer worldwide, accounting for 12.4% of all
cancers diagnosed. It also is responsible for the most cancer-related deaths, 17.6%. Historically,
the lung cancer epidemic seems to involve the developed world only. Recent data suggest that
the incidence of lung cancer is dramatically rising with nearly half of new cases, 49.9%,
diagnosed in the under-developed world. In the United States, mortality is high in men compared
to women. Overall, there is no difference between blacks and whites, but age-adjusted mortality
is higher in black males than their white counterparts. No such distinction exists between black
and white women

Pathophysiology
The pathophysiology of lung cancer is very complex and incompletely understood. It is
hypothesized that repeated exposure to carcinogens, cigarette smoke in-particular, leads to
dysplasia of lung epithelium. If the exposure continues, it leads to genetic mutations and affects
protein synthesis. This, in turn, disrupts the cell cycle and promotes carcinogenesis. The most
common genetic mutations responsible for lung cancer development are MYC, BCL2,
and p53 for small cell lung cancer (SCLC) and EGFR, KRAS, and p16 for non-small cell lung
cancer (NSCLC)

Recommendation
The USPSTF recommends annual screening for lung cancer with low-dose computed
tomography (LDCT) in adults aged 50 to 80 years who have a 20 pack-year smoking history and
currently smoke or have quit within the past 15 years. Screening should be discontinued once a
person has not smoked for 15 years or develops a health problem that substantially limits life
expectancy or the ability or willingness to have curative lung surgery.