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Combining liquid biopsy and radiomics for personalized treatment of lung

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 Pharmacological Research 169 (2021) 105643

Contents lists available at ScienceDirect

Pharmacological Research
journal homepage: www.elsevier.com/locate/yphrs

Review

Combining liquid biopsy and radiomics for personalized treatment of lung

cancer patients. State of the art and new perspectives
Federico Cucchiara a, Iacopo Petrini b, Chiara Romei c, Stefania Crucitta a, Maurizio Lucchesi b,
Simona Valleggi b, Cristina Scavone d, Annalisa Capuano d, Annalisa De Liperi c, Antonio Chella b,
Romano Danesi a, *, Marzia Del Re a
a
Unit of Clinical Pharmacology and Pharmacogenetics, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
b
Unit of Pneumology, Department of Translational Research and New Technologies in Medicine, University Hospital of Pisa, Pisa, Italy
c
Unit II of Radio-diagnostics, Department of Diagnostic and Imaging, University Hospital of Pisa, Pisa, Italy
d
Department of Experimental Medicine, University of Campania Luigi Vanvitelli, Naples, Italy

A R T I C L E I N F O A B S T R A C T

Keywords: Lung cancer has become a paradigm for precision medicine in oncology, and liquid biopsy (LB) together with
Lung cancer radiomics may have a great potential in this scenario. They are both minimally invasive, easy to perform, and can
Liquid biopsy (LB) be repeated during patient’s follow-up. Also, increasing evidence suggest that LB and radiomics may provide an
Radiomics
efficient way to screen and diagnose tumors at an early stage, including the monitoring of any change in the
Artificial Intelligence (AI)
Precision medicine
tumor molecular profile. This could allow treatment optimization, improvement of patients’ quality of life, and
healthcare-related costs reduction. Latest reports on lung cancer patients suggest a combination of these two
strategies, along with cutting-edge data analysis, to decode valuable information regarding tumor type,
aggressiveness, progression, and response to treatment. The approach seems more compatible with clinical
practice than the current standard, and provides new diagnostic companions being able to suggest the best
treatment strategy compared to conventional methods. To implement radiomics and liquid biopsy directly into
clinical practice, an artificial intelligence (AI)-based system could help to link patients’ clinical data together
with tumor molecular profiles and imaging characteristics. AI could also solve problems and limitations related
to LB and radiomics methodologies. Further work is needed, including new health policies and the access to large
amounts of high-quality and well-organized data, allowing a complementary and synergistic combination of LB
and imaging, to provide an attractive choice e in the personalized treatment of lung cancer.

2–5%), v-RAF murine sarcoma viral homolog B1 (BRAF; 1–3%) and

1. Introduction
Lung cancer is the second most common neoplasm in both males and
females [1] and the leading cause of tumor death in western countries
[1,2] accounting for 18.4% of mortality, with 1.8 million deaths
worldwide every year [1,2]. Since 2015, tumor molecular profile is part
of the histopathological and immunohistochemical characterization at
disease diagnosis [3]. Several oncogenic drivers have been identified in
non-small cell lung cancer (NSCLC), including the epidermal growth
factor receptor (EGFR; 10–30% of cases), fibroblast growth factor re­
ceptor 1 (FGFR1; 20%), Kirsten-rat sarcoma (KRAS; 15–30%),
phosphatidylinositol-4,5-bisphosphate 3-kinase, catalytic subunit alpha
(PIK3CA; 2–5%), human epidermal growth factor receptor 2 (HER2;
mitogen-activated protein (MAP) kinase/extracellular signal-regulated
kinase (ERK) 1 (MEK1; 1%) genes, mesenchymal-epithelial transition
factor (c-MET) gene amplification (3.5%), and rearrangements in the
anaplastic lymphoma kinase (ALK; 3%) or ROS proto-oncogene 1
receptor tyrosine kinase (ROS1; 1%) genes [4,5]. Moreover,
remarkable differences have been reported in the frequency of the
genetic landscape of smoking-related versus non-smoking-related can­
cers [6,7], highlighting also a different spectrum of mutated genes, such
as c-MET, RAS, tumor protein 53 (TP53), BRAF, AT-rich interaction
domain 1 A (ARID1A) and mismatch repair genes mutations in smokers
versus EGFR mutations, ALK and ROS1 fusions in never-smokers [7].
The identification of such mutations led to the development of the
paradigm of targeted anticancer therapies and has raised the clinical

* Correspondence to: Unit of Clinical Pharmacology and Pharmacogenetics, Department of Clinical and Experimental Medicine, University Hospital of Pisa, 56126,
Pisa, Italy.
E-mail address: romano.danesi@unipi.it (R. Danesi).

https://doi.org/10.1016/j.phrs.2021.105643
Received 11 March 2021; Received in revised form 22 April 2021; Accepted 22 April 2021
Available online 30 April 2021
1043-6618/© 2021 Elsevier Ltd. All rights reserved.
F. Cucchiara et al. Pharmacological Research 169 (2021) 105643

Nomenclature MS-PCR methylation-specific PCR

NBC naive bayesian classifier
ALK anaplastic lymphoma kinase NGS next generation sequencing
ARID1A AT-rich interaction domain 1A NSCLC non-small cell lung cancer
ARMS-PCR amplification-refractory mutation system PCR ORR overall response rate HU, Hounsfield Unit
AUROC area under the receiver operator characteristic curve OS overall survival
BFAST blood first assay screening trial PCR polymerase chain reaction
BRAF v-RAF murine sarcoma viral homolog B1 PD-1 programmed cell death-protein-1
CD cluster of differentiation PD-L1 programmed death-ligand 1
cfDNA cell free DNA PET positron emission tomography
cfRNA cell free RNA PFS progression-free survival
cMET mesenchymal-epithelial transition factor Pik platelet isolation kit
CT computed tomography PIK3CA phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic
CTAG1B Cancer/Testis Antigen 1B subunit alpha
CTCs circulating tumor cells PLAP placental alkaline phosphatase
CTLA-4 cytotoxic T-lymphocytes associated with protein 4 PPV positive predictive values
ddPCR droplet digital PCR PTGER4 prostaglandin E receptor 4
dsDNA double-stranded DNA qPCR quantitative PCR
DT decision tree RET rearranged during transfection
EGFR epidermal growth factor receptor RF random forest
EMA European Medicines Agency ROS1 ROS proto-oncogene 1 receptor tyrosine kinase
FA fractional abundance SCLC small cell lung cancer
FDA Food and Drug Administration SEC Size exclusion chromatography
FDG fluorodeoxyglucose SFTPD surfactant protein D
FGFR1 fibroblast growth factor receptor 1 SHOX2 short stature homeobox 2
FISH Fluorescence in situ hybridization SNV single-nucleotide variants
HER2 human epidermal growth factor receptor 2 SUV standardized uptake value
IHC immunohistochemistry SVM support vector machine
IFS immuno fluorescent staining TCGA the cancer genome atlas
KNN K-nearest neighbor TEPs tumor educated platelet
KRAS Kirsten-rat sarcoma TKI tyrosine kinase inhibitor
LB liquid biopsy TMB tumor mutational burden
MEK mitogen-activated protein (MAP) kinase/extracellular TP53 tumor protein 53
signal-regulated kinase (ERK) 1 TSPAN8 tetraspanin 8
miR miRNA TTF time-to-treatment failure
miRNA micro-RNA VOI volume of interest
MLR multinomial logistic regression WES whole exome sequencing
mRNA messenger RNA

need to develop sensitive technologies for the search of prognostic and
predictive biomarkers.
2. Sources and selection criteria
This narrative review looked at published data from PubMed, Sco­
pus, and Web of Science. The databases were investigated for relevant
research articles published between January 2010 and September 2020,
using the key search terms “cancer”, “lung cancer”, “NSCLC”, “liquid
biopsy”, “radiomic”, “radiogenomic”, “biomarkers”, “artificial intelli­
gence”, “machine learning”, “deep learning”, “prognostic”, “predictive”,
“targeted therapy”, “TKI”, “immunotherapy”. These searches were
combined using appropriate Boolean operators to yield 2292 abstracts,
which were hand searched. The full text was obtained for articles
considered to be eligible by each author. Research articles published in
English that reported the preclinical and clinical application of both
liquid biopsy (LB) and imaging quantitative features were included in
this review. No restrictions were adopted for the geographical origin of
the articles: data from Asia, Africa, Europe, North and South America,
and Oceania were allowed. Research studies were included in the review
if they met the following criteria: (1) the study looked at the diagnostic,
prognostic and/or predictive value of LB in lung cancer; (2) the study
looked at the diagnostic, prognostic and/or predictive value of imaging
quantitative features in lung cancer; (3) the study examined the clinical
combination of LB and imaging quantitative features; (3) the study re­
ported data from abstracts on such methodologies presented at inter­
national meetings but not yet published in extenso on scientific journals.
Moreover, additional articles, such as reviews and editorials which dealt
with the general concepts of the review, were also included.
3. Genomics through liquid biopsy. The reason why
At a molecular level, tumor progression arises from the selection of
independent genetic mutations in distinct tumor-cell sub-populations
over time, and across different disease sites [8]. These sub-clones have
different capacities to grow, invade, and metastasize, but also determine
primary and acquired resistance to treatment [9,10]. Interestingly, Hu
Zheng and colleagues [11] compared the whole exosome sequencing
(WES) data of 457 paired primary tumors and metastatic samples from
136 patients with breast, colorectal or lung cancer. Untreated and
treated metastases were included, showing that treated metastases often
harbored new driver mutations - not detected in the primitive lesion -
whereas untreated metastasis did not, suggesting a clonal evolution
promotion by medication. The ratio of non-synonymous versus synon­
ymous single-nucleotide variants (SNVs) is another way to infer the
selective pressures on protein-coding sequences [12]. A ratio greater
than 1 implies positive or Darwinian selection (driving change), less
than 1 implies purifying or stabilizing selection (acting against change),
and a ratio of exactly 1 indicates neutral (i.e., no) selection. Hu Zheng

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et al. also investigated this ratio among putative driver genes in me­
tastases, pointing out a minor selective pressure relative to colorectal
and breast cancer development, but not lung cancer [11]. These data
suggest that treatment has a pivotal role in determining longitudinal
molecular trajectories of NSCLC. Furthermore, since treatment also in­
fluences the clonality of metastases [11], it would be expected that
polyclonal seeding of distant metastases might be more common among
untreated patients than treated ones. Hence, as the prevalence of poly­
clonal seeding was variable across the primary lesion and the metastatic
sites, and as it depends on treatment, the concept of a single-site biopsy
to monitor disease dynamics is practically unfeasible, because it is
invasive and may result in an underestimation of tumor heterogeneity.
To overcome certain scientific and practical issues, the interest in the
development of minimally invasive LBs has grown. In today’s era of
precision oncology, LBs could be implemented both at pre-treatment
baseline as predictive marker, and longitudinally, to monitor response
and anticipate treatment resistance [13]. LBs often involve the extrac­
tion of circulating tumor DNA (ctDNA) [14–17], a fraction of
plasma-derived cell free DNA (cfDNA) to evaluate somatic mutations,
circulating tumor cells (CTCs) [15–17], tumor microvesiscles [16–18],
tumor educated platelet (TEPs) [16,17,19], cell free RNA (cfRNA) [16,
17,20] and circulating micro-RNA (miRNA) [16,17,20] (Table 1 and
Fig. 1).
Besides, the recent use of immunotherapy has raised new clinical
needs. Assessment of tumor-derived programmed death-ligand 1 (PD-
L1) expression in tumor tissues is currently used to predict drug
response [21,22]. Nonetheless, a broadly and functional
pro-inflammatory environment is required for treatment to be effec­
tive, and evaluation of tumor immunogenicity is also mandatory [23]. A
possible indirect expression of tumor immunogenicity is represented by
the tumor mutational burden (TMB) [24]. The underlying hypothesis is
that the more non-synonymous mutations are present in the tumor, the
greater the chance that neoantigens will arise, triggering an immune
response [24]. TMB can be assessed by quantifying the number of
non-synonymous mutations in the whole exome or in a genetic panel
defined by next generation sequencing (NGS) [25]. Published data are
growing [26,27], confirming that TMB analysis in ctDNA and molecular
cargo of exosomes derived from the peripheral tumor microenviron­
ment, potentially adding new LB candidates to a growing list of blood
tests to manage cancer patients.
Additionally, with advances in artificial intelligence (AI) software
and hardware, especially machine learning algorithms [28], the next
challenges include the possibility to use NGS to quantify and qualify
somatic mutations respect to tumor pathogenesis, biology,
microenvironmental interactions, and therapeutic vulnerabilities. NGS
is a high-throughput sequencing method that can simultaneously
interrogate variable areas of the genome, and a growing body of evi­
dence is pointing to its usefulness in clinical practice by detecting so­
matic mutations, including single-nucleotide variations (SNVs), copy
number variations (CNVs), insertions/deletions or gene fusions [29].
Different NGS-based methods have been developed and subsequently
validated for mutation detection on cfDNA in lung cancer [30]. Efficient
use of cfDNA NGS-based methods could be exploited to highlight
distinct effects of individual oncogenic alleles (e.g., activating EGFR
mutations in NSCLC [31]) and patterns of co-mutations yielding diver­
gent clinical behaviors and variable sensitivity to anticancer therapies
within the same driver mutation-defined subgroups [32]. From an
evolutionary standpoint, co-occurrence of oncogenic mutations implies
functional cooperation, whereas mutual exclusivity indicates redun­
dancy or antagonism [32,33]. Exploration of concomitant mutations
network can expand knowledge of essential biological interactions
befalling over tumor growth, and could be related with radiomic fea­
tures to envisage tumor resistance to treatment resulting from the
accumulation of subclones.
4. Radiomic through imaging. A promising contribution
Medical imaging play a major role in decision-making processes for
cancer patients, even if with a semi-quantitative (semantic [34,35])
meaning. Usually, an experienced radiologist/oncologist assign a score
to certain parameters, stemming from expertise-based observation.
Nonetheless, out of the information contained in digital medical pic­
tures, sight can only extract about 10%.
In 2012, Lambin et al. [36] and Kumar et al. [37] formally defined
“radiomics” as a new automated and reproducible analysis to extract
large amounts of quantitative features from medical images using mul­
tiple data-characterization algorithms and powerful computers. Among
radiomic features, shape and texture are mainly investigated in lung
cancer images. Shape features describe the geometry volume of interest
(VOI) [38], while texture ones aim at quantifying its variability in the
grey-scale levels [39,40] (Table 2).
Ganeshan et al. in 2012 [41] and Mattonen et al. in 2015 [42,43]
showed the potential of changes in computed tomography (CT) texture
analysis as predictive markers of local recurrence and poorer survival. A
retrospective analysis [44] on 1,160 radiomics features obtained from
the largest measurable lesion from 188 patients with NSCLC enrolled in
3 multicenter clinical trials [45–47], showed the power of a radiomic
signature in foreseeing sensitivity to treatment. The signature resulting
from the selection and combination of the four most distinguishable

Table 1
Comparison of the analysis capabilities of ctDNA, CTCs, exosomes, TEPs and cfRNA.
ctDNA CTCs exosomes TEPs cfRNA

Current technologies ARMS-PCR MS-PCR Flow cytometry IHC; IFS; SEC; chemical precipitation PIK qPCR; qPCR
qPCR; ddPCR NGS FISH qPCR; ddPCR NGS Immunocapture qPCR; ddPCR NGS ddPCR NGS ddPCR NGS

Applications Physical properties ✓ ✓

Biological features ✓ ✓
Metabolomic analyses ✓ ✓
Methylation patterns ✓
Epigenetic alterations ✓
Gene expression ✓ ✓ ✓ ✓
Somatic mutations ✓ ✓ ✓
CNA ✓
Gene fusion ✓ ✓ ✓ ✓
Splicing variants ✓ ✓ ✓
miRNA analyses ✓ ✓
DNA/RNA and protein-based ✓ ✓ ✓
molecular profiling

Abbreviations: ctDNA, circulating tumor DNA; CTCs, circulating tumor cells; TEPs, tumor educated platelets; cfRNA, cell free RNA; miRNA, micro RNA; PCR, poly­
merase chain reaction; ARMS-PCR, amplification-refractory mutation system PCR; MS-PCR, methylation-specific PCR; ddPCR, droplet digital PCR; qPCR, quantitative
PCR; NGS, next generation sequencing; IHC, immunocytochemistry; IFS, immuno fluorescent staining; FISH, Fluorescence in situ hybridization; SEC, Size exclusion
chromatography; Pik, platelet isolation kit.

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F. Cucchiara et al. Pharmacological Research 169 (2021) 105643

Fig. 1. Liquid biopsy to assess tumor heterogeneity. Schematic of clones dynamicity model (on the left), where treatment exerts pressure for selection of resistant
subclones in lung cancer. Metastases can originate from the major (driver) clones of the primitive lesion, leading to homogeneity between paired primary tumor and
metastases, or they can originate from minor clones in the primary tumor, leading to spatial heterogeneity among lesions. Seeding of polyclonal disseminated cells, as
well as their treatment-affected plasticity over tumor growth and disease progression, contributes to the spatial and temporal heterogeneity that characterizes the
neoplasm. Liquid biopsy (on the right) can cover such heterogeneity and overcome practical and scientific issues of canonical tumor sampling. CTCs, ctDNA, cfRNA
(miRNA), tumor exosomes and tumor educated platelet can be isolated from many biological fluids (mainly blood), both for a qualitative and quantitative analysis
that allows early cancer diagnosis and monitoring of disease progression.

Table 2
Radiomic features.
Size Shape Textures

Effective Diameter of the imaginary Roundness It is a dimensionless measure. The value Contrast Contrast is a measure of the local grey-level intensity
diameter ellipsoid intersecting the tumor range is 0 < roundness ≤ 1, where 1 (HU) variation
(mm) surface indicates a perfect circle. Roundness looks
for tumor spherical disproportion
Maximum The greatest Euclidean distance Smoothness Regularity of the edges of the geometric Correlation Correlation shows the linear dependency of gray-
linear size between two vertices of the figure which is built on the neoplastic mass level values to their respective voxels in a grey-level
(mm) polygon mesh built on the co-occurrence matrix. The value range is
tumor surface. 0 < correlation ≤ 1, where 1 indicates a perfect
correlation
Surface area Tumor lesion surface area Regularity Geometry associated with the tumor lesion. Entropy Entropy specifies the randomness in neighborhood
(mm2) The greater the regularity, the simpler the voxel-related grey-level intensity value differences.
geometric shape rrelated to the neoplastic
mass
Volume Tumor lesion volume Compactness Density of the neoplastic mass Homogeneity Uniformity of the image array. A greater
(mm3) homogeneity implies a smaller range of discrete grey-
level intensity values.
Surface-to- Relationship between tumor Elongation Elongation shows the relationship between Variance Variance is the mean of the squared distances of each
volume lesion surface area and volume the two largest principal components in the grey-level intensity value from the grey-level mean
ratio ROI shape value.
It is a measure of the spread of the distribution about
the mean.

