Clinical best practices in interdisciplinary management of human epidermal growth factor receptor 2 antibody-drug conjugates-induced interstitial lung disease/pneumonitis: An expert consensus in China.

Antibody-drug conjugates (ADCs) have demonstrated effectiveness in treating various cancers, particularly exhibiting specificity in targeting human epidermal growth factor receptor 2 (HER2)-positive breast cancer. Recent advancements in phase 3 clinical trials have broadened current understanding of ADCs, especially trastuzumab deruxtecan, in treating other HER2-expressing malignancies. This expansion of knowledge has led to the US Food and Drug Administration's approval of trastuzumab deruxtecan for HER2-positive and HER2-low breast cancer, HER2-positive gastric cancer, and HER2-mutant nonsmall cell lung cancer. Concurrent with the increasing use of ADCs in oncology, there is growing concern among health care professionals regarding the rise in the incidence of interstitial lung disease or pneumonitis (ILD/p), which is associated with anti-HER2 ADC therapy. Studies on anti-HER2 ADCs have reported varying ILD/p mortality rates. Consequently, it is crucial to establish guidelines for the diagnosis and management of ILD/p in patients receiving anti-HER2 ADC therapy. To this end, a panel of Chinese experts was convened to formulate a strategic approach for the identification and management of ILD/p in patients treated with anti-HER2 ADC therapy. This report presents the expert panel's opinions and recommendations, which are intended to guide the management of ILD/p induced by anti-HER2 ADC therapy in clinical practice.

Sequential separation of critical metals from lithium-ion batteries based on deep eutectic solvent and electrodeposition.

The rise and development of electric vehicles have brought much attention to the recycling of lithium-ion batteries (LIBs). However, the recovery of critical metals from LiNixCoyMn1-x-yO2 (NCM) is a challenge, especially for the nickel and cobalt, which have similar chemical properties. Here, a novel ternary deep eutectic solvent (DES) composed of choline chloride, ethylene glycol, and tartaric acid was proposed. Our protocol of DES synthesis, nickel separation, and leaching of cobalt and manganese were integrated into one step, which significantly simplified the recovery process. The crystallization occurring during DES leaching was subjected to detailed investigation. The lithium, nickel, and cobalt were sequentially separated as Li2CO3, NiO, and Co(OH)2 by anterior formic acid leaching and posterior electrodeposition. After electrodeposition, DES was reused. This work provides new ideas for the sequential separation of critical metals from NCM and has great application prospects.

A prognostic signature for lung adenocarcinoma by five genes associated with chemotherapy in lung adenocarcinoma.

BACKGROUND: Lung adenocarcinoma (LUAD) is one of the most common subtypes of lung cancer. Finding prognostic biomarkers is helpful in stratifying LUAD patients with different prognosis. METHODS: We explored the correlation of LUAD prognosis and genes associated with chemotherapy in LUAD and obtained data of LUAD patients from the Cancer Genome Atlas (TCGA) and Gene Expression Omnibus (GEO) databases. Drug sensitivity data were acquired from the Genomics of Drug Sensitivity in Cancer (GDSC) database. Differential and enrichment analyses were used to screen the target genes utilizing limma and "clusterProfiler" packages. Then univariate and LASSO Cox analyses were used to select the prognosis-related genes. Survival analysis was used to estimate the overall survival (OS) of different groups. RESULTS: Twenty-three differentially expressed genes (DEGs) were screened between LUAD samples and healthy samples, and BTK, FGFR2, PIM2, CHEK1, and CDK1 were selected to construct a prognostic signature. The OS of patients in the high-risk group (risk score higher than 0.69) was worse than that in the low-risk group (risk score lower than 0.69). CONCLUSION: The risk score model constructed by five genes is a potential prognostic biomarker for LUAD patients.

Life quality improvement of patients with non-small cell lung cancer undergoing targeted therapy: A case study of continuous care.

To investigate the improvement effect of targeted therapy on non-small cell carcinoma patients life quality after the continuous nursing intervention. 104 non-small cell lung cancer patients in our hospital from July 2017 to November 2019 were allocated evenly and randomly into the control group (C) and the study group (S). By using clinical baseline data, quality of life questionnaire core 30 for cancer patients, evaluation of patient compliance behavior, the MOS item short-form health survey (SF-36), self rating depression scale (SDS), self rating anxiety scale (SAS), Overall Survival (OS) progression-free survival and adverse reaction symptoms were evaluated for the life quality of patients. There was comparability between the 2 sets of basic data. There was no significant difference in quality of life questionnaire core 30, SF-36, SAS, or SDS scores before treatment. After 3 months, there was a significant difference in the scores of various scales before treatment. At the same time, there was significant statistical significance before and after treatment in Group S. Their compliance rates were 84.62% and 98.08%. Adverse reactions incidence in Group S was lower. Taking a 2-year follow-up period as an example, significant statistical differences existed in OS and progression-free survival rates between adenocarcinoma and squamous carcinoma. SDS and SAS had high consistency in scoring with QLQ-30 and SF-36 scales. Targeted treatment for non-small cell carcinoma patients significantly improves their life quality and reduces the incidence of adverse reactions after continuous nursing intervention.

Mechanistic study on the formation of the alkyl acrylates from CO