Abbreviations: mm, millimeters; VOI, volume of interest; HU, Hounsfield Unit

features, suggested a supporting role in risk stratification and manage­
ment of patients.
Radiomic analysis can also reflect pathophysiological processes un­
derlying tumor development, and growing evidence suggest its use to
decode and monitor tumor genotype [48,49,58–64,50–57]. As an
example, several papers emphasize the association between NSCLC
radiomic quantitative features and EGFR mutations [48,49,58,63,
50–57], ALK rearrangement status [51,59–61], or other significant al­
terations such as KRAS mutations, ROS1 and rearranged during trans­
fection (RET) gene fusions [51,59,63]. This additional imaging-derived
information, allowed to obtain new correlations between cellular gene
expression and tissue-scale imaging, introducing the notion of
radio-genomics [65] (Fig. 2).
5. Combining liquid biopsy and radiomics for diagnostic and
prognostic purposes
5.1. The diagnostic and prognostic values of liquid biopsy
Currently, LB is mainly used as an auxiliary tool for routine exami­
nation in lung cancer [66]. Although it seems to have a limited impact
on diagnosis and staging, recent studies proved that LB might confer an
advantage on the initial molecular investigation [13]. Yang and col­
laborators [67] - investigating the prognostic role of CTCs in 107

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Fig. 2. Outline of radiogenomic pipeline. After image acquisition, areas of interest are manually or automatically segmented through computational approaches.
Shape, texture and several other radiomic features are then extracted thanks to the use of specialized user-defined algorithms or through machine learning techniques
(deep learning). Subsequently, the imaging traits could be integrated with the gene expression map and other clinical data, to select a radiogenomic model using
either statistical or machine learning methodologies. Models can be purely correlative or prognostic/predictive. The model is used to gain clinical data, including
prognostic and predictive information, for a given set of imaging features and genomic information. Incorporation of outcomes data into the radiogenomic model
leads to further refinement and model validation.

patients with EGFR-mutated advanced NSCLC receiving first-line ther­
apy with either erlotinib or gefitinib - found that subjects with low
baseline CTCs count (< 5 CTCs) showed longer median progression-free
survival (PFS) and time-to-treatment failure (TTF) than the others (11.1
vs. 6.8 months, p = 0.009 and 12.4 vs. 8.0 months, p = 0.0107;
respectively). Conversely, although a significant difference was
observed between the two groups also on day 28 for PFS (11.6 vs. 6.3
months, p < 0.0001), no difference emerged for TTF.
In line with this, other papers showed that dynamic ctDNA mea­
surements also have prognostic significance in EGFR-mutated lung
cancer treated with tyrosine kinase inhibitors (TKIs) [68–72], regardless
of tumor histological type or patient characteristics like age and smoking
habits. On this topic, Cargnin and colleagues [73] performed a system­
atic review and meta-analysis. Interestingly, they observed a harmful
impact of high baseline ctDNA levels on lung cancer patients’ survival
(p < 0.001, out of 1723 patients enrolled in 16 studies), while no as­
sociation with PFS was reported (p = 0.29, in 640 patients from five
studies). By contrast, mutations in ctDNA appeared less useful to detect
and diagnose lung cancer at an early stage [9], showing only 50%
sensitivity in early detection (possibly due to the lower detectable
amounts of ctDNA released by early-stage lung neoplasms [74]).
Besides, epigenetic biomarkers - including cfDNA/RNA methylation -
gained increasing attention as a non-invasive material for lung cancer
diagnosis. It has been reported that in the early stage, tumor-suppressor
genes are usually hypermethylated, and proto-oncogenes
hypomethylated [75]. For instance, specific enrichment of methylated
fragments of cfDNA, such as methylated SHOX2 and PTGER4 [76],
proved to distinguish early-stage lung cancer from healthy control, with
91–98% area under the receiver operator characteristic curve (AUROC)
[76,77]. Conversely, cfRNA methylation was demonstrated to mediate
miRNA expression and cancer cell migration [78], however further
studies are needed to validate its use for early diagnosis. miRNAs are the
most suitable cfRNA molecules in fluid samples and various researchers
proposed to look at them for diagnosis. The detection of different miRNA
levels [79] and patterns [80] can be used not only to identify patients
with stage I-IIIA lung cancer but also for histological classification,
whether it is a benign or malignant nodule [81], squamous cell carci­
noma or adenocarcinoma [79], NSCLC or small cell lung cancer (SCLC)
[20].
Tumor-derived proteins and metabolites have also been described as
LB markers in lung carcinoma diagnosis [82,83], and can be used to
distinguish benign and malignant nodules within a CT screening [84].
5.1.1. Exosomes
DNA, RNA, and proteins are also carried by microvesicles, including
exosomes. Exosomes are 30–150 nm vesicles of endosomes that can be
released into the extracellular space as messengers by different cell types
[85–88], including cancer cells [89]. Rab-GTPases, including Rab27a
and Rab27b, are the key regulators of exosomes secretion and Rab27 is
closely related to tumor onset and development [90], which indicates

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Table 3
Advantages, drawbacks, and potential synergies of liquid biopsy and radiomics approaches.
Liquid biopsy Radiomics

Advantages Isolation of different biomarkers from many biological fluids and sources: Multimodality
• CTCs are tumoral cells derived from solid tumors circulating in peripheral Conversion of clinical images into high-dimensional, mineable data (beyond
blood which have relevance for initial investigation, metastatic process, and the human sight) via high-throughput extraction of quantitative features
disease progression thanks machine-learning algorithm.
• cfDNA/RNA are small fragments of nucleic acid with short half-life, which are Local and global approach
easily and quickly extracted from biological fluids (e.g. blood) and analysed, Cost-effectiveness
both qualitatively and quantitatively
• exosomes are membrane-bound EVs that are produced in the endosomal
compartment of both healthy and cancer cells. Tumor EVs can be isolated. They
are high concentrated in blood (≥ 109 EVs/ml), carrying abundant content and
they are stable (i.e. maintain the integrity of contents)
Assessment of tumor heterogeneity and dynamics Assessment of tumor heterogeneity and dynamics
Minimally invasive techniques (minimal pain/risk) for early cancer diagnosis and Minimally invasive techniques (minimal pain/risk) for early cancer diagnosis
monitoring of disease progression and monitoring of disease progression
Easily repeated. Possibility to perform continuous follow-up examination and Easily repeated. Possibility to perform continuous follow-up examination and
real-time monitoring for drug-response and resistance (e.g. CTCs allow for real-time monitoring for drug-response and resistance
immuno-labelling based approaches and for molecular characterization of both
cellular and subcellular level; ctDNA are sensitive for detection of disease burden,
may predicting acquired drug resistance)
Drawbacks Still too few laboratory application. Molecular protocols need to be standardized Radiation
(different isolation technologies and different detection rates)
Difficulty in detection: Heterogeneity of analysed cohorts. Dearth of standardization for image
• Low-input amount and isolation of rare CTCs with limited capture techniques acquisition. Dearth of standardization for computational approaches and
• Challenging discrimination of ctDNA from normal cfDNA features selection
• Laborious isolation and purification of exosomes
Handling of small quantities and easily degradable material after harvesting, thus Biased discovery rates and type I error inflation
requiring extremely sensitive and specific analytic methods
Microenvironmental changes may influence the release of the amount of Need of validation on large cohort of data, collected from multiple centres,
biological materials ideally prospectively and analysed using modern methods capable of
Poor information on adequate controls addressing their heterogeneity
False positive and false negative results: risk of not correctly evaluating the Black-box issue (non-interpretable advanced machine-learning algorithms
efficacy of a pharmacological treatment work like black boxes, hindering clinical translation)
It is still unclear if liquid biopsy provides a representative sampling of all genetic Indirect and not-detailed quantification of underlying biological processes
clones or there is a propensity for specific subpopulation within the intra-tumor
heterogeneity landscape
Potential Correlating biopsies and radiomics at early cancer diagnosis and over monitoring of disease progression
synergy Create common patient-oriented liquid biopsies and radiomic databases (medical imaging and blood withdrawn are part of standard of care)
Avoid unnecessary radiation by using liquid biopsy
Use radiomics to refine liquid biopsy results and provide a full-field analyses of patient’s lesions in virtually real-time response

Abbreviations: CTCs, circulating tumor cells; cfDNA/RNA, cell free DNA/RNA; EVs, extracellular vesicles; ctDNA, circulating tumor DNA; ml, millilitres.

the role of exosomes secretion in tumor biology. Tumor-derived exo­
somes are carrier of important information of the tumor cell and can be
found in many body fluids such as blood, urine, pleural effusions, asci­
tes, and bronchoalveolar fluid [91]. Given their minimally invasive
isolation, exosomes can be considered as potential circulating bio­
markers for tumor diagnosis and prognosis [91]. As an example, as early
as in 2009 it was shown that exosome-derived miRNA isolated from
NSCLC patients mirrored the miRNA pattern expressed in NSCLC tissue
(i.e. overexpression of miR-17–3p, miR-21, miR-106a, miR-146,
miR-155, miR-191, miR192, miR-203, miR-205, miR-210, miR-212,
and miR-214), suggesting their use as surrogate material for NSCLC
[92]. Along the same lines, other notable studies [93,94] also demon­
strated the diagnostic accuracy of a multi-marker model including the
overexpression of several exosome-derived proteins (e.g. CD151,
TSPAN8, CD171, SFTPD, CD82, PLAP, CTAG1B, HER2, flotillin-1 and
mucin-16 [94]) in diagnose lung cancer. Conversely, although Mon­
termini and colleagues [95] successfully detected EGFR-mutations in
plasma-derived exosome double-stranded DNA (dsDNA) from xeno­
grafts mice of human lung cancer (A549) treated with TKIs, there is still
no clinical evidence [96].
5.2. The contribution of radiomics
Combining imaging-derived quantitative features could strengthen
the aforementioned diagnostic and prognostic values of LB. Radiologic
examination, like CT scans, is known as a useful tool to screen and detect
lung cancer at an early stage [97]. However, the application is limited by
the false-positive rate [97] and radiation exposure [98]. A combination
of minimally invasive circulating biomarkers and screening scans could
be more valuable and reliable than the independent use of the two
strategies. As an example, a panel of three miRNAs selected from The
Cancer Genome Atlas (TCGA) database demonstrated a sensitivity of
81.2% to discriminate lung cancer from healthy controls, while
combining two miRNAs from the same panel with measuring pulmonary
nodules size improved diagnostic sensitivity to 89.9% [99]. Moreover,
102 patients with untreated stage I-IIIA NSCLC who underwent radical
resection were enrolled at Virgen de las Nieves University Hospital.
CTCs were detected before and one month after surgery, and compared
with the maximum standardized uptake value (SUVmax) measured on
preoperative fluorodeoxyglucose (FDG)-positron emission tomography
(PET)/CT scans [100]. In this single-center prospective study,
Bayarri-Lara and colleagues interestingly found that SUVmax is an

6
F. Cucchiara et al.
independent predictor for the presence of CTCs after surgery [100] and
that CTCs were also blended with a reduction in PFS on multivariate
analysis, regardless of disease staging [100]. In this context, other recent
studies also showed that prediction models based on radiomic imaging
features can further help distinguishing between benign, malignant and
inflammatory lung nodules [101–106], between different histological
subtypes [107–112], and between primary and metastatic lesions [113].
The latter reports suggest that the combination of LB and radiomics has
the potential to serve as an alarm signal in patients with a high proba­
bility of lung cancer onset, thus providing an efficient way to screen and
find tumor at an early stage. This could potentially eliminate or signif­
icantly reduce the risk of radiation exposure by performing multiple
follow-up radiologic investigations for stable lung injury and reduce the
complications related to the high false-positive rates observed in
low-dose radiologic screening (Table 3). In the future, the values of the
combination of liquid and radiomic biopsy in the diagnosis of lung
cancer, particularly during the screening of early lung cancer in the
high-risk population, require well-designed prospective studies
involving large cohorts.
6. Combine liquid biopsy and radiomics for predictive purposes
6.1. Target therapy
6.1.1. The predictive value of liquid biopsy
LB can predict treatment response, especially for patients with
oncogene-addicted tumors undertaking targeted-therapies. About 15%
of western and 40% of Asian patients with NSCLC harbor EGFR sensitive
mutations (e.g. ex19del and L858R) [114], to which first/second
[115–117] and third-generation [118] EGFR-TKIs are effective. Also, the
T790M mutation inevitably occur in 50–60% of patients with acquired
resistance to first- or second-generation TKIs [119], but it is sensitive to
the third-generation TKI osimertinib [120,121].
Nowadays, exon 20 insertions remain an area of unmet need and
should be considered. Moreover, limited available clinical data suggest
that other rare variants, including E709X, L747P/S, exon 18 mutations,
and certain rare insertion/deletions of the EGFR exon 19 are sensitive to
afatinib or osimertinib [122]. In 2015, the European Medicines Agency
(EMA) approved the Qiagen Therascreen EGFR RGQ PCR kit for the
discovering and monitoring of both ex19del and T790M mutations in
ctDNA [17]. Likewise, one year later the Food and Drug Administration
(FDA) approved the use of the Roche cobas® EGFR Mutation Test v2 on
plasma samples [17]. In the WJOG8114LTR [123] prospective
multi-institutional study, the clinical significance of detecting ctDNA
was evaluated in 57 EGFR mutant lung adenocarcinoma patients treated
with afatinib. At baseline, 62.5% of patients were also positive for EGFR
mutations in plasma, and the rate of detection was higher among pa­
tients with a systemic disease. Interestingly, among positive patients,
those with undetectable circulating EGFR mutations within four weeks
after treatment showed a significantly longer PFS than those who did not
achieve negative conversion (13.6 vs. 5.1 months, p < 0.0001).
More notably, LB constitutes a very appealing option at progression,
to track mechanisms of resistance [124–126]. This setting is different
from the initial diagnosis because tumor biology is more heterogeneous
and subclonal [127]. In 2016, Sundaresan and collaborators [125]
analyzed the T790M both in CTCs and ctDNA, comparing it with data
from simultaneously collected tumor biopsies in 40 patients with
EGFR-mutant lung cancers progressing on TKIs. Although CTC- and
ctDNA-based genotyping failed in about 20% of cases, the two assays
together enabled genotyping in all patients with available blood sam­
ples, and identified the T790M mutation in 14 (35%) patients in whom
the concurrent biopsy was negative or indeterminate. Even Oxnard et al.
[126] showed that ~30% of patients who test negative for the presence
of T790M in tissue are positive in plasma and benefit from osimertinib
treatment, establishing that these apparent false positives were not
sequencing errors, but the result of tumor heterogeneity [126]. T790M
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fractional abundance (FA) is also an additional tool in interpreting a
liquid biopsy test, by informing the clinician whether T790M is the
dominant mechanism of resistance or a subclonal phenomenon within
heterogeneous biology (i.e. T790M FA <10%). The detection of EGFR
driver mutation at high FA could confirm that ctDNA is shed by the
tumor and would make a negative T790M result more likely than a true
negative, although its presence as a minor subclone is still possible.
Overall, Oxnard and colleagues also found ~30% of false negative
T790M due to a lack of sensitivity/DNA shedding [126]. A negative
result should always be validated by tissue sampling, which will enable
the detection of other mechanisms of resistance, not covered by
currently approved cfDNA assays (e.g. histotype transformation [128,
129], MET [130] and HER2 [131] amplification, or PIK3CA mutations
[132]).
Besides T790M mutation, C797S also hinders third-generation EGFR-
TKI inhibition by preventing irreversible binding, between the small
molecule and the ATP-binding pocket [133]. Thress and colleagues
confirmed its emergence as a specific mechanism of acquired resistance
to osimertinib by screening cfDNA from fifteen EGFR T790M mutant
patients during treatment [134].
Furthermore, in addition to EGFR, recent studies have also evaluated
the possibility of using LB to detect both ALK rearrangement and point
mutations, prior and during ALK-inhibitors treatment [135–139].
Among them, positive results came from a single-arm cohort of the
Phase II/III blood first assay screening trial (BFAST) [139], evaluating
blood-based NGS to detect specific fusions in 2188 patients with
advanced NSCLC. Blood-based detection of ALK fusions produced high
overall response rate (ORR) and clinical benefits in patients receiving
alectinib, validating the clinical utility of blood-based NGS as an addi­
tional companion diagnostic tool to inform clinical decision making in
ALK-positive NSCLC.
Papadimitrakopoulou’s group also proved cfDNA to be a clinically
viable source for other guideline-recommended biomarkers, including
ALK [140]. By looking at 282 patients with newly diagnosed metastatic
NSCLC, it was found a 100% positive predictive value for cfDNA versus
tissue, with a concordance greater than 98.2%. Utilizing cfDNA in
addition to tissue increased detection by 48%, including those with
negative, not assessed, or insufficient tissue results. Moreover, cfDNA
median turnaround time was significantly shorter than tissue (9 vs 15
days; p < 0.0001).
The aforementioned results support a new paradigm for detecting
mutations at progression, with plasma genotyping proposed as a first-
line screening test - since its lower turnaround time - and tumor bi­
opsy requested in the case of negative results.
6.1.2. The contribution of radiomics
Since genomic analysis is becoming conventional, research interest
in investigating whether radiomics can predict the genetic status of the
neoplasm is also rising. Radiogenomic research on lung cancer started in
2012 with Gevaert et al. [141], by correlating PET/CT features and
aggregated gene expression patterns, with encouraging preliminary re­
sults. Two years later, Halpenny and colleagues [142] started a series of
publications linking specific imaging parameters to selected mutations,
such as EGFR [51,53,150–152,63,143–149], ALK [51,152] and KRAS
[51,63,145,147]. So far, many research teams have shown that radiomic
analysis can lead to the molecular classification of the tumor, although
the selected features and approaches were not consistent with each
other. As an example, EGFR activating mutation was independently
associated to selected features such as, contrast [143], Laws-Energy
[144], median Hounsfield Unit (HU) [145], SUVmax [146], pleural
retraction [51], small size [51,147], speculation [147], irregular nod­
ules [148], poorly defined margins [148], ground glass [53,148],
emphysema [149], locoregional infiltration [149], normalized inverse
difference moment [150], as well as combined radiomic profiles [63,
151]; ALK rearrangement was linked to pleural effusion [51] and
lobulated margin [152]; while KRAS was related to round shape [51],
F. Cucchiara et al.
nodules in non-tumor lobes [51], multiple small nodules [147], as well
as general radiomic profiles [63].
Machine learning approaches could overcome the problem and
compute the most distinguishable radiomic features - whatever they are
- through n-fold bootstrapped training sets and then incorporating them
into a model for mutation status prediction, fitted on the specific studied
cohort. Different studies used different approaches. Most frequently, top
ranking features were incorporated in a signature via multinomial lo­
gistic regression (MLR; often used in small data sets due to their re­
sistivity to overfitting) [50–52,54,57,58,144], although some authors
preferred other models, such as naive bayesian classifier (NBC) [58],
K-nearest neighbor (KNN) [58], random forest (RF) [55,56,58,63],
support vector machine (SVM) [58] and decision tree (DT) [53,58]. All
works assessed model performance by measuring the AUROC in the
validation cohort, evidencing good capability with acceptable repre­
sentativeness for predicting mutation status.
Yet, a dearth of standardization for image acquisition and the het­
erogeneity of the small cohorts analyzed, still means a lack of repro­
ducibility and generalizability in methodology [153]. Furthermore,
radiomic indices should be considered as indirect and non-detailed
quantification of underlying biological processes.
To identify truly reliable radiogenomic features or signatures, large
cohorts of heterogeneous patients should be collected from multiple
centers, ideally prospectively, and analyzed using modern methods
capable of addressing such data heterogeneity [154]. To strengthen the
trustworthiness of the results, radiomics-based genotype predictions
could also be interestingly compared with information from LB [155],
over time. As previously mentioned, a combination of these two mini­
mally invasive strategies, together with cutting-edge data analysis
strategies, could be more valuable and reliable than their independent
use, and may help decode tumor valuable information regarding type,
aggressiveness, progression, and response to treatment [144,154]. A
study from the University of Oklahoma reported that while radiomics
(AUROC = 0.78) and genomics (AUROC = 0.78) models were capable of
predicting survival, accuracy significantly improved (AUROC = 0.84)
when both data were combined [156]. This approach seems more
compatible with clinic practice than current standard, providing new
instrumental and more objective diagnostic support, being able to sug­
gest a change in treatment strategy earlier than conventional methods
(Table 3).
6.2. Immunotherapy
6.2.1. The predictive value of liquid biopsy
Given the LB’s promising results obtained in targeted therapies, the
growing effort in use it to predict response to immunotherapy is
unsurprising.
Immunotherapy is able to switch off the inhibitory effect of tumor on
the immune system [157]. Among them, immune checkpoint inhibitors
(ICIs; i.e. ipilimumab [158,159], pembrolizumab [160–162], nivolumab
[158,159], atezolizumab [163,164] and durvalumab [165,166]) pre­
vent the binding of PD-L1 and cluster of differentiation 86 (CD86), to
their respective receptors programmed cell death-protein-1 (PD-1) and
cytotoxic T-lymphocytes associated with protein 4 (CTLA-4), on cyto­
toxic T-cell, which would otherwise contribute to the host immune
system evasion by promoting self-tolerance and suppressing inflamma­
tory activity [167].
Assessment of PD-L1 expression in NSCLC tissues is currently used to
predict drug response in the clinics [21,22]; however, since CTCs arise
from more than one tumor site, they should provide a better overall
representation of PD-L1 expression in the metastatic setting [168].
Studies on CTC PD-L1 expression have accumulated for several solid
tumors including lung [168–174], establishing their feasibility. There
are many methods for detecting CTCs. An attractive one would be to
acquire CTCs by a negative enrichment method that used
magnetic-activated cell sorting, and then fix the derived dried specimen
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to identify CTCs by fluorescent immunohistochemistry (IHC) [175].
Nonetheless, CTCs data in lung cancer are very preliminary and
hurdles concerning their isolation have also emerged [176–178]. The
hypothesis that PD-L1 expression on CTCs could be used as a predictive
marker of response to ICIs has unfortunately not been confirmed so far.
Furthermore, it remains to be clarified whether PD-L1 is expressed on all
CTCs or in some subpopulations; whether prognosis and predictive
response to immunotherapy is correlated with CTC-derived PD-L1
expression at baseline or during follow-up of treated patients; and
whether the expression of PD-L1 in CTCs is related to synchronously
matched tissue biopsies. Only Ilie et al. [168] were able to show good
concordance between tissue and CTCs, but the rate of positive samples
was low and correlation with response to PD1/PD-L1 inhibitors could
not be investigated.
Apart, recent work by Lee and Rho’s groups reports that lung cancer
cells release PD-L1 positive extracellular vesicles into the circulation,
mainly exosomes [179]. First, they found that the exosomal expression
did not differ among cultures of three distinct NSCLC cell lines, although
the amount of PD-L1 in the exosomes was proportional to the quantity of
PD-L1 expression on the cells from which the exosomes were derived.
Hence, they next tested that PD-L1-containing exosomes can affect
tumor growth in vitro and in vivo by systemically suppressing the im­
mune system. Finally, the clinical relevance of the findings was
confirmed by observing a correlation between the proportion of
PD-L1-positive exosomes and the PD-L1 expression level in the related
cancer tissue upon 24 patients. Consistent with these results, Danesi
study-group investigated the association between PD-L1 mRNA in
plasma-derived exosomes and response to nivolumab and pem­
brolizumab in patients with NSCLC (8) or melanoma (18) [180]. Exo­
somal PD-L1 mRNA was obtained from blood at baseline and after 2
months of treatment, and measured by digital droplet PCR. A significant
reduction in PD-L1 mRNA copies/ml was found at baseline vs 2 months
of treatment for patients with complete and partial responses, but not for
patients with stable disease. Vice versa, a significant increase in PD-L1
levels was observed in patients who progressed.
This finding suggests that PD-L1 positive extracellular vesicles are
also able to counteract the immune pressure at the effector stage and
offer a novel marker for immunotherapy beside CTCs [181].
6.2.1.1. Tumor mutational burden. TMB has recently been evaluated
prospectively, alone or in association with PD-L1 IHC, for the stratifi­
cation of late stage NSCLC patients who benefit from PD-1 blockade [23,
182]. In addition to exosomal PD-L1, WES for determination of TMB in
LB from patients with advanced NSCLC suggests that blood-based TMB
could also be used as a clinically actionable biomarker for predicting
anti-PD-L1 therapy, especially if tumor biopsy is not accessible or has
been resampled [183]. However, the first results on the concordance
between tissue and cfDNA are contrasting [184]. One of the major issues
in the TMB evaluation is the lack of standardization. For instance, the
TMB calculation, intended as the type of somatic mutations (e.g. pas­
senger or driver mutations), varied among the studies. And this also
because different sequencing panels covered different genomic regions.
Also, no clear binary cut-point is used to stratify patients with low/high
TMB [185]. Furthermore, others challenges persist and, for instance,
patients with both high TMB and PD-L1 tumor cells positivity, immu­
notherapy might still fail, revealing both the complexity and our
incomplete understanding of the immunopathology of cancer [186].
Additionally, a critical review by Passaro et al. [187] confirmed ECOG
PS, bone metastasis and liver metastases to negatively affect the efficacy
of ICIs, while the combination of chemo- and immuno-therapy seems to
be more effective in women and in patients with a history of smoking.
However, although useful in clinical practice for risk–benefit ratio
stratification, the authors conclude that a single prognostic factor is not
the best way to understand tumor clinical behavior and
biological-related microenvironment. Thus, given the immune response
F. Cucchiara et al.
heterogeneity and both tumor and patient diversity, the use of a single
predictor is impracticable and new approaches using additional and
more robust biomarkers should be associated with ICIs.
6.2.2. The contribution of radiomics
As proposed for target therapy, Tang et al. [188] presented a NSCLC
radiomic signature using unsupervised classification approach. Four
distinct clusters were grouped by combining tissue-based CD3 count and
PD-L1 low/high expressions from an early-stage NSCLCs cohort. Texture
features and intensity measures were then correlated to these four
clusters. Therefore, corresponding survival models were carried out,
indicating the highest overall survival (OS) in the radiomic cluster that
was strongly correlated with high CD3 and low PD-L1 expressions.
Radiomic features pertaining to vessel tortuosity extracted from
baseline pretherapy CT scans have also been recently identified as a
potential independent predictor of response to nivolumab in locally
advanced NSCLC [189], and changes in CT radiomic features concerning
intra- and peri-tumor areas were associated with lymphocyte distribu­
tion [190–192], leveraging on predicting OS and response to immuno­
therapy [190,193]. Similar findings were obtained by including most
predictive radiomic features and clinical covariates in DT models to
stratify patients into survival risk-groups [194]. By doing so, a texture
radiomic feature (the Gray-Level Co-Occurrence Matrix inverse difference)
was found to be not only significantly related with OS in four inde­
pendent NSCLC cohorts (HR = 2.74; 95% CI 1.04 – 7.24), but also
positively associated with the hypoxia-related carbonic anhydrase,
tumor acidosis, and treatment resistance. Dr. Aerts and his group carried
out an AI-based characterization of NSCLC primary and metastatic le­
sions on the pre-treatment contrast-enhanced CT imaging data to
develop and validate a noninvasive machine learning biomarker capable
of distinguishing between immunotherapy responding and non­
responding (AUROC = 0.83, p < 0.001) [195]. It was also found highly
significant associations with pathways involved in mitosis, indicating a
relationship between increased proliferative potential and preferential
response to immunotherapy [195].
To conclude, it is also interesting to describe an early report on 228
NSCLC patients treated with single agent or double agent immuno­
therapy identified a clinical-radiomic model of both TTF
(AUROC = 0.804% and 73.41% accuracy) and hyper-progressive dis­
ease (AUROC = 0.865% and 82.28% accuracy). The models have
potentially important practical implications in identifying highly
vulnerable NSCLC patients treated with immunotherapy that experience
rapid disease progression and poor survival outcomes [196].
7. Conclusion
LB and radiomics have promising and attractive characteristics, they
are quantifiable and can be repeated to evaluate tumor progression.
Furthermore, in comparison to tissue molecular profiling, limited by the
invasiveness of the procedure, medical imaging and withdrawal of blood
samples are more commonly part of the standard of care [197] and may
provide a full-field analysis of the lesion, in virtually real-time response.
Nevertheless, the proposed literature must be carefully considered.
Publications naturally tend to overestimate the positive results over the
negative ones [198,199], however, the lack of reproducibility is known
and is mainly due to the absence of standardization in all the workflow
phases [200,201]. Additionally, many studies suffer from severe vali­
dation limitations, including improper statistical analysis (e.g. lack of
p-value adjustment for multiple tests) and/or absence of an independent
dataset to confirm results. This can easily lead to biased discovery rates
and type I error inflation [202].
For instance, due to the risk of false-negative results, LB is not yet
considered a standard alternative to the tissue biopsy but is rather used
as a complementary test for patients undergoing TKI if tissue-specimens
are lacking [203] (and there is still no indication to perform it on pa­
tients selected for immunotherapy [204]). CTCs and ctDNA are
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Pharmacological Research 169 (2021) 105643
relatively rare and fragile compared to the number of hematological
molecules found in the blood sample, and ctDNA analysis could be
contaminated by genomic DNA as well [205]. Therefore, there are dif­
ficulties in detection [205]. Besides, it is unclear whether the LB pro­
vides a representative sampling of all genetic clones or there is a
propensity for a specific subpopulation within the intra-tumor hetero­
geneity landscape [206]. Concerning this, an NGS effort could be
attempted to explore the co-occurrence patterns of subclone-derived
mutations during tumor progression and related to divergent clinical
behaviors and treatment resistance. Depending on the size of the
analyzed panel, the advantages of ctDNA-based NGS methods lie in the
simultaneous detection of dozens of targetable genetic abnormalities,
including single nucleotide variations (SNV), copy number variations
(CNV), insertions/deletions, or fusion gene, reflecting the overall het­
erogeneity of the intrapatient tumor, while space-limited tissue NGS
could lose new potential therapeutic targets [207]. This is particularly
relevant considering the expected increase in enrollment of umbrella
trials or expanded access programs requiring molecular assignment.
Conversely, subsequent tissue NGS could identify substantial differences
between neoplastic masses separated by time (temporal) or anatomic
location (spatial) in the same patient. A paper from Kurzrock’s Center
for Personalized Cancer Therapy showed high concordance between
genomic results of ctDNA and tissue NGS, but demonstrated that there
could be significant differences if the acquisition of of LB from tissue
biopsy exceedes 6 months [208]. Therefore, a complementary NGS
analysis of tissue and ctDNA could capture intrapatient tumor hetero­
geneity, being repeatable during treatment. CtDNA-based NGS methods
also allow tracking variant allelic frequency (VAF), which is the relative
proportion of mutant forms compared to wild-type ones at a given locus.
VAF monitoring during patient’s treatment is under investigation and
offers a promising opportunity for long-term disease management as
well [209]. However, given the considerable dilution of somatic muta­
tions from plasma, the innate error rates of NGS calls are a primary
concern for ctDNA analysis and may affect data interpretation. To
address this, many labs are adopting sophisticated foolproof computa­
tional approaches to greatly improve sequencing specificity, reduce the
chance of false-positive calls and thus increase sensitivity [210,211].
Overall, the improvement of analytical methods is necessary to in­
crease LB sensitivity [212].
Additionally, the viability of platforms in one’s own region are other
issues for the use of ctDNA-based NGS methods, and each clinical setting
will need to evaluate and balance between assay availability, cost, and
sensitivity.
Radiomics could ameliorate NGS cost-effectiveness by adding new
high-throughput imaging features reflecting underlying gene expression
patterns and revealing heterogeneous tumor metabolism and anatomy
[213]. This extraction is typically preparatory to a data mining process
[11] to increase precision in diagnosis, assessment of prognosis, pre­
diction of treatment response, and provide valuable information for
patient care throughout the disease [214].
More should also be learned about the functioning of radiomics to
understand the underlying clinical and/or molecular connotation [215]
of imaging features (i.e. the black-box problem).
We posit that the embedding of LB-related genomic testing and
radiomic features through AI could overcome problems and limitations
related to methodologies and permit research findings implementation
directly into clinical practice. The purpose is twofold: provide a cost-
effective treatment personalization, by using an approach where clini­
cians and patients promptly share the best minimally invasive available
evidence when faced with the task of making decision.
The global precision medicine (diagnostics/therapeutics) market
size is projected to reach $ 85.5 billion by 2025 [216], and progress and
promises of multiple new treatment choices for lung cancer come with
exorbitant prices, too. Quickly diagnosis of the tumor, detecting any
change in tumor molecular profile, responsiveness to treatment and
tumor recurrence, would focus treatment options for patient well-being,
F. Cucchiara et al.
increase the success rate, improve patient QoL and reduce
healthcare-related costs. As reported by Sholl and colleagues, the mo­
lecular genetics of tumors has yet to take hold in clinical oncology
training, and many oncologists are not comfortable interpreting mo­
lecular tumor findings [212]. Therefore, to achieve the goal and reduce
the risk of interpretation they will have to consult a multidisciplinary
group of experts trained in molecular pathology [212], combine a new
narrative, mechanistic and mathematical thinking in their training [217,
218] and consider a new bio-psycho-social model of patient-centered
disease [212,217,218].
Although these skills are not even currently accredited in medical
education programs, a survey conducted by the American Medical As­
sociation (AMA) in 2016 shows that 85% of physicians perceived ben­
efits from new digital tools [219]. Yet, the implementation of AI in
medical education is challenging because the tuition will beef up the
existing curriculum rather than replace existing coursework, and
another practical problem is that many senior physicians have little to
no experience with AI.
Finally, there are also important legal and regulatory aspects to
address [220] concerning the use of AI in the healthcare system, such as
the data privacy and ownership [221]. The key to success will require
policies that properly regulate large reserves of linked information
(around seven gigabytes of health data for single patient [222]),
ensuring accessibility and security. Ideally, data should be easily avail­
able for those who need, while security should be efficient to prevent
inappropriate access. Strong user authentication methods should be in
place to consider the high-security constraints, and traceability should
also be important at all levels of data processing. Linking and coordi­
nating medical records are also steps not to be overlooked and often
require a third party to govern these procedures.
These challenges, while not trivial, also present significant new op­
portunities for the development of novel theoretical approaches and
practical applications in data-driven medical decisions. If new health
policies take hold, and new studies will access to large amounts of well-
organized high-quality data, the complementary and possibly synergis­
tic combination of LB and imaging could provide an attractive choice to
the traditional molecular pathology profile in the personalized treat­
ment of NSCLC.
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Availability of data and materials
Not applicable.
Funding
This research was funded to Romano Danesi under grant n.
2017NR7W5K (PRIN 2017) from MIUR, Italy.
Authors’ contributions
Federico Cucchiara, Marzia Del Re, Romano Danesi: Conceptuali­
zation. All authors: Investigation, Formal analysis. All authors: Data
curation. Federico Cucchiara: Writing - original draft preparation.
Marzia Del Re: Writing - review & editing. Romano Danesi: Visualiza­
tion. Romano Danesi: Supervision. All authors have read and agreed to
the published version of the manuscript.
10
Pharmacological Research 169 (2021) 105643
Competing interests
The authors declare no conflict of interest.
Acknowledgments
None.
References
[1] R.L. Siegel, K.D. Miller, A. Jemal, Cancer statistics, 2019, CA Cancer J. Clin. 69
(2019) 7–34, https://doi.org/10.3322/caac.21551.
[2] F. Bray, J. Ferlay, I. Soerjomataram, R.L. Siegel, L.A. Torre, A. Jemal, Global
cancer statistics 2018: GLOBOCAN estimates of incidence and mortality
worldwide for 36 cancers in 185 countries, CA Cancer J. Clin. 68 (2018)
394–424, https://doi.org/10.3322/caac.21492.
[3] W.D. Travis, E. Brambilla, A.P. Burke, A. Marx, A.G. Nicholson, Introduction to
The 2015 World Health Organization classification of tumors of the lung, pleura,
thymus, and heart, J. Thorac. Oncol. Publ. Int. Assoc. Study Lung Cancer 10
(2015) 1240–1242, https://doi.org/10.1097/JTO.0000000000000663.
[4] U. Testa, G. Castelli, E. Pelosi, Lung Cancers: Molecular Characterization, Clonal
Heterogeneity and Evolution, and Cancer Stem Cells, in: Cancers (Basel), 10,
2018, https://doi.org/10.3390/cancers10080248.
[5] M. Shea, D.B. Costa, D. Rangachari, Management of advanced non-small cell lung
cancers with known mutations or rearrangements: latest evidence and treatment
approaches. Ther. Adv. Respir. Dis. 10 (2016) 113–129, https://doi.org/
10.1177/1753465815617871.
[6] S. Couraud, P.-J. Souquet, C. Paris, P. Dô, H. Doubre, E. Pichon, A. Dixmier,
I. Monnet, B. Etienne-Mastroianni, M. Vincent, J. Trédaniel, M. Perrichon,
P. Foucher, B. Coudert, D. Moro-Sibilot, E. Dansin, S. Labonne, P. Missy, F. Morin,
H. Blanché, G. Zalcman, BioCAST/IFCT-1002: epidemiological and molecular
features of lung cancer in never-smokers. Eur. Respir. J. 45 (2015) 1403–1414,
https://doi.org/10.1183/09031936.00097214.
[7] R. Govindan, L. Ding, M. Griffith, J. Subramanian, N.D. Dees, K.L. Kanchi, C.
A. Maher, R. Fulton, L. Fulton, J. Wallis, K. Chen, J. Walker, S. McDonald,
R. Bose, D. Ornitz, D. Xiong, M. You, D.J. Dooling, M. Watson, E.R. Mardis, R.
K. Wilson, Genomic landscape of non-small cell lung cancer in smokers and
never-smokers, Cell 150 (2012) 1121–1134, https://doi.org/10.1016/j.
cell.2012.08.024.
[8] I. Dagogo-Jack, A.T. Shaw, Tumour heterogeneity and resistance to cancer
therapies, Nat. Rev. Clin. Oncol. 15 (2018) 81–94, https://doi.org/10.1038/
nrclinonc.2017.166.
[9] M. Jamal-Hanjani, G.A. Wilson, N. McGranahan, N.J. Birkbak, T.B.K. Watkins,
S. Veeriah, S. Shafi, D.H. Johnson, R. Mitter, R. Rosenthal, M. Salm, S. Horswell,
M. Escudero, N. Matthews, A. Rowan, T. Chambers, D.A. Moore, S. Turajlic,
H. Xu, S.-M. Lee, M.D. Forster, T. Ahmad, C.T. Hiley, C. Abbosh, M. Falzon,
E. Borg, T. Marafioti, D. Lawrence, M. Hayward, S. Kolvekar, N. Panagiotopoulos,
S.M. Janes, R. Thakrar, A. Ahmed, F. Blackhall, Y. Summers, R. Shah, L. Joseph,
A.M. Quinn, P.A. Crosbie, B. Naidu, G. Middleton, G. Langman, S. Trotter,
M. Nicolson, H. Remmen, K. Kerr, M. Chetty, L. Gomersall, D.A. Fennell,
A. Nakas, S. Rathinam, G. Anand, S. Khan, P. Russell, V. Ezhil, B. Ismail, M. Irvin-
Sellers, V. Prakash, J.F. Lester, M. Kornaszewska, R. Attanoos, H. Adams,
H. Davies, S. Dentro, P. Taniere, B. O’Sullivan, H.L. Lowe, J.A. Hartley, N. Iles,
H. Bell, Y. Ngai, J.A. Shaw, J. Herrero, Z. Szallasi, R.F. Schwarz, A. Stewart, S.
A. Quezada, J. Le Quesne, P. Van Loo, C. Dive, A. Hackshaw, C. Swanton,
Tracking the evolution of non-small-cell lung cancer, N. Engl. J. Med 376 (2017)
2109–2121, https://doi.org/10.1056/NEJMoa1616288.
[10] C.M. Lovly, A.K.S. Salama, R. Salgia, Tumor heterogeneity and therapeutic
resistance. Am. Soc. Clin. Oncol. Educ. Book. Am. Soc. Clin. Oncol. Annu. Meet.
35 (2016) e585–e593, https://doi.org/10.1200/EDBK_158808.
[11] Z. Hu, Z. Li, Z. Ma, C. Curtis, Multi-cancer analysis of clonality and the timing of
systemic spread in paired primary tumors and metastases, Nat. Genet. 52 (2020)
701–708, https://doi.org/10.1038/s41588-020-0628-z.
[12] K. Hanada, S.-H. Shiu, W.-H. Li, The nonsynonymous/synonymous substitution
rate ratio versus the radical/conservative replacement rate ratio in the evolution
of mammalian genes, Mol. Biol. Evol. 24 (2007) 2235–2241, https://doi.org/
10.1093/molbev/msm152.
[13] C. Rolfo, P.C. Mack, G.V. Scagliotti, P. Baas, F. Barlesi, T.G. Bivona, R.S. Herbst, T.
S. Mok, N. Peled, R. Pirker, L.E. Raez, M. Reck, J.W. Riess, L.V. Sequist, F.
A. Shepherd, L.M. Sholl, D.S.W. Tan, H.A. Wakelee, I.I. Wistuba, M.W. Wynes, D.
P. Carbone, F.R. Hirsch, D.R. Gandara, Liquid biopsy for advanced non-small cell
lung cancer (NSCLC): a statement paper from the IASLC, J. Thorac. Oncol. 13
(2018) 1248–1268, https://doi.org/10.1016/j.jtho.2018.05.030.
[14] M. Elazezy, S.A. Joosse, Techniques of using circulating tumor DNA as a liquid
biopsy component in cancer management. Comput. Struct. Biotechnol. J. 16
(2018) 370–378, https://doi.org/10.1016/j.csbj.2018.10.002.
[15] M.H.D. Neumann, S. Bender, T. Krahn, T. Schlange, ctDNA and CTCs in liquid
biopsy − current status and where we need to progress, Comput. Struct.
Biotechnol. J. 16 (2018) 190–195, https://doi.org/10.1016/j.csbj.2018.05.002.
[16] G. De Rubis, S. Rajeev Krishnan, M. Bebawy, Liquid biopsies in cancer diagnosis,
monitoring, and prognosis, Trends Pharmacol. Sci. 40 (2019) 172–186, https://
doi.org/10.1016/j.tips.2019.01.006.
F. Cucchiara et al.
[17] G. Siravegna, S. Marsoni, S. Siena, A. Bardelli, Integrating liquid biopsies into the
management of cancer, Nat. Rev. Clin. Oncol. 14 (2017) 531–548, https://doi.
org/10.1038/nrclinonc.2017.14.
[18] S. Cui, Z. Cheng, W. Qin, L. Jiang, Exosomes as a liquid biopsy for lung cancer,
Lung Cancer 116 (2018) 46–54, https://doi.org/10.1016/j.lungcan.2017.12.012.
[19] L. Liu, F. Lin, X. Ma, Z. Chen, J. Yu, Tumor-educated platelet as liquid biopsy in
lung cancer patients, Crit. Rev. Oncol. Hematol. 146 (2020), 102863, https://doi.
org/10.1016/j.critrevonc.2020.102863.
[20] S. Lu, H. Kong, Y. Hou, D. Ge, W. Huang, J. Ou, D. Yang, L. Zhang, G. Wu, Y. Song,
X. Zhang, C. Zhai, Q. Wang, H. Zhu, Y. Wu, C. Bai, Two plasma microRNA panels
for diagnosis and subtype discrimination of lung cancer, Lung Cancer 123 (2018)
44–51, https://doi.org/10.1016/j.lungcan.2018.06.027.
[21] E. Jimenez Aguilar, H. Rizvi, S. Kravets, C.A. Lydon, A.E. Adeni, S. Subegdjo, M.
D. Hellmann, M.M. Awad, Comparison of outcomes with PD-L1 tumor proportion
score (TPS) of 50-74% vs 75-100% in patients with non-small cell lung cancer
(NSCLC) treated with first-line PD-1 inhibitors, JCO 36 (2018) 9037, https://doi.
org/10.1200/JCO.2018.36.15_suppl.9037.
[22] K. Ancevski Hunter, M.A. Socinski, L.C. Villaruz, PD-L1 testing in guiding patient
selection for PD-1/PD-L1 inhibitor therapy in lung cancer, Mol. Diagn. Ther. 22
(2018) 1–10, https://doi.org/10.1007/s40291-017-0308-6.
[23] N.A. Rizvi, M.D. Hellmann, A. Snyder, P. Kvistborg, V. Makarov, J.J. Havel,
W. Lee, J. Yuan, P. Wong, T.S. Ho, M.L. Miller, N. Rekhtman, A.L. Moreira,
F. Ibrahim, C. Bruggeman, B. Gasmi, R. Zappasodi, Y. Maeda, C. Sander, E.
B. Garon, T. Merghoub, J.D. Wolchok, T.N. Schumacher, T.A. Chan, Cancer
immunology. Mutational landscape determines sensitivity to PD-1 blockade in
non-small cell lung cancer, Science 348 (2015) 124–128, https://doi.org/
10.1126/science.aaa1348.
[24] F. Galuppini, C.A. Dal Pozzo, J. Deckert, F. Loupakis, M. Fassan, R. Baffa, Tumor
mutation burden: from comprehensive mutational screening to the clinic, Cancer
Cell Int. 19 (2019) 209, https://doi.org/10.1186/s12935-019-0929-4.
[25] H. Rizvi, F. Sanchez-Vega, K. La, W. Chatila, P. Jonsson, D. Halpenny,
A. Plodkowski, N. Long, J.L. Sauter, N. Rekhtman, T. Hollmann, K.A. Schalper, J.
F. Gainor, R. Shen, A. Ni, K.C. Arbour, T. Merghoub, J. Wolchok, A. Snyder, J.
E. Chaft, M.G. Kris, C.M. Rudin, N.D. Socci, M.F. Berger, B.S. Taylor, A. Zehir, D.
B. Solit, M.E. Arcila, M. Ladanyi, G.J. Riely, N. Schultz, M.D. Hellmann, Molecular
determinants of response to anti-programmed cell death (PD)-1 and anti-
programmed death-ligand 1 (PD-L1) blockade in patients with non-small-cell
lung cancer profiled with targeted next-generation sequencing, J. Clin. Oncol. J.
Am. Soc. Clin. Oncol. 36 (2018) 633–641, https://doi.org/10.1200/
JCO.2017.75.3384.
[26] T.A. Chan, M. Yarchoan, E. Jaffee, C. Swanton, S.A. Quezada, A. Stenzinger,
S. Peters, Development of tumor mutation burden as an immunotherapy
biomarker: Utility for the oncology clinic, Ann. Oncol. 30 (2019) 44–56, https://
doi.org/10.1093/annonc/mdy495.
[27] A. Costantini, P. Takam Kamga, C. Dumenil, T. Chinet, J.-F. Emile, E.
Giroux Leprieur, Plasma biomarkers and immune checkpoint inhibitors in non-
small cell lung cancer: new tools for better patient selection? Cancers (Basel) 11
(2019) https://doi.org/10.3390/cancers11091269.
[28] G. Marceddu, T. Dallavilla, G. Guerri, A. Zulian, C. Marinelli, M. Bertelli, Analysis
of machine learning algorithms as integrative tools for validation of next
generation sequencing data, Eur. Rev. Med. Pharmacol. Sci. 23 (2019)
8139–8147, https://doi.org/10.26355/eurrev_201909_19034.
[29] S. Behjati, P.S. Tarpey, What is next generation sequencing? Arch. Dis. Child.
Educ. Pract. Ed. 98 (2013) 236–238, https://doi.org/10.1136/archdischild-2013-
304340.
[30] J.A. Vendrell, F.T. Mau-Them, B. Béganton, S. Godreuil, P. Coopman, J. Solassol,
Circulating cell free tumor DNA detection as a routine tool forlung cancer patient
management, IJMS 18 (2017) 264, https://doi.org/10.3390/ijms18020264.
[31] Q.S. Chu, Targeting non-small cell lung cancer: driver mutation beyond
epidermal growth factor mutation and anaplastic lymphoma kinase fusion, Ther.
Adv. Med. Oncol. 12 (2020), 1758835919895756, https://doi.org/10.1177/
1758835919895756.
[32] F. Skoulidis, J.V. Heymach, Co-occurring genomic alterations in non-small-cell
lung cancer biology and therapy, Nat. Rev. Cancer 19 (2019) 495–509, https://
doi.org/10.1038/s41568-019-0179-8.
[33] M. Mina, F. Raynaud, D. Tavernari, E. Battistello, S. Sungalee, S. Saghafinia,
T. Laessle, F. Sanchez-Vega, N. Schultz, E. Oricchio, G. Ciriello, Conditional
selection of genomic alterations dictates cancer evolution and oncogenic
dependencies, Cancer Cell 32 (2017) 155–168.e6, https://doi.org/10.1016/j.
ccell.2017.06.010.
[34] S.S.F. Yip, Y. Liu, C. Parmar, Q. Li, S. Liu, F. Qu, Z. Ye, R.J. Gillies, H.J.W.L. Aerts,
Associations between radiologist-defined semantic and automatically computed
radiomic features in non-small cell lung cancer, Sci. Rep. 7 (2017) 3519, https://
doi.org/10.1038/s41598-017-02425-5.
[35] R.J. Gillies, P.E. Kinahan, H. Hricak, Radiomics: images are more than pictures,
they are data, Radiology 278 (2016) 563–577, https://doi.org/10.1148/
radiol.2015151169.
[36] P. Lambin, E. Rios-Velazquez, R. Leijenaar, S. Carvalho, R.G.P.M. van Stiphout,
P. Granton, C.M.L. Zegers, R. Gillies, R. Boellard, A. Dekker, H.J.W.L. Aerts,
Radiomics: extracting more information from medical images using advanced
feature analysis, Eur. J. Cancer 48 (2012) 441–446, https://doi.org/10.1016/j.
ejca.2011.11.036.
[37] V. Kumar, Y. Gu, S. Basu, A. Berglund, S.A. Eschrich, M.B. Schabath, K. Forster, H.
J.W.L. Aerts, A. Dekker, D. Fenstermacher, D.B. Goldgof, L.O. Hall, P. Lambin,
Y. Balagurunathan, R.A. Gatenby, R.J. Gillies, Radiomics: the process and the
11
Pharmacological Research 169 (2021) 105643
challenges, Magn. Reson. Imaging 30 (2012) 1234–1248, https://doi.org/
10.1016/j.mri.2012.06.010.
[38] E.J. Limkin, S. Reuzé, A. Carré, R. Sun, A. Schernberg, A. Alexis, E. Deutsch,
C. Ferté, C. Robert, The complexity of tumor shape, spiculatedness, correlates
with tumor radiomic shape features, Sci. Rep. 9 (2019) 4329, https://doi.org/
10.1038/s41598-019-40437-5.
[39] R.M. Haralick, K. Shanmugam, I. Dinstein, Textural features for image
classification, IEEE Trans. Syst. Man. Cybern. SMC-3 (1973) 610–621, https://
doi.org/10.1109/TSMC.1973.4309314.
[40] F. Han, H. Wang, G. Zhang, H. Han, B. Song, L. Li, W. Moore, H. Lu, H. Zhao,
Z. Liang, Texture feature analysis for computer-aided diagnosis on pulmonary
nodules, J. Digit. Imaging 28 (2015) 99–115, https://doi.org/10.1007/s10278-
014-9718-8.
[41] B. Ganeshan, E. Panayiotou, K. Burnand, S. Dizdarevic, K. Miles, Tumour
heterogeneity in non-small cell lung carcinoma assessed by CT texture analysis: a
potential marker of survival, Eur. Radiol. 22 (2012) 796–802, https://doi.org/
10.1007/s00330-011-2319-8.
[42] S.A. Mattonen, D.A. Palma, C. Johnson, A.V. Louie, M. Landis, G. Rodrigues,
I. Chan, R. Etemad-Rezai, T.P.C. Yeung, S. Senan, A.D. Ward, Detection of local
cancer recurrence after stereotactic ablative radiation therapy for lung cancer:
physician performance versus radiomic assessment, Int. J. Radiat. Oncol. Biol.
Phys. 94 (2016) 1121–1128, https://doi.org/10.1016/j.ijrobp.2015.12.369.
[43] S.A. Mattonen, S. Tetar, D.A. Palma, A.V. Louie, S. Senan, A.D. Ward, Imaging
texture analysis for automated prediction of lung cancer recurrence after
stereotactic radiotherapy, J. Med Imaging (Bellingham) 2 (2015), 041010,
https://doi.org/10.1117/1.JMI.2.4.041010.
[44] L. Dercle, M. Fronheiser, L. Lu, S. Du, W. Hayes, D.K. Leung, A. Roy, J. Wilkerson,
P. Guo, A.T. Fojo, L.H. Schwartz, B. Zhao, Identification of non–small cell lung
cancer sensitive to systemic cancer therapies using radiomics, Clin. Cancer Res.
26 (2020) 2151–2162, https://doi.org/10.1158/1078-0432.CCR-19-2942.
[45] Study of BMS-936558 (Nivolumab) Compared to Docetaxel in Previously Treated
Advanced or Metastatic Squamous Cell Non-small Cell Lung Cancer (NSCLC)
(CheckMate 017) - Full Text View - ClinicalTrials.gov, n.d. 〈https://www.
clinicaltrials.gov/ct2/show/NCT01642004〉 (accessed 18 July 2020).
[46] Phase II Trial to Correlate Radiographic Response Induced By Gefitinib With
Mutations in the Protein-Tyrosine Kinase Domain of the EGF Receptor Gene - Full
Text View - ClinicalTrials.gov, n.d. 〈https://www.clinicaltrials.gov/ct2/show/
NCT00588445〉 (accessed 18 July 2020).
[47] Study of Nivolumab (BMS-936558) in Patients With Advanced or Metastatic
Squamous Cell Nonsmall-cell Lung Cancer Who Have Received At Least 2 Prior
Systemic Regimens - Full Text View - ClinicalTrials.gov, n.d. 〈https://www.
clinicaltrials.gov/ct2/show/NCT01721759〉 (accessed 18 July 2020).
[48] W. Zhao, Y. Wu, Y. Xu, Y. Sun, P. Gao, M. Tan, W. Ma, C. Li, L. Jin, Y. Hua, J. Liu,
M. Li, The potential of radiomics nomogram in non-invasively prediction of
epidermal growth factor receptor mutation status and subtypes in lung
adenocarcinoma, Front. Oncol. 9 (2019) 1485, https://doi.org/10.3389/
fonc.2019.01485.
[49] B. He, W. Zhao, J.-Y. Pi, D. Han, Y.-M. Jiang, Z.-G. Zhang, W. Zhao, A biomarker
basing on radiomics for the prediction of overall survival in non-small cell lung
cancer patients, Respir. Res. 19 (2018) 199, https://doi.org/10.1186/s12931-
018-0887-8.
[50] J.K.R. Nair, U.A. Saeed, C.C. McDougall, A. Sabri, B. Kovacina, B.V.S. Raidu, R.
A. Khokhar, S. Probst, V. Hirsh, J. Chankowsky, L.C. Van Kempen, J. Taylor,
Radiogenomic models using machine learning techniques to predict EGFR
mutations in non-small cell lung cancer, Can. Assoc. Radiol. J. (2020), https://
doi.org/10.1177/0846537119899526.
[51] S. Rizzo, F. Petrella, V. Buscarino, F. De Maria, S. Raimondi, M. Barberis,
C. Fumagalli, G. Spitaleri, C. Rampinelli, F. De Marinis, L. Spaggiari, M. Bellomi,
CT radiogenomic characterization of EGFR, K-RAS, and ALK mutations in non-
small cell lung cancer, Eur. Radiol. 26 (2016) 32–42, https://doi.org/10.1007/
s00330-015-3814-0.
[52] Y. Liu, J. Kim, Y. Balagurunathan, Q. Li, A.L. Garcia, O. Stringfield, Z. Ye, R.
J. Gillies, Radiomic features are associated with EGFR mutation status in lung
adenocarcinomas, Clin. Lung Cancer 17 (2016) 441–448.e6, https://doi.org/
10.1016/j.cllc.2016.02.001.
[53] O. Gevaert, S. Echegaray, A. Khuong, C.D. Hoang, J.B. Shrager, K.C. Jensen, G.
J. Berry, H.H. Guo, C. Lau, S.K. Plevritis, D.L. Rubin, S. Napel, A.N. Leung,
Predictive radiogenomics modeling of EGFR mutation status in lung cancer, Sci.
Rep. 7 (2017) 41674, https://doi.org/10.1038/srep41674.
[54] S.R. Digumarthy, A.M. Padole, R. Lo Gullo, L.V. Sequist, M.K. Kalra, Can CT
radiomic analysis in NSCLC predict histology and EGFR mutation status?
Medicine (Baltimore) 98 (2019) 13963, https://doi.org/10.1097/
MD.0000000000013963.
[55] T.-Y. Jia, J.-F. Xiong, X.-Y. Li, W. Yu, Z.-Y. Xu, X.-W. Cai, J.-C. Ma, Y.-C. Ren,
R. Larsson, J. Zhang, J. Zhao, X.-L. Fu, Identifying EGFR mutations in lung
adenocarcinoma by noninvasive imaging using radiomics features and random
forest modeling, Eur. Radiol. 29 (2019) 4742–4750, https://doi.org/10.1007/
s00330-019-06024-y.
[56] X. Yang, X. Dong, J. Wang, W. Li, Z. Gu, D. Gao, N. Zhong, Y. Guan, Computed
tomography-based radiomics signature: a potential indicator of epidermal growth
factor receptor mutation in pulmonary adenocarcinoma appearing as a subsolid
nodule, Oncologist 24 (2019) e1156–e1164, https://doi.org/10.1634/
theoncologist.2018-0706.
[57] S. Li, C. Ding, H. Zhang, J. Song, L. Wu, Radiomics for the prediction of EGFR
mutation subtypes in non-small cell lung cancer, Med. Phys. 46 (2019)
4545–4552, https://doi.org/10.1002/mp.13747.
F. Cucchiara et al.
[58] D. Hong, K. Xu, L. Zhang, X. Wan, Y. Guo, Radiomics signature as a predictive
factor for EGFR mutations in advanced lung adenocarcinoma, Front. Oncol. 10
(2020) 28, https://doi.org/10.3389/fonc.2020.00028.
[59] H.J. Yoon, I. Sohn, J.H. Cho, H.Y. Lee, J.-H. Kim, Y.-L. Choi, H. Kim, G. Lee, K.
S. Lee, J. Kim, Decoding tumor phenotypes for ALK, ROS1, and RET fusions in
lung adenocarcinoma using a radiomics approach, Medicine (Baltimore) 94
(2015) 1753, https://doi.org/10.1097/MD.0000000000001753.
[60] S. Yamamoto, R.L. Korn, R. Oklu, C. Migdal, M.B. Gotway, G.J. Weiss, A.J. Iafrate,
D.-W. Kim, M.D. Kuo, ALK molecular phenotype in non–small cell lung cancer: CT
radiogenomic characterization, Radiology 272 (2014) 568–576, https://doi.org/
10.1148/radiol.14140789.
[61] L. Song, Z. Zhu, L. Mao, X. Li, W. Han, H. Du, H. Wu, W. Song, Z. Jin, Clinical,
conventional CT and radiomic feature-based machine learning models for
predicting ALK rearrangement status in lung adenocarcinoma patients, Front.
Oncol. 10 (2020) 369, https://doi.org/10.3389/fonc.2020.00369.
[62] M. Zhou, A. Leung, S. Echegaray, A. Gentles, J.B. Shrager, K.C. Jensen, G.J. Berry,
S.K. Plevritis, D.L. Rubin, S. Napel, O. Gevaert, Non–small cell lung cancer
radiogenomics map identifies relationships between molecular and imaging
phenotypes with prognostic implications, Radiology 286 (2017) 307–315,
https://doi.org/10.1148/radiol.2017161845.
[63] E. Rios Velazquez, C. Parmar, Y. Liu, T.P. Coroller, G. Cruz, O. Stringfield, Z. Ye,
M. Makrigiorgos, F. Fennessy, R.H. Mak, R. Gillies, J. Quackenbush, H.J.W.
L. Aerts, Somatic mutations drive distinct imaging phenotypes in lung cancer,
Cancer Res. 77 (2017) 3922–3930, https://doi.org/10.1158/0008-5472.CAN-17-
0122.
[64] S. Bakr, O. Gevaert, S. Echegaray, K. Ayers, M. Zhou, M. Shafiq, H. Zheng, J.
A. Benson, W. Zhang, A.N.C. Leung, M. Kadoch, C.D. Hoang, J. Shrager, A. Quon,
D.L. Rubin, S.K. Plevritis, S. Napel, A radiogenomic dataset of non-small cell lung
cancer, Sci. Data 5 (2018), 180202, https://doi.org/10.1038/sdata.2018.202.
[65] M.A. Mazurowski, Radiogenomics: what it is and why it is important, J. Am. Coll.
Radiol. 12 (2015) 862–866, https://doi.org/10.1016/j.jacr.2015.04.019.
[66] A.E. Revelo, A. Martin, R. Velasquez, P.C. Kulandaisamy, J. Bustamante,
S. Keshishyan, G. Otterson, Liquid biopsy for lung cancers: an update on recent
developments, Ann. Transl. Med. 7 (2019) 349, https://doi.org/10.21037/
atm.2019.03.28.
[67] B. Yang, A. Qin, K. Zhang, H. Ren, S. Liu, X. Liu, X. Pan, G. Yu, Circulating tumor
cells predict prognosis following tyrosine kinase inhibitor treatment in EGFR-
mutant non-small cell lung cancer patients, Oncol. Res. 25 (2017) 1601–1606,
https://doi.org/10.3727/096504017X14928634401178.
[68] M. Provencio, M. Torrente, V. Calvo, D. Pérez-Callejo, L. Gutiérrez, F. Franco,
C. Pérez-Barrios, M. Barquín, A. Royuela, F. García-García, C. Bueno, A. Garcia-
Grande, C. Camps, B. Massuti, E. Sotomayor, A. Romero, Prognostic value of
quantitative ctDNA levels in non small cell lung cancer patients, Oncotarget 9
(2018) 488–494, https://doi.org/10.18632/oncotarget.22470.
[69] C. Zhang, B. Wei, P. Li, K. Yang, Z. Wang, J. Ma, Y. Guo, Prognostic value of
plasma EGFR ctDNA in NSCLC patients treated with EGFR-TKIs, PLoS One 12
(2017), 0173524, https://doi.org/10.1371/journal.pone.0173524.
[70] Y. Song, S. Ma, M. Shi, X. Xu, X. Chen, Y. Wang, Z. Yang, T. Zhang, M. Li, H. Li,
L. Zhang, X. Mao, Predictive and prognostic values of circulating tumor DNA
(ctDNA) clearance in osimertinib treated advanced non-small cell lung cancer
cohort, JCO 37 (2019) 3036, https://doi.org/10.1200/JCO.2019.37.15_
suppl.3036.
[71] Y. Song, C. Hu, Z. Xie, L. Wu, Z. Zhu, C. Rao, L. Liu, Y. Chen, N. Liang, J. Chen,
C. Hu, N. Yang, J. Hu, W. Zhao, G. Tong, X. Dong, D. Zheng, M. Jin, J. Chen,
M. Huang, Y. He, R. Rosell, G. Lippi, M. Mino-Kenudson, H. Han-Zhang, X. Mao,
L. Zhang, H. Liu, J.K. Field, S. Chuai, J. Ye, Y. Han, S. Lu, Circulating tumor DNA
clearance predicts prognosis across treatment regimen in a large real-world
longitudinally monitored advanced non-small cell lung cancer cohort, Transl.
Lung Cancer Res 9 (2020) 269–279, https://doi.org/10.21037/tlcr.2020.03.17.
[72] Y. Lee, S. Park, W.S. Kim, J.C. Lee, S.J. Jang, J. Choi, C.-M. Choi, Correlation
between progression-free survival, tumor burden, and circulating tumor DNA in
the initial diagnosis of advanced-stage EGFR-mutated non-small cell lung cancer,
Thorac. Cancer 9 (2018) 1104–1110, https://doi.org/10.1111/1759-
7714.12793.
[73] S. Cargnin, P.L. Canonico, A.A. Genazzani, S. Terrazzino, Quantitative analysis of
circulating cell-free DNA for correlation with lung cancer survival: a systematic
review and meta-analysis, J. Thorac. Oncol. Publ. Int. Assoc. Study Lung Cancer
12 (2017) 43–53, https://doi.org/10.1016/j.jtho.2016.08.002.
[74] A. Szpechcinski, P. Rudzinski, W. Kupis, R. Langfort, T. Orlowski,
J. Chorostowska-Wynimko, Plasma cell-free DNA levels and integrity in patients
with chest radiological findings: NSCLC versus benign lung nodules, Cancer Lett.
374 (2016) 202–207, https://doi.org/10.1016/j.canlet.2016.02.002.
[75] W. Gai, K. Sun, Epigenetic biomarkers in cell-free DNA and applications in liquid
biopsy, Genes 10 (2019) 32, https://doi.org/10.3390/genes10010032.
[76] G. Weiss, A. Schlegel, D. Kottwitz, T. König, R. Tetzner, Validation of the SHOX2/
PTGER4 DNA methylation marker panel for plasma-based discrimination
between patients with malignant and nonmalignant lung disease, J. Thorac.
Oncol. Publ. Int. Assoc. Study Lung Cancer 12 (2017) 77–84, https://doi.org/
10.1016/j.jtho.2016.08.123.
[77] S.Y. Shen, R. Singhania, G. Fehringer, A. Chakravarthy, M.H.A. Roehrl,
D. Chadwick, P.C. Zuzarte, A. Borgida, T.T. Wang, T. Li, O. Kis, Z. Zhao,
A. Spreafico, T. da, S. Medina, Y. Wang, D. Roulois, I. Ettayebi, Z. Chen, S. Chow,
T. Murphy, A. Arruda, G.M. O’Kane, J. Liu, M. Mansour, J.D. McPherson,
C. O’Brien, N. Leighl, P.L. Bedard, N. Fleshner, G. Liu, M.D. Minden, S. Gallinger,
A. Goldenberg, T.J. Pugh, M.M. Hoffman, S.V. Bratman, R.J. Hung, D.D.
De Carvalho, Sensitive tumour detection and classification using plasma cell-free
12
Pharmacological Research 169 (2021) 105643
DNA methylomes, Nature 563 (2018) 579–583, https://doi.org/10.1038/s41586-
018-0703-0.
[78] L. Yang, Y. Ma, W. Han, W. Li, L. Cui, X. Zhao, Y. Tian, Z. Zhou, W. Wang,
H. Wang, Proteinase-activated receptor 2 promotes cancer cell migration through
RNA methylation-mediated repression of miR-125b, J. Biol. Chem. 290 (2015)
26627–26637, https://doi.org/10.1074/jbc.M115.667717.
[79] J. Shen, N.W. Todd, H. Zhang, L. Yu, X. Lingxiao, Y. Mei, M. Guarnera, J. Liao,
A. Chou, C.L. Lu, Z. Jiang, H. Fang, R.L. Katz, F. Jiang, Plasma microRNAs as
potential biomarkers for non-small-cell lung cancer, Lab. Invest. 91 (2011)
579–587, https://doi.org/10.1038/labinvest.2010.194.
[80] M.B. Wozniak, G. Scelo, D.C. Muller, A. Mukeria, D. Zaridze, P. Brennan,
Circulating MicroRNAs as non-invasive biomarkers for early detection of non-
small-cell lung cancer, PLoS One 10 (2015), 0125026, https://doi.org/10.1371/
journal.pone.0125026.
[81] A. Bagheri, H.R.K. Khorshid, M. Tavallaie, S.J. Mowla, M. Sherafatian,
M. Rashidi, M. Zargari, M.E. Boroujeni, S.M. Hosseini, A panel of noncoding RNAs
in non-small-cell lung cancer, J. Cell. Biochem. (2018), https://doi.org/10.1002/
jcb.28111.
[82] L. Niu, X. Song, N. Wang, L. Xue, X. Song, L. Xie, Tumor-derived exosomal
proteins as diagnostic biomarkers in non-small cell lung cancer, Cancer Sci. 110
(2019) 433–442, https://doi.org/10.1111/cas.13862.
[83] M. Roś-Mazurczyk, A. Wojakowska, Ł. Marczak, K. Polański, M. Pietrowska,
J. Polanska, R. Dziadziuszko, J. Jassem, W. Rzyman, P. Widlak, Panel of serum
metabolites discriminates cancer patients and healthy participants of lung cancer
screening − a pilot study. Acta Biochim. Pol. 64 (2017) 513–518, https://doi.org/
10.18388/abp.2017_1517.
[84] J.F. Fahrmann, D. Grapov, B.C. DeFelice, S. Taylor, K. Kim, K. Kelly, W.R. Wikoff,
H. Pass, W.N. Rom, O. Fiehn, S. Miyamoto, Serum phosphatidylethanolamine
levels distinguish benign from malignant solitary pulmonary nodules and
represent a potential diagnostic biomarker for lung cancer, Cancer Biomark. 16
(2016) 609–617, https://doi.org/10.3233/CBM-160602.
[85] B.T. Pan, K. Teng, C. Wu, M. Adam, R.M. Johnstone, Electron microscopic
evidence for externalization of the transferrin receptor in vesicular form in sheep
reticulocytes. J. Cell Biol. 101 (1985) 942–948, https://doi.org/10.1083/
jcb.101.3.942.
[86] C. Théry, A. Regnault, J. Garin, J. Wolfers, L. Zitvogel, P. Ricciardi-Castagnoli,
G. Raposo, S. Amigorena, Molecular characterization of dendritic cell-derived
exosomes. Selective accumulation of the heat shock protein hsc73, J. Cell Biol.
147 (1999) 599–610, https://doi.org/10.1083/jcb.147.3.599.
[87] N. Blanchard, D. Lankar, F. Faure, A. Regnault, C. Dumont, G. Raposo, C. Hivroz,
TCR activation of human T cells induces the production of exosomes bearing the
TCR/CD3/zeta complex, J. Immunol. 168 (2002) 3235–3241, https://doi.org/
10.4049/jimmunol.168.7.3235.
[88] G. Raposo, H.W. Nijman, W. Stoorvogel, R. Liejendekker, C.V. Harding, C.
J. Melief, H.J. Geuze, B lymphocytes secrete antigen-presenting vesicles, J. Exp.
Med. 183 (1996) 1161–1172, https://doi.org/10.1084/jem.183.3.1161.
[89] J. Wolfers, A. Lozier, G. Raposo, A. Regnault, C. Théry, C. Masurier, C. Flament,
S. Pouzieux, F. Faure, T. Tursz, E. Angevin, S. Amigorena, L. Zitvogel, Tumor-
derived exosomes are a source of shared tumor rejection antigens for CTL cross-
priming, Nat. Med. 7 (2001) 297–303, https://doi.org/10.1038/85438.
[90] M. Ostrowski, N.B. Carmo, S. Krumeich, I. Fanget, G. Raposo, A. Savina, C.
F. Moita, K. Schauer, A.N. Hume, R.P. Freitas, B. Goud, P. Benaroch, N. Hacohen,
M. Fukuda, C. Desnos, M.C. Seabra, F. Darchen, S. Amigorena, L.F. Moita,
C. Thery, Rab27a and Rab27b control different steps of the exosome secretion
pathway, Nat. Cell Biol. 12 (2010) 13–19, https://doi.org/10.1038/ncb2000.
[91] H. Zheng, Y. Zhan, S. Liu, J. Lu, J. Luo, J. Feng, S. Fan, The roles of tumor-derived
exosomes in non-small cell lung cancer and their clinical implications, J. Exp.
Clin. Cancer Res. 37 (2018) 226, https://doi.org/10.1186/s13046-018-0901-5.
[92] G. Rabinowits, C. Gerçel-Taylor, J.M. Day, D.D. Taylor, G.H. Kloecker, Exosomal
MicroRNA: a diagnostic marker for lung cancer, Clin. Lung Cancer 10 (2009)
42–46, https://doi.org/10.3816/CLC.2009.n.006.
[93] B. Sandfeld-Paulsen, N. Aggerholm-Pedersen, R. Bæk, K.R. Jakobsen,
P. Meldgaard, B.H. Folkersen, T.R. Rasmussen, K. Varming, M.M. Jørgensen, B.
S. Sorensen, Exosomal proteins as prognostic biomarkers in non-small cell lung
cancer, Mol. Oncol. 10 (2016) 1595–1602, https://doi.org/10.1016/j.
molonc.2016.10.003.
[94] K.R. Jakobsen, B.S. Paulsen, R. Bæk, K. Varming, B.S. Sorensen, M.M. Jørgensen,
Exosomal proteins as potential diagnostic markers in advanced non-small cell
lung carcinoma, J. Extracell. Vesicles 4 (2015) 26659, https://doi.org/10.3402/
jev.v4.26659.
[95] L. Montermini, B. Meehan, D. Garnier, W.J. Lee, T.H. Lee, A. Guha, K. Al-Nedawi,
J. Rak, Inhibition of oncogenic epidermal growth factor receptor kinase triggers
release of exosome-like extracellular vesicles and impacts their phosphoprotein
and DNA content, J. Biol. Chem. 290 (2015) 24534–24546, https://doi.org/
10.1074/jbc.M115.679217.
[96] R. Kalluri, V.S. LeBleu, Discovery of double-stranded genomic DNA in circulating
exosomes, Cold Spring Harb. Symp. Quant. Biol. 81 (2016) 275–280, https://doi.
org/10.1101/sqb.2016.81.030932.
[97] N. Hollings, P. Shaw, Diagnostic imaging of lung cancer, Eur. Respir. J. 19 (2002)
722–742, https://doi.org/10.1183/09031936.02.00280002.
[98] P.K. Nguyen, J.C. Wu, Radiation exposure from imaging tests: is there an
increased cancer risk? Expert Rev. Cardiovasc. Ther. 9 (2011) 177–183, https://
doi.org/10.1586/erc.10.184.
[99] K. Trudgen, N.H. Khattar, E. Bensadoun, S. Arnold, A.J. Stromberg, E.
A. Hirschowitz, Autoantibody profiling for lung cancer screening longitudinal
F. Cucchiara et al.
retrospective analysis of CT screening cohorts, PLoS One 9 (2014) 87947, https://
doi.org/10.1371/journal.pone.0087947.
[100] C.I. Bayarri-Lara, D. de Miguel Pérez, A. Cueto Ladrón de Guevara, A. Rodriguez
Fernández, J.L. Puche, A. Sánchez-Palencia Ramos, J. Ruiz Zafra, C.F. Giraldo
Ospina, M. Delgado-Rodríguez, M. Expósito Ruiz, M.J. Moyano Rodriguez, J.
A. Lorente, M.J. Serrano, Association of circulating tumour cells with early
relapse and 18F-fluorodeoxyglucose positron emission tomography uptake in
resected non-small-cell lung cancers. Eur. J. Cardio-Thorac. Surg. J. Eur. Assoc.
Cardio-Thorac. Surg. 52 (2017) 55–62, https://doi.org/10.1093/ejcts/ezx049.
[101] S. Hawkins, H. Wang, Y. Liu, A. Garcia, O. Stringfield, H. Krewer, Q. Li,
D. Cherezov, R.A. Gatenby, Y. Balagurunathan, D. Goldgof, M.B. Schabath,
L. Hall, R.J. Gillies, Predicting malignant nodules from screening CT scans,
J. Thorac. Oncol. Publ. Int. Assoc. Study Lung Cancer 11 (2016) 2120–2128,
https://doi.org/10.1016/j.jtho.2016.07.002.
[102] W. Wu, H. Hu, J. Gong, X. Li, G. Huang, S. Nie, Malignant-benign classification of
pulmonary nodules based on random forest aided by clustering analysis, Phys.
Med. Biol. 64 (2019), 035017, https://doi.org/10.1088/1361-6560/aafab0.
[103] S. Suo, J. Cheng, M. Cao, Q. Lu, Y. Yin, J. Xu, H. Wu, Assessment of heterogeneity
difference between edge and core by using texture analysis: differentiation of
malignant from inflammatory pulmonary nodules and masses, Acad. Radiol. 23
(2016) 1115–1122, https://doi.org/10.1016/j.acra.2016.04.009.
[104] J.R.J. Ferreira, M.C. Oliveira, P.M. de Azevedo-Marques, Characterization of
pulmonary nodules based on features of margin sharpness and texture, J. Digit.
Imaging 31 (2018) 451–463, https://doi.org/10.1007/s10278-017-0029-8.
[105] W. Wu, L.A. Pierce, Y. Zhang, S.N.J. Pipavath, T.W. Randolph, K.J. Lastwika, P.
D. Lampe, A.M. Houghton, H. Liu, L. Xia, P.E. Kinahan, Comparison of prediction
models with radiological semantic features and radiomics in lung cancer
diagnosis of the pulmonary nodules: a case-control study, Eur. Radiol. 29 (2019)
6100–6108, https://doi.org/10.1007/s00330-019-06213-9.
[106] Y. Balagurunathan, M.B. Schabath, H. Wang, Y. Liu, R.J. Gillies, Quantitative
imaging features improve discrimination of malignancy in pulmonary nodules,
Sci. Rep. 9 (2019) 8528, https://doi.org/10.1038/s41598-019-44562-z.
[107] L. Brunese, B. Greco, F.R. Setola, F. Lassandro, M.R. Guarracino, M. De Rimini,
S. Piccolo, N. De Rosa, R. Muto, A. Bianco, P. Muto, R. Grassi, A. Rotondo, Non-
small cell lung cancer evaluated with quantitative contrast-enhanced CT and PET-
CT: net enhancement and standardized uptake values are related to tumour size
and histology. Med. Sci. Monit. Int. Med. J. Exp. Clin. Res. 19 (2013) 95–101,
https://doi.org/10.12659/msm.883759.
[108] F. Bianconi, I. Palumbo, M.L. Fravolini, R. Chiari, M. Minestrini, L. Brunese,
B. Palumbo, Texture analysis on [(18)F]FDG PET/CT in non-small-cell lung
cancer: correlations between PET features, CT features, and histological types,
Mol. Imaging Biol. 21 (2019) 1200–1209, https://doi.org/10.1007/s11307-019-
01336-3.
[109] T. Fukui, T. Taniguchi, K. Kawaguchi, K. Fukumoto, S. Nakamura, Y. Sakao,
K. Yokoi, Comparisons of the clinicopathological features and survival outcomes
between lung cancer patients with adenocarcinoma and squamous cell
carcinoma, Gen. Thorac. Cardiovasc. Surg. 63 (2015) 507–513, https://doi.org/
10.1007/s11748-015-0564-5.
[110] S. Rinaldi, R. Berardi, Lung cancer prognosis: can histological patterns and
morphological features have a role in the management of lung cancer patients?
Ann. Transl. Med. 5 (2017) 353, https://doi.org/10.21037/atm.2017.05.18.
[111] W. Wu, C. Parmar, P. Grossmann, J. Quackenbush, P. Lambin, J. Bussink, R. Mak,
H.J.W.L. Aerts, Exploratory study to identify radiomics classifiers for lung cancer
histology, Front. Oncol. 6 (2016) 71, https://doi.org/10.3389/fonc.2016.00071.
[112] M. Saad, T.-S. Choi, Computer-assisted subtyping and prognosis for non-small cell
lung cancer patients with unresectable tumor, Comput. Med. Imaging Graph. 67
(2018) 1–8, https://doi.org/10.1016/j.compmedimag.2018.04.003.
[113] D.S. Zander, Primary vs metastatic pulmonary adenocarcinoma: toward a fuller
understanding of truth, Chest 137 (2010) 3–4, https://doi.org/10.1378/chest.09-
1514.
[114] W. Pao, J. Chmielecki, Rational, biologically based treatment of EGFR-mutant
non-small-cell lung cancer, Nat. Rev. Cancer 10 (2010) 760–774, https://doi.org/
10.1038/nrc2947.
[115] M.H. Cohen, J.R. Johnson, Y.-F. Chen, R. Sridhara, R. Pazdur, FDA drug approval
summary: erlotinib (Tarceva) tablets, Oncologist 10 (2005) 461–466, https://doi.
org/10.1634/theoncologist.10-7-461.
[116] M. Maemondo, A. Inoue, K. Kobayashi, S. Sugawara, S. Oizumi, H. Isobe,
A. Gemma, M. Harada, H. Yoshizawa, I. Kinoshita, Y. Fujita, S. Okinaga,
H. Hirano, K. Yoshimori, T. Harada, T. Ogura, M. Ando, H. Miyazawa, T. Tanaka,
Y. Saijo, K. Hagiwara, S. Morita, T. Nukiwa, Gefitinib or chemotherapy for non-
small-cell lung cancer with mutated EGFR, N. Engl. J. Med. 362 (2010)
2380–2388, https://doi.org/10.1056/NEJMoa0909530.
[117] B. Ricciuti, S. Baglivo, A. De Giglio, R. Chiari, Afatinib in the first-line treatment
of patients with non-small cell lung cancer: clinical evidence and experience.
Ther. Adv. Respir. Dis. 12 (2018), 1753466618808659 https://doi.org/10.1177/
1753466618808659.
[118] J.-C. Soria, Y. Ohe, J. Vansteenkiste, T. Reungwetwattana, B. Chewaskulyong, K.
H. Lee, A. Dechaphunkul, F. Imamura, N. Nogami, T. Kurata, I. Okamoto, C. Zhou,
B.C. Cho, Y. Cheng, E.K. Cho, P.J. Voon, D. Planchard, W.-C. Su, J.E. Gray, S.-
M. Lee, R. Hodge, M. Marotti, Y. Rukazenkov, S.S. Ramalingam, Osimertinib in
untreated EGFR-mutated advanced non-small-cell lung cancer, N. Engl. J. Med.
378 (2018) 113–125, https://doi.org/10.1056/NEJMoa1713137.
[119] D. Westover, J. Zugazagoitia, B.C. Cho, C.M. Lovly, L. Paz-Ares, Mechanisms of
acquired resistance to first-and second-generation EGFR tyrosine kinase
inhibitors, Ann. Oncol. 29 (2018) i10–i19, https://doi.org/10.1093/annonc/
mdx703.
13
Pharmacological Research 169 (2021) 105643
[120] T.S. Mok, Y.-L. Wu, M.-J. Ahn, M.C. Garassino, H.R. Kim, S.S. Ramalingam, F.
A. Shepherd, Y. He, H. Akamatsu, W.S.M.E. Theelen, C.K. Lee, M. Sebastian,
A. Templeton, H. Mann, M. Marotti, S. Ghiorghiu, V.A. Papadimitrakopoulou,
Osimertinib or platinum-pemetrexed in EGFR T790M-positive lung cancer,
N. Engl. J. Med. 376 (2017) 629–640, https://doi.org/10.1056/
NEJMoa1612674.
[121] A. Passaro, E. Guerini-Rocco, A. Pochesci, D. Vacirca, G. Spitaleri, C.M. Catania,
A. Rappa, M. Barberis, F. de Marinis, Targeting EGFR T790M mutation in NSCLC:
from biology to evaluation and treatment, Pharmacol. Res. 117 (2017) 406–415,
https://doi.org/10.1016/j.phrs.2017.01.003.
[122] A. Passaro, T. Mok, S. Peters, S. Popat, M.-J. Ahn, F. de Marinis, Recent advances
on the role of EGFR tyrosine kinase inhibitors in the management of NSCLC with
uncommon, non exon 20 insertions, EGFR mutations, J. Thorac. Oncol. Publ. Int.
Assoc. Study Lung Cancer (2020), https://doi.org/10.1016/j.jtho.2020.12.002.
[123] H. Akamatsu, Y. Koh, I. Okamoto, D. Fujimoto, A. Bessho, K. Azuma, S. Morita,
N. Yamamoto, K. Nakagawa, Clinical significance of monitoring EGFR mutation
in plasma using multiplexed digital PCR in EGFR mutated patients treated with
afatinib (West Japan Oncology Group 8114LTR study), Lung Cancer 131 (2019)
128–133, https://doi.org/10.1016/j.lungcan.2019.03.021.
[124] Y. Kuang, A. Rogers, B.Y. Yeap, L. Wang, M. Makrigiorgos, K. Vetrand, S. Thiede,
R.J. Distel, P.A. Jänne, Noninvasive detection of EGFR T790M in gefitinib or
erlotinib resistant non-small cell lung cancer. Clin. Cancer Res. J. Am. Assoc.
Cancer Res. 15 (2009) 2630–2636, https://doi.org/10.1158/1078-0432.CCR-08-
2592.
[125] T.K. Sundaresan, L.V. Sequist, J.V. Heymach, G.J. Riely, P.A. Jänne, W.H. Koch, J.
P. Sullivan, D.B. Fox, R. Maher, A. Muzikansky, A. Webb, H.T. Tran, U. Giri,
M. Fleisher, H.A. Yu, W. Wei, B.E. Johnson, T.A. Barber, J.R. Walsh, J.
A. Engelman, S.L. Stott, R. Kapur, S. Maheswaran, M. Toner, D.A. Haber,
Detection of T790M, the acquired resistance EGFR mutation, by tumor biopsy
versus noninvasive blood-based analyses, Clin. Cancer Res. J. Am. Assoc. Cancer
Res. 22 (2016) 1103–1110, https://doi.org/10.1158/1078-0432.CCR-15-1031.
[126] G.R. Oxnard, K.S. Thress, R.S. Alden, R. Lawrance, C.P. Paweletz, M. Cantarini, J.
C.-H. Yang, J.C. Barrett, P.A. Jänne, Association between plasma genotyping and
outcomes of treatment with osimertinib (AZD9291) in advanced non–small-cell
lung cancer, J. Clin. Oncol. 34 (2016) 3375–3382, https://doi.org/10.1200/
JCO.2016.66.7162.
[127] G.R. Oxnard, The cellular origins of drug resistance in cancer, Nat. Med. 22
(2016) 232–234, https://doi.org/10.1038/nm.4058.
[128] K. Suda, I. Murakami, K. Sakai, H. Mizuuchi, S. Shimizu, K. Sato, K. Tomizawa,
S. Tomida, Y. Yatabe, K. Nishio, T. Mitsudomi, Small cell lung cancer
transformation and T790M mutation: complimentary roles in acquired resistance
to kinase inhibitors in lung cancer, Sci. Rep. 5 (2015) 14447, https://doi.org/
10.1038/srep14447.
[129] H. Izumi, A. Yamasaki, Y. Ueda, T. Sumikawa, H. Maeta, S. Nakamoto, E. Shimizu,
Squamous cell carcinoma transformation from EGFR-mutated lung
adenocarcinoma: a case report and literature review, Clin. Lung Cancer 19 (2018)
e63–e66, https://doi.org/10.1016/j.cllc.2017.10.005.
[130] Z. Zhang, S. Yang, Q. Wang, Impact of MET alterations on targeted therapy with
EGFR-tyrosine kinase inhibitors for EGFR-mutant lung cancer, Biomark. Res. 7
(2019) 27, https://doi.org/10.1186/s40364-019-0179-6.
[131] G.S. Herter-Sprie, H. Greulich, K.-K. Wong, Activating mutations in ERBB2 and
their impact on diagnostics and treatment, Front. Oncol. 3 (2013) 86, https://doi.
org/10.3389/fonc.2013.00086.
[132] J. Eng, K.M. Woo, C.S. Sima, A. Plodkowski, M.D. Hellmann, J.E. Chaft, M.G. Kris,
M.E. Arcila, M. Ladanyi, A. Drilon, Impact of concurrent PIK3CA mutations on
response to EGFR tyrosine kinase inhibition in EGFR-mutant lung cancers and on
prognosis in oncogene-driven lung adenocarcinomas, J. Thorac. Oncol. Off. Publ.
Int. Assoc. Study Lung Cancer 10 (2015) 1713–1719, https://doi.org/10.1097/
JTO.0000000000000671.
[133] J. Xu, J. Wang, S. Zhang, Mechanisms of resistance to irreversible epidermal
growth factor receptor tyrosine kinase inhibitors and therapeutic strategies in
non-small cell lung cancer, Oncotarget 8 (2017) 90557–90578, https://doi.org/
10.18632/oncotarget.21164.
[134] K.S. Thress, C.P. Paweletz, E. Felip, B.C. Cho, D. Stetson, B. Dougherty, Z. Lai,
A. Markovets, A. Vivancos, Y. Kuang, D. Ercan, S.E. Matthews, M. Cantarini, J.
C. Barrett, P.A. Jänne, G.R. Oxnard, Acquired EGFR C797S mutation mediates
resistance to AZD9291 in non-small cell lung cancer harboring EGFR T790M, Nat.
Med. 21 (2015) 560–562, https://doi.org/10.1038/nm.3854.
[135] S. Cui, W. Zhang, L. Xiong, F. Pan, Y. Niu, T. Chu, H. Wang, Y. Zhao, L. Jiang, Use
of capture-based next-generation sequencing to detect ALK fusion in plasma cell-
free DNA of patients with non-small-cell lung cancer, Oncotarget 8 (2017)
2771–2780, https://doi.org/10.18632/oncotarget.13741.
[136] I. Dagogo-Jack, A.R. Brannon, L.A. Ferris, C.D. Campbell, J.J. Lin, K.R. Schultz,
J. Ackil, S. Stevens, L. Dardaei, S. Yoda, H. Hubbeling, S.R. Digumarthy,
M. Riester, A.N. Hata, L.V. Sequist, I.T. Lennes, A.J. Iafrate, R.S. Heist, C.
G. Azzoli, A.F. Farago, J.A. Engelman, J.K. Lennerz, C.H. Benes, R.J. Leary, A.
T. Shaw, J.F. Gainor, Tracking the evolution of resistance to ALK tyrosine kinase
inhibitors through longitudinal analysis of circulating tumor DNA., JCO precis,
Oncol (2018) (2018), https://doi.org/10.1200/PO.17.00160.
[137] P. Bordi, M. Tiseo, E. Rofi, I. Petrini, G. Restante, R. Danesi, M. Del Re, Detection
of ALK and KRAS mutations in circulating tumor DNA of patients with advanced
ALK-positive NSCLC with disease progression during crizotinib treatment, Clin.
Lung Cancer 18 (2017) 692–697, https://doi.org/10.1016/j.cllc.2017.04.013.
[138] C.E. McCoach, C.M. Blakely, K.C. Banks, B. Levy, B.M. Chue, V.M. Raymond, A.
T. Le, C.E. Lee, J. Diaz, S.N. Waqar, W.T. Purcell, D.L. Aisner, K.D. Davies, R.
B. Lanman, A.T. Shaw, R.C. Doebele, Clinical utility of cell-free DNA for the
F. Cucchiara et al.
detection of ALK fusions and genomic mechanisms of ALK inhibitor resistance in
non-small cell lung cancer, Clin. Cancer Res. J. Am. Assoc. Cancer Res. 24 (2018)
2758–2770, https://doi.org/10.1158/1078-0432.CCR-17-2588.
[139] S.M. Gadgeel, T.S.K. Mok, S. Peters, J.A.A. Alexander, N.B. Leighl,
V. Sriuranpong, M. Perol, G. De Castro, E. Nadal, F. De Marinis, J.-Y. Han, M. Yan,
T. Riehl, E. Schleifman, S.M. Paul, S. Mocci, D. Shames, M.S. Mathisen,
R. Dziadziuszko, Phase II/III blood first assay screening trial (BFAST) in patients
(pts) with treatment-naïve NSCLC: Initial results from the ALK+ cohort, Ann.
Oncol. 30 (2019) v918, https://doi.org/10.1093/annonc/mdz394.079.
[140] N.B. Leighl, R.D. Page, V.M. Raymond, D.B. Daniel, S.G. Divers, K.L. Reckamp, M.
A. Villalona-Calero, D. Dix, J.I. Odegaard, R.B. Lanman, V.
A. Papadimitrakopoulou, Clinical utility of comprehensive cell-free DNA analysis
to identify genomic biomarkers in patients with newly diagnosed metastatic non-
small cell lung cancer, Clin. Cancer Res. Off. J. Am. Assoc. Cancer Res 25 (2019)
4691–4700, https://doi.org/10.1158/1078-0432.CCR-19-0624.
[141] O. Gevaert, J. Xu, C.D. Hoang, A.N. Leung, Y. Xu, A. Quon, D.L. Rubin, S. Napel, S.
K. Plevritis, Non-small cell lung cancer: identifying prognostic imaging
biomarkers by leveraging public gene expression microarray data–methods and
preliminary results, Radiology 264 (2012) 387–396, https://doi.org/10.1148/
radiol.12111607.
[142] D.F. Halpenny, G.J. Riely, S. Hayes, H. Yu, J. Zheng, C.S. Moskowitz, M.
S. Ginsberg, Are there imaging characteristics associated with lung
adenocarcinomas harboring ALK rearrangements? Lung Cancer 86 (2014)
190–194, https://doi.org/10.1016/j.lungcan.2014.09.007.
[143] E. Ozkan, A. West, J.A. Dedelow, B.F. Chu, W. Zhao, V.O. Yildiz, G.A. Otterson,
K. Shilo, S. Ghosh, M. King, R.D. White, B.S. Erdal, CT gray-level texture analysis
as a quantitative imaging biomarker of epidermal growth factor receptor
mutation status in adenocarcinoma of the lung, Ajr. Am. J. Roentgenol. 205
(2015) 1016–1025, https://doi.org/10.2214/AJR.14.14147.
[144] H.J.W.L. Aerts, P. Grossmann, Y. Tan, G.R. Oxnard, N. Rizvi, L.H. Schwartz,
B. Zhao, Defining a radiomic response phenotype: a pilot study using targeted
therapy in NSCLC, Sci. Rep. 6 (2016) 33860, https://doi.org/10.1038/srep33860.
[145] E.E.C. De Jong, W. Van Elmpt, L.E.L. Hendriks, R.T.H. Leijenaar, A.M.
C. Dingemans, P. Lambin, OC-0609: radiomic CT features for evaluation of EGFR
and KRAS mutation status in patients with advanced NSCLC, Radiother. Oncol.
119 (2016) S290–S291, https://doi.org/10.1016/s0167-8140(16)31859-x.
[146] J. Guan, N.J. Xiao, M. Chen, W.L. Zhou, Y.W. Zhang, S. Wang, Y.M. Dai, L. Li,
Y. Zhang, Q.Y. Li, X.Z. Li, M. Yang, H.B. Wu, L.H. Chen, L.Y. Liu, 18F-FDG uptake
for prediction EGFR mutation status in non-small cell lung cancer, Medicine
(Baltimore) 95 (2016) 4421, https://doi.org/10.1097/MD.0000000000004421.
[147] J. Lv, H. Zhang, J. Ma, Y. Ma, G. Gao, Z. Song, Y. Yang, Comparison of CT
radiogenomic and clinical characteristics between EGFR and KRAS mutations in
lung adenocarcinomas, Clin. Radiol. 73 (2018) 590.e1–590.e8, https://doi.org/
10.1016/j.crad.2018.01.009.
[148] M. Zhou, A. Leung, S. Echegaray, A. Gentles, J.B. Shrager, K.C. Jensen, G.J. Berry,
S.K. Plevritis, D.L. Rubin, S. Napel, O. Gevaert, Non–small cell lung cancer
radiogenomics map identifies relationships between molecular and imaging
phenotypes with prognostic implications, Radiology 286 (2017) 307–315,
https://doi.org/10.1148/radiol.2017161845.
[149] B. Sacconi, M. Anzidei, A. Leonardi, F. Boni, L. Saba, R. Scipione, M. Anile,
M. Rengo, F. Longo, M. Bezzi, F. Venuta, A. Napoli, A. Laghi, C. Catalano, Analysis
of CT features and quantitative texture analysis in patients with lung
adenocarcinoma: a correlation with EGFR mutations and survival rates, Clin.
Radiol. 72 (2017) 443–450, https://doi.org/10.1016/j.crad.2017.01.015.
[150] S.S.F. Yip, J. Kim, T.P. Coroller, C. Parmar, E.R. Velazquez, E. Huynh, R.H. Mak,
H.J.W.L. Aerts, Associations between somatic mutations and metabolic imaging
phenotypes in non-small cell lung cancer, J. Nucl. Med. 58 (2017) 569–576,
https://doi.org/10.2967/jnumed.116.181826.
[151] L. Zhang, B. Chen, X. Liu, J. Song, M. Fang, C. Hu, D. Dong, W. Li, J. Tian,
Quantitative biomarkers for prediction of epidermal growth factor receptor
mutation in non-small cell lung cancer, Transl. Oncol. 11 (2018) 94–101, https://
doi.org/10.1016/j.tranon.2017.10.012.
[152] T.J. Kim, C.-T. Lee, S.H. Jheon, J.-S. Park, J.-H. Chung, Radiologic characteristics
of surgically resected non-small cell lung cancer with ALK rearrangement or EGFR
mutations, Ann. Thorac. Surg. 101 (2016) 473–480, https://doi.org/10.1016/j.
athoracsur.2015.07.062.
[153] R. Berenguer, M.D.R. Pastor-Juan, J. Canales-Vazquez, M. Castro-Garcia, M.
V. Villas, F. Mansilla Legorburo, S. Sabater, Radiomics of CT features may be
nonreproducible and redundant: influence of CT acquisition parameters,
Radiology 288 (2018) 407–415, https://doi.org/10.1148/radiol.2018172361.
[154] P. Grossmann, O. Stringfield, N. El-Hachem, M.M. Bui, E. Rios Velazquez,
C. Parmar, R.T. Leijenaar, B. Haibe-Kains, P. Lambin, R.J. Gillies, H.J. Aerts,
Defining the biological basis of radiomic phenotypes in lung cancer, Elife 6
(2017), https://doi.org/10.7554/eLife.23421.
[155] E. Neri, M. Del Re, F. Paiar, P. Erba, P. Cocuzza, D. Regge, R. Danesi, Radiomics
and liquid biopsy in oncology: the holons of systems medicine, Insights Imaging 9
(2018) 915–924, https://doi.org/10.1007/s13244-018-0657-7.
[156] N. Emaminejad, W. Qian, Y. Guan, M. Tan, Y. Qiu, H. Liu, B. Zheng, Fusion of
quantitative image and genomic biomarkers to improve prognosis assessment of
early stage lung cancer patients, IEEE Trans. Biomed. Eng. 63 (2016) 1034–1043,
https://doi.org/10.1109/TBME.2015.2477688.
[157] A.C. Chiang, R.S. Herbst, Frontline immunotherapy for NSCLC — the tale of the
tail, Nat. Rev. Clin. Oncol. 17 (2020) 73–74, https://doi.org/10.1038/s41571-
019-0317-y.
[158] M.D. Hellmann, L. Paz-Ares, R. Bernabe Caro, B. Zurawski, S.-W. Kim,
E. Carcereny Costa, K. Park, A. Alexandru, L. Lupinacci, E. de la Mora Jimenez,
14
Pharmacological Research 169 (2021) 105643
H. Sakai, I. Albert, A. Vergnenegre, S. Peters, K. Syrigos, F. Barlesi, M. Reck,
H. Borghaei, J.R. Brahmer, K.J. O’Byrne, W.J. Geese, P. Bhagavatheeswaran, S.
K. Rabindran, R.S. Kasinathan, F.E. Nathan, S.S. Ramalingam, Nivolumab plus
ipilimumab in advanced non–small-cell lung cancer, N. Engl. J. Med. 381 (2019)
2020–2031, https://doi.org/10.1056/NEJMoa1910231.
[159] F.S. Hodi, V. Chiarion-Sileni, R. Gonzalez, J.-J. Grob, P. Rutkowski, C.L. Cowey,
C.D. Lao, D. Schadendorf, J. Wagstaff, R. Dummer, P.F. Ferrucci, M. Smylie,
A. Hill, D. Hogg, I. Marquez-Rodas, J. Jiang, J. Rizzo, J. Larkin, J.D. Wolchok,
Nivolumab plus ipilimumab or nivolumab alone versus ipilimumab alone in
advanced melanoma (CheckMate 067): 4-year outcomes of a multicentre,
randomised, phase 3 trial, Lancet Oncol. 19 (2018) 1480–1492, https://doi.org/
10.1016/S1470-2045(18)30700-9.
[160] M. Reck, D. Rodríguez-Abreu, A.G. Robinson, R. Hui, T. Csőszi, A. Fülöp,
M. Gottfried, N. Peled, A. Tafreshi, S. Cuffe, M. O’Brien, S. Rao, K. Hotta, M.
A. Leiby, G.M. Lubiniecki, Y. Shentu, R. Rangwala, J.R. Brahmer, M. O’Brien,
S. Rao, K. Hotta, M.A. Leiby, G.M. Lubiniecki, Y. Shentu, R. Rangwala, J.
R. Brahmer, KEYNOTE-024 investigators, pembrolizumab versus chemotherapy
for PD-L1–positive non–small-cell lung cancer, N. Engl. J. Med. 375 (2016)
1823–1833, https://doi.org/10.1056/NEJMoa1606774.
[161] E.B. Garon, N.A. Rizvi, R. Hui, N. Leighl, A.S. Balmanoukian, J.P. Eder,
A. Patnaik, C. Aggarwal, M. Gubens, L. Horn, E. Carcereny, M.J. Ahn, E. Felip, J.
S. Lee, M.D. Hellmann, O. Hamid, J.W. Goldman, J.C. Soria, M. Dolled-Filhart, R.
Z. Rutledge, J. Zhang, J.K. Lunceford, R. Rangwala, G.M. Lubiniecki, C. Roach,
K. Emancipator, L. Gandhi, Pembrolizumab for the treatment of non-small-cell
lung cancer, N. Engl. J. Med. 372 (2015) 2018–2028, https://doi.org/10.1056/
NEJMoa1501824.
[162] T.S.K. Mok, Y.-L. Wu, I. Kudaba, D.M. Kowalski, B.C. Cho, H.Z. Turna, G.J. Castro,
V. Srimuninnimit, K.K. Laktionov, I. Bondarenko, K. Kubota, G.M. Lubiniecki,
J. Zhang, D. Kush, G. Lopes, Pembrolizumab versus chemotherapy for previously
untreated, PD-L1-expressing, locally advanced or metastatic non-small-cell lung
cancer (KEYNOTE-042): a randomised, open-label, controlled, phase 3 trial,
Lancet (London, England) 393 (2019) 1819–1830, https://doi.org/10.1016/
S0140-6736(18)32409-7.
[163] M.A. Socinski, R.M. Jotte, F. Cappuzzo, F. Orlandi, D. Stroyakovskiy, N. Nogami,
D. Rodríguez-Abreu, D. Moro-Sibilot, C.A. Thomas, F. Barlesi, G. Finley, C. Kelsch,
A. Lee, S. Coleman, Y. Deng, Y. Shen, M. Kowanetz, A. Lopez-Chavez, A. Sandler,
M. Reck, Atezolizumab for first-line treatment of metastatic nonsquamous NSCLC,
N. Engl. J. Med. 378 (2018) 2288–2301, https://doi.org/10.1056/
NEJMoa1716948.
[164] H. West, M. McCleod, M. Hussein, A. Morabito, A. Rittmeyer, H.J. Conter, H.-
G. Kopp, D. Daniel, S. McCune, T. Mekhail, A. Zer, N. Reinmuth, A. Sadiq,
A. Sandler, W. Lin, T. Ochi Lohmann, V. Archer, L. Wang, M. Kowanetz,
F. Cappuzzo, Atezolizumab in combination with carboplatin plus nab-paclitaxel
chemotherapy compared with chemotherapy alone as first-line treatment for
metastatic non-squamous non-small-cell lung cancer (IMpower130): a
multicentre, randomised, open-label, phase 3 tri, Lancet Oncol. 20 (2019)
924–937, https://doi.org/10.1016/S1470-2045(19)30167-6.
[165] S.J. Antonia, A. Villegas, D. Daniel, D. Vicente, S. Murakami, R. Hui, T. Kurata,
A. Chiappori, K.H. Lee, M. de Wit, B.C. Cho, M. Bourhaba, X. Quantin, T. Tokito,
T. Mekhail, D. Planchard, Y.-C. Kim, C.S. Karapetis, S. Hiret, G. Ostoros,
K. Kubota, J.E. Gray, L. Paz-Ares, J. de Castro Carpeño, C. Faivre-Finn, M. Reck,
J. Vansteenkiste, D.R. Spigel, C. Wadsworth, G. Melillo, M. Taboada, P.A. Dennis,
M. Özgüroğlu, Overall survival with durvalumab after chemoradiotherapy in
stage III NSCLC, N. Engl. J. Med. 379 (2018) 2342–2350, https://doi.org/
10.1056/NEJMoa1809697.
[166] S.J. Antonia, A. Villegas, D. Daniel, D. Vicente, S. Murakami, R. Hui, T. Yokoi,
A. Chiappori, K.H. Lee, M. de Wit, B.C. Cho, M. Bourhaba, X. Quantin, T. Tokito,
T. Mekhail, D. Planchard, Y.-C. Kim, C.S. Karapetis, S. Hiret, G. Ostoros,
K. Kubota, J.E. Gray, L. Paz-Ares, J. de Castro Carpeño, C. Wadsworth, G. Melillo,
H. Jiang, Y. Huang, P.A. Dennis, M. Özgüroğlu, Durvalumab after
chemoradiotherapy in stage III non–small-cell lung cancer, N. Engl. J. Med. 377
(2017) 1919–1929, https://doi.org/10.1056/NEJMoa1709937.
[167] S.C. Wei, C.R. Duffy, J.P. Allison, Fundamental mechanisms of immune
checkpoint blockade therapy, Cancer Discov. 8 (2018) 1069–1086, https://doi.
org/10.1158/2159-8290.CD-18-0367.
[168] M. Ilié, E. Szafer-Glusman, V. Hofman, E. Chamorey, S. Lalvée, E. Selva, S. Leroy,
C.-H. Marquette, M. Kowanetz, P. Hedge, E. Punnoose, P. Hofman, Detection of
PD-L1 in circulating tumor cells and white blood cells from patients with
advanced non-small-cell lung cancer, Ann. Oncol. J. Eur. Soc. Med. Oncol. 29
(2018) 193–199, https://doi.org/10.1093/annonc/mdx636.
[169] D.L. Adams, D.K. Adams, J. He, N. Kalhor, M. Zhang, T. Xu, H. Gao, J.M. Reuben,
Y. Qiao, R. Komaki, Z. Liao, M.J. Edelman, C.-M. Tang, S.H. Lin, Sequential
tracking of PD-L1 expression and RAD50 induction in circulating tumor and
stromal cells of lung cancer patients undergoing radiotherapy, Clin. Cancer Res. J.
Am. Assoc. Cancer Res. 23 (2017) 5948–5958, https://doi.org/10.1158/1078-
0432.CCR-17-0802.
[170] D.J. Boffa, R.P. Graf, M.C. Salazar, J. Hoag, D. Lu, R. Krupa, J. Louw, L. Dugan,
Y. Wang, M. Landers, M. Suraneni, S.B. Greene, M. Magaña, S. Makani,
L. Bazhenova, R.V. Dittamore, J. Nieva, Cellular expression of PD-L1 in the
peripheral blood of lung cancer patients is associated with worse survival, Cancer
Epidemiol. Biomark. Prev. a Publ. Am. Assoc. Cancer Res. Cosponsored Am. Soc.
Prev. Oncol. 26 (2017) 1139–1145, https://doi.org/10.1158/1055-9965.EPI-17-
0120.
[171] M. Dhar, J. Wong, J. Che, M. Matsumoto, T. Grogan, D. Elashoff, E.B. Garon, J.
W. Goldman, E. Sollier Christen, D. Di Carlo, R.P. Kulkarni, Evaluation of PD-L1
F. Cucchiara et al.
expression on vortex-isolated circulating tumor cells in metastatic lung cancer,
Sci. Rep. 8 (2018) 2592, https://doi.org/10.1038/s41598-018-19245-w.
[172] N. Guibert, M. Delaunay, A. Lusque, N. Boubekeur, I. Rouquette, E. Clermont,
J. Mourlanette, S. Gouin, I. Dormoy, G. Favre, J. Mazieres, A. Pradines, PD-L1
expression in circulating tumor cells of advanced non-small cell lung cancer
patients treated with nivolumab, Lung Cancer 120 (2018) 108–112, https://doi.
org/10.1016/j.lungcan.2018.04.001.
[173] G. Kallergi, E.-K. Vetsika, D. Aggouraki, E. Lagoudaki, A. Koutsopoulos, F. Koinis,
P. Katsarlinos, M. Trypaki, I. Messaritakis, C. Stournaras, V. Georgoulias,
A. Kotsakis, Evaluation of PD-L1/PD-1 on circulating tumor cells in patients with
advanced non-small cell lung cancer, Ther. Adv. Med. Oncol. 10 (2018),
1758834017750121, https://doi.org/10.1177/1758834017750121.
[174] C. Nicolazzo, C. Raimondi, M. Mancini, S. Caponnetto, A. Gradilone, O. Gandini,
M. Mastromartino, G. Del Bene, A. Prete, F. Longo, E. Cortesi, P. Gazzaniga,
Monitoring PD-L1 positive circulating tumor cells in non-small cell lung cancer
patients treated with the PD-1 inhibitor Nivolumab, Sci. Rep. 6 (2016) 31726,
https://doi.org/10.1038/srep31726.
[175] S.-P. Li, Q.-L. Guan, D. Zhao, G.-J. Pei, H.-X. Su, L.-N. Du, J.-X. He, Z.-C. Liu,
Detection of circulating tumor cells by fluorescent immunohistochemistry in
patients with esophageal squamous cell carcinoma: potential clinical applications,
Med. Sci. Monit. Int. Med. J. Exp. Clin. Res 22 (2016) 1654–1662, https://doi.
org/10.12659/msm.898335.
[176] A. Asgarova, K. Asgarov, Y. Godet, P. Peixoto, A. Nadaradjane, M. Boyer-Guittaut,
J. Galaine, D. Guenat, V. Mougey, J. Perrard, J.R. Pallandre, A. Bouard,
J. Balland, C. Tirole, O. Adotevi, E. Hendrick, M. Herfs, P.F. Cartron, C. Borg,
E. Hervouet, PD-L1 expression is regulated by both DNA methylation and NF-kB
during EMT signaling in non-small cell lung carcinoma, Oncoimmunology 7
(2018), 1423170, https://doi.org/10.1080/2162402X.2017.1423170.
[177] Q.-X. Qu, Q. Huang, Y. Shen, Y.-B. Zhu, X.-G. Zhang, The increase of circulating
PD-L1-expressing CD68(+) macrophage in ovarian cancer. Tumour Biol. J. Int.
Soc. Oncodev. Biol. Med. 37 (2016) 5031–5037, https://doi.org/10.1007/
s13277-015-4066-y.
[178] J.L. Schehr, Z.D. Schultz, J.W. Warrick, D.J. Guckenberger, H.M. Pezzi, J.
M. Sperger, E. Heninger, A. Saeed, T. Leal, K. Mattox, A.M. Traynor, T.
C. Campbell, S.M. Berry, D.J. Beebe, J.M. Lang, High specificity in circulating
tumor cell identification is required for accurate evaluation of programmed
death-ligand 1, PLoS One 11 (2016), 0159397, https://doi.org/10.1371/journal.
pone.0159397.
[179] D.H. Kim, H. Kim, Y.J. Choi, S.Y. Kim, J.-E. Lee, K.J. Sung, Y.H. Sung, C.-G. Pack,
M. Jung, B. Han, K. Kim, W.S. Kim, S.J. Nam, C.-M. Choi, M. Yun, J.C. Lee, J.
K. Rho, Exosomal PD-L1 promotes tumor growth through immune escape in non-
small cell lung cancer, Exp. Mol. Med. 51 (2019) 1–13, https://doi.org/10.1038/
s12276-019-0295-2.
[180] M. Del Re, R. Marconcini, G. Pasquini, E. Rofi, C. Vivaldi, F. Bloise, G. Restante,
E. Arrigoni, C. Caparello, M.G. Bianco, S. Crucitta, I. Petrini, E. Vasile, A. Falcone,
R. Danesi, M. Grazia Bianco, S. Crucitta, I. Petrini, E. Vasile, A. Falcone, R. Danesi,
PD-L1 mRNA expression in plasma-derived exosomes is associated with response
to anti-PD-1 antibodies in melanoma and NSCLC, Br. J. Cancer 118 (2018)
820–824, https://doi.org/10.1038/bjc.2018.9.
[181] M. Del Re, R.H.N. van Schaik, S. Fogli, R.H.J. Mathijssen, F. Cucchiara,
A. Capuano, C. Scavone, G.W. Jenster, R. Danesi, Blood-based PD-L1 analysis in
tumor-derived extracellular vesicles: applications for optimal use of anti-PD-1/
PD-L1 axis inhibitors, Biochim Biophys. Acta Rev. Cancer 1875 (2021), 188463,
https://doi.org/10.1016/j.bbcan.2020.188463.
[182] M.D. Hellmann, T.-E. Ciuleanu, A. Pluzanski, J.S. Lee, G.A. Otterson, C. Audigier-
Valette, E. Minenza, H. Linardou, S. Burgers, P. Salman, H. Borghaei, S.
S. Ramalingam, J. Brahmer, M. Reck, K.J. O’Byrne, W.J. Geese, G. Green,
H. Chang, J. Szustakowski, P. Bhagavatheeswaran, D. Healey, Y. Fu, F. Nathan,
L. Paz-Ares, Nivolumab plus ipilimumab in lung cancer with a high tumor
mutational burden, N. Engl. J. Med. 378 (2018) 2093–2104, https://doi.org/
10.1056/NEJMoa1801946.
[183] F. Koeppel, S. Blanchard, C. Jovelet, B. Genin, C. Marcaillou, E. Martin,
E. Rouleau, E. Solary, J.-C. Soria, F. André, L. Lacroix, Whole exome sequencing
for determination of tumor mutation load in liquid biopsy from advanced cancer
patients, PLoS One 12 (2017), 0188174, https://doi.org/10.1371/journal.
pone.0188174.
[184] F. Fenizia, R. Pasquale, C. Roma, F. Bergantino, A. Iannaccone, N. Normanno,
Measuring tumor mutation burden in non-small cell lung cancer: tissue versus
liquid biopsy, Transl. Lung Cancer Res 7 (2018) 668–677, https://doi.org/
10.21037/tlcr.2018.09.23.
[185] D.R. Camidge, R.C. Doebele, K.M. Kerr, Comparing and contrasting predictive
biomarkers for immunotherapy and targeted therapy of NSCLC, Nat. Rev. Clin.
Oncol. 16 (2019) 341–355, https://doi.org/10.1038/s41571-019-0173-9.
[186] M. Ilie, J. Benzaquen, V. Hofman, S. Lassalle, N. Yazbeck, S. Leroy, S. Heeke,
C. Bence, B. Mograbi, N. Glaichenhaus, C.-H. Marquette, P. Hofman,
Immunotherapy in non-small cell lung cancer: biological principles and future
opportunities, Curr. Mol. Med. 17 (2017) 527–540, https://doi.org/10.2174/
1566524018666180222114038.
[187] A. Passaro, I. Attili, S. Morganti, E. Del Signore, L. Gianoncelli, G. Spitaleri,
V. Stati, C. Catania, G. Curigliano, F. de Marinis, Clinical features affecting
survival in metastatic NSCLC treated with immunotherapy: a critical review of
published data, Cancer Treat. Rev. 89 (2020), 102085, https://doi.org/10.1016/j.
ctrv.2020.102085.
[188] C. Tang, B. Hobbs, A. Amer, X. Li, C. Behrens, J.R. Canales, E.P. Cuentas,
P. Villalobos, D. Fried, J.Y. Chang, D.S. Hong, J.W. Welsh, B. Sepesi, L. Court, I.
I. Wistuba, E.J. Koay, Development of an immune-pathology informed radiomics
15
Pharmacological Research 169 (2021) 105643
model for non-small cell lung cancer, Sci. Rep. 8 (2018) 1922, https://doi.org/
10.1038/s41598-018-20471-5.
[189] V. Velcheti, M. Alilou, M. Khunger, R. Thawani, A. Madabhushi, Changes in
computer extracted features of vessel tortuosity on CT scans post-treatment in
responders compared to non-responders for non-small cell lung cancer on
immunotherapy, JCO 35 (2017) 11518, https://doi.org/10.1200/
JCO.2017.35.15_suppl.11518.
[190] M. Khorrami, P. Prasanna, A. Gupta, P. Patil, P.D. Velu, R. Thawani, G.
G. Corredor, M. Alilou, K. Bera, P. Fu, M. Feldman, V. Velcheti, A. Madabhushi,
Changes in CT radiomic features associated with lymphocyte distribution predict
overall survival and response to immunotherapy in non-small cell lung cancer,
Cancer Immunol. Res. 8 (2020) 108–119, https://doi.org/10.1158/2326-6066.
CIR-19-0476.
[191] R. Sun, E.J. Limkin, M. Vakalopoulou, L. Dercle, S. Champiat, S.R. Han,
L. Verlingue, D. Brandao, A. Lancia, S. Ammari, A. Hollebecque, J.-Y. Scoazec,
A. Marabelle, C. Massard, J.-C. Soria, C. Robert, N. Paragios, E. Deutsch, C. Ferté,
A radiomics approach to assess tumour-infiltrating CD8 cells and response to anti-
PD-1 or anti-PD-L1 immunotherapy: an imaging biomarker, retrospective
multicohort study, Lancet Oncol. 19 (2018) 1180–1191, https://doi.org/
10.1016/S1470-2045(18)30413-3.
[192] H.J. Yoon, J. Kang, H. Park, I. Sohn, S.-H. Lee, H.Y. Lee, Deciphering the tumor
microenvironment through radiomics in non-small cell lung cancer: Correlation
with immune profiles, PLoS One 15 (2020), 0231227, https://doi.org/10.1371/
journal.pone.0231227.
[193] Y. Xie, M. Khunger, R. Thawani, V. Velcheti, A. Madabhushi, Metastasis-free
survival is a strong surrogate of overall survival in localized prostate cancer,
J. Clin. Oncol. 35 (2017) 3097–3104, https://doi.org/10.1200/JCO.2017.35.15_
suppl.e14534.
[194] I. Tunali, Y. Tan, J.E. Gray, E. Katsoulakis, S.A. Eschrich, J. Saller, T. Boyle, J. Qi,
A. Guvenis, R.J. Gillies, M.B. Schabath, Hypoxia-related radiomics predict
immunotherapy response: a multi-cohort study of NSCLC, BioRxiv (2020),
https://doi.org/10.1101/2020.04.02.020859.
[195] S. Trebeschi, S.G. Drago, N.J. Birkbak, I. Kurilova, A.M. Calin, A. Delli Pizzi,
F. Lalezari, D.M.J. Lambregts, M.W. Rohaan, C. Parmar, E.A. Rozeman, K.
J. Hartemink, C. Swanton, J.B.A.G. Haanen, C.U. Blank, E.F. Smit, R.G.H. Beets-
Tan, H.J.W.L. Aerts, Predicting response to cancer immunotherapy using
noninvasive radiomic biomarkers. Ann. Oncol. Off. J. Eur. Soc. Med. Oncol. 30
(2019) 998–1004, https://doi.org/10.1093/annonc/mdz108.
[196] I. Tunali, J.E. Gray, J. Qi, M. Abdalah, D.K. Jeong, A. Guvenis, R.J. Gillies, M.
B. Schabath, Novel clinical and radiomic predictors of rapid disease progression
phenotypes among lung cancer patients treated with immunotherapy: An early
report, Lung Cancer 129 (2019) 75–79, https://doi.org/10.1016/j.
lungcan.2019.01.010.
[197] P. Lambin, R.G.P.M. van Stiphout, M.H.W. Starmans, E. Rios-Velazquez,
G. Nalbantov, H.J.W.L. Aerts, E. Roelofs, W. van Elmpt, P.C. Boutros, P. Granone,
V. Valentini, A.C. Begg, D. De Ruysscher, A. Dekker, Predicting outcomes in
radiation oncology–multifactorial decision support systems, Nat. Rev. Clin. Oncol.
10 (2013) 27–40, https://doi.org/10.1038/nrclinonc.2012.196.
[198] R. Joober, N. Schmitz, L. Annable, P. Boksa, Publication bias: what are the
challenges and can they be overcome? J. Psychiatry Neurosci. 37 (2012)
149–152, https://doi.org/10.1503/jpn.120065.
[199] I. Buvat, F. Orlhac, The dark side of radiomics: on the paramount importance of
publishing negative results, J. Nucl. Med. 60 (2019) 1543–1544, https://doi.org/
10.2967/jnumed.119.235325.
[200] R. Thawani, M. McLane, N. Beig, S. Ghose, P. Prasanna, V. Velcheti,
A. Madabhushi, Radiomics and radiogenomics in lung cancer: a review for the
clinician, Lung Cancer 115 (2018) 34–41, https://doi.org/10.1016/j.
lungcan.2017.10.015.
[201] C. Hassani, B.A. Varghese, J. Nieva, V. Duddalwar, Radiomics in pulmonary
lesion imaging, Ajr. Am. J. Roentgenol. 212 (2019) 497–504, https://doi.org/
10.2214/AJR.18.20623.
[202] A. Chalkidou, M.J. O’Doherty, P.K. Marsden, False discovery rates in PET and CT
studies with texture features: a systematic review, PLoS One 10 (2015), 0124165,
https://doi.org/10.1371/journal.pone.0124165.
[203] N. Karachaliou, A.E. Sosa, M.A. Molina, M. Centelles Ruiz, R. Rosell, Possible
application of circulating free tumor DNA in non-small cell lung cancer patients,
J. Thorac. Dis. 9 (2017) S1364–S1372, https://doi.org/10.21037/jtd.2017.09.59.
[204] P. Hofman, S. Heeke, C. Alix-Panabières, K. Pantel, Liquid biopsy in the era of
immuno-oncology: is it ready for prime-time use for cancer patients? Ann. Oncol.
Off. J. Eur. Soc. Med. Oncol. 30 (2019) 1448–1459, https://doi.org/10.1093/
annonc/mdz196.
[205] J. Saarenheimo, N. Eigeliene, H. Andersen, M. Tiirola, A. Jekunen, The value of
liquid biopsies for guiding therapy decisions in non-small cell lung cancer, Front.
Oncol. 9 (2019) 129, https://doi.org/10.3389/fonc.2019.00129.
[206] B.A. Sisson, J. Uvalic, K. Kelly, P. Selvam, A.N. Hesse, G. Ananda, H. Chandok,
D. Bergeron, L. Holinka, H.V. Reddi, Technical and regulatory considerations for
taking liquid biopsy to the clinic: validation of the JAX plasmaMonitor(TM) assay,
Biomark. Insights 14 (2019), 1177271919826545, https://doi.org/10.1177/
1177271919826545.
[207] A.W. Hahn, R.H. Nussenzveig, S.K. Pal, N. Agarwal, Blood- and tissue-based
tumor genomics: a battle royale or match made in heaven? Ann. Oncol. 28 (2017)
2333–2335, https://doi.org/10.1093/annonc/mdx418.
[208] R. Shatsky, B.A. Parker, N.Q. Bui, T. Helsten, R.B. Schwab, S.G. Boles,
R. Kurzrock, Next-generation sequencing of tissue and circulating tumor DNA: the
UC San Diego Moores Center for personalized cancer therapy experience with
F. Cucchiara et al.
breast malignancies, Mol. Cancer Ther. 18 (2019) 1001–1011, https://doi.org/
10.1158/1535-7163.MCT-17-1038.
[209] 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. Watkins, 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. Johnson, 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. Blackhall, 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. Remmen, K. Kerr,
M. Chetty, L. Gomersall, D.A. Fennell, A. Nakas, S. Rathinam, G. Anand, 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. Herrero, 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. Zimmermann, C. Swanton, M. Jamal-Hanjani, C. Abbosh, S. Veeriah, S. Shafi,
J. Czyzewska-Khan, D. Johnson, J. Laycock, L. Bosshard-Carter, G. Goh,
R. Rosenthal, P. Gorman, N. Murugaesu, R.E. Hynds, G.A. Wilson, N.J. Birkbak, T.
B.K. Watkins, N. McGranahan, S. Horswell, M. Al Bakir, E. Grönroos, R. Mitter,
M. Escudero, A. Stewart, P. Van Loo, A. Rowan, H. Xu, S. Turajlic, C. Hiley,
J. Goldman, R.K. Stone, T. Denner, N. Matthews, G. Elgar, S. Ward, J. Biggs,
M. Costa, S. Begum, B. Phillimore, T. Chambers, E. Nye, S. Graca, K. Joshi,
A. Furness, A. Ben Aissa, Y.N.S. Wong, A. Georgiou, S.A. Quezada, K.S. Peggs, J.
A. Hartley, H.L. Lowe, J. Herrero, D. Lawrence, M. Hayward, N. Panagiotopoulos,
S. Kolvekar, M. Falzon, E. Borg, T. Marafioti, C. Simeon, G. Hector, A. Smith,
M. Aranda, M. Novelli, D. Oukrif, A.U. Akarca, S.M. Janes, R. Thakrar, M.
D. Forster, T. Ahmad, S.M. Lee, D. Papadatos-Pastos, D. Carnell, R. Mendes,
J. George, N. Navani, A. Ahmed, M. Taylor, J. Choudhary, Y. Summers,
R. Califano, P. Taylor, R. Shah, P. Krysiak, K. Rammohan, E. Fontaine, R. Booton,
M. Evison, P.A. Crosbie, S. Moss, F. Idries, L. Joseph, P. Bishop, A. Chaturvedi, A.
M. Quinn, H. Doran, A. Leek, P. Harrison, K. Moore, R. Waddington, J. Novasio,
F. Blackhall, J. Rogan, E. Smith, C. Dive, J. Tugwood, G. Brady, D.G. Rothwell,
F. Chemi, J. Pierce, S. Gulati, B. Naidu, G. Langman, S. Trotter, M. Bellamy,
H. Bancroft, A. Kerr, S. Kadiri, J. Webb, G. Middleton, M. Djearaman, D.
A. Fennell, J.A. Shaw, J. Le Quesne, D.A. Moore, A. Thomas, H. Walter, J. Riley,
L. Martinson, A. Nakas, S. Rathinam, W. Monteiro, H. Marshall, L. Nelson,
J. Bennett, L. Primrose, G. Anand, S. Khan, A. Amadi, M. Nicolson, K. Kerr,
S. Palmer, H. Remmen, J. Miller, K. Buchan, M. Chetty, L. Gomersall, J.F. Lester,
A. Edwards, F. Morgan, H. Adams, H. Davies, M. Kornaszewska, R. Attanoos,
S. Lock, A. Verjee, M. MacKenzie, M. Wilcox, H. Bell, N. Iles, A. Hackshaw,
Y. Ngai, S. Smith, N. Gower, C. Ottensmeier, S. Chee, B. Johnson, A. Alzetani,
E. Shaw, E. Lim, P. De Sousa, M.T. Barbosa, A. Bowman, S. Jordan, A. Rice,
H. Raubenheimer, C. Proli, M.E. Cufari, J.C. Ronquillo, A. Kwayie, H. Bhayani,
M. Hamilton, Y. Bakar, N. Mensah, L. Ambrose, A. Devaraj, S. Buderi, J. Finch,
L. Azcarate, H. Chavan, S. Green, H. Mashinga, A.G. Nicholson, K. Lau, M. Sheaff,
P. Schmid, T. Tracer. consortium, Phylogenetic ctDNA analysis depicts early-stage
lung cancer evolution, Nature 545 (2017) 446–451, https://doi.org/10.1038/
nature22364.
[210] R.B. Lanman, S.A. Mortimer, O.A. Zill, D. Sebisanovic, R. Lopez, S. Blau, E.
A. Collisson, S.G. Divers, D.S.B. Hoon, E.S. Kopetz, J. Lee, P.G. Nikolinakos, A.
16
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Pharmacological Research 169 (2021) 105643
M. Baca, B.G. Kermani, H. Eltoukhy, A. Talasaz, Analytical and clinical validation
of a digital sequencing panel for quantitative, highly accurate evaluation of cell-
free circulating tumor DNA, PLoS One 10 (2015), 0140712, https://doi.org/
10.1371/journal.pone.0140712.
[211] M.W. Schmitt, S.R. Kennedy, J.J. Salk, E.J. Fox, J.B. Hiatt, L.A. Loeb, Detection of
ultra-rare mutations by next-generation sequencing, Proc. Natl. Acad. Sci. 109
(2012) 14508–14513, https://doi.org/10.1073/pnas.1208715109.
[212] L.M. Sholl, G.R. Oxnard, C.P. Paweletz, Traditional diagnostics versus disruptive
technology: the role of the pathologist in the era of liquid biopsy, Cancer Res. 80
(2020) 3197–3199, https://doi.org/10.1158/0008-5472.CAN-20-0134.
[213] R.J. Gillies, A.R. Anderson, R.A. Gatenby, D.L. Morse, The biology underlying
molecular imaging in oncology: from genome to anatome and back again, Clin.
Radiol. 65 (2010) 517–521, https://doi.org/10.1016/j.crad.2010.04.005.
[214] R. Lo Gullo, I. Daimiel, E.A. Morris, K. Pinker, Combining molecular and imaging
metrics in cancer: radiogenomics, Insights Imaging 11 (2020) 1, https://doi.org/
10.1186/s13244-019-0795-6.
[215] E.J. Limkin, R. Sun, L. Dercle, E.I. Zacharaki, C. Robert, S. Reuzé, A. Schernberg,
N. Paragios, E. Deutsch, C. Ferté, Promises and challenges for the implementation
of computational medical imaging (radiomics) in oncology, Ann. Oncol. Off. J.
Eur. Soc. Med. Oncol. 28 (2017) 1191–1206, https://doi.org/10.1093/annonc/
mdx034.
[216] Precision Medicine Market Worth $85.5 Billion by 2025 | CAGR: 9.9%, n.d.
〈https://www.grandviewresearch.com/press-release/global-precision-medicine-
diagnostics-therapeutics-market〉 (accessed 25 July 2020).
[217] J. de Leon, Teaching medical students how to think: narrative, mechanistic and
mathematical thinking, Actas Esp. Psiquiatr. 46 (2018) 133–145.
[218] J. de Leon, C. De Las Cuevas, The art of pharmacotherapy: reflections on
pharmacophobia, J. Clin. Psychopharmacol. 37 (2017) 131–137, https://doi.org/
10.1097/JCP.0000000000000675.
[219] AMA, AMA Digital Health Study: Physicians’ motivations and requirements for
adopting digital clinical tools | Adoption and attitudinal shifts from 2016 to 2019,
2020; 1–37. 〈https://www.ama-assn.org/practice-management/digital〉.
[220] P. Lambin, R.T.H. Leijenaar, T.M. Deist, J. Peerlings, E.E.C. de Jong, J. van
Timmeren, S. Sanduleanu, R.T.H.M. Larue, A.J.G. Even, A. Jochems, Y. van Wijk,
H. Woodruff, J. van Soest, T. Lustberg, E. Roelofs, W. van Elmpt, A. Dekker, F.
M. Mottaghy, J.E. Wildberger, S. Walsh, Radiomics: the bridge between medical
imaging and personalized medicine, Nat. Rev. Clin. Oncol. 14 (2017) 749–762,
https://doi.org/10.1038/nrclinonc.2017.141.
[221] L. Leyens, M. Reumann, N. Malats, A. Brand, Use of big data for drug development
and for public and personal health and care, Genet. Epidemiol. 41 (2017) 51–60,
https://doi.org/10.1002/gepi.22012.
[222] C. Auffray, R. Balling, I. Barroso, L. Bencze, M. Benson, J. Bergeron, E. Bernal-
Delgado, N. Blomberg, C. Bock, A. Conesa, S. Del Signore, C. Delogne, P. Devilee,
A. Di Meglio, M. Eijkemans, P. Flicek, N. Graf, V. Grimm, H.-J. Guchelaar, Y.-
K. Guo, I.G. Gut, A. Hanbury, S. Hanif, R.-D. Hilgers, Á. Honrado, D.R. Hose,
J. Houwing-Duistermaat, T. Hubbard, S.H. Janacek, H. Karanikas, T. Kievits,
M. Kohler, A. Kremer, J. Lanfear, T. Lengauer, E. Maes, T. Meert, W. Müller,
D. Nickel, P. Oledzki, B. Pedersen, M. Petkovic, K. Pliakos, M. Rattray, J.R. i Màs,
R. Schneider, T. Sengstag, X. Serra-Picamal, W. Spek, L.A.I. Vaas, O. van
Batenburg, M. Vandelaer, P. Varnai, P. Villoslada, J.A. Vizcaíno, J.P.M. Wubbe,
G. Zanetti, Making sense of big data in health research: Towards an EU action
plan, Genome Med. 8 (2016) 71, https://doi.org/10.1186/s13073-016-0323-y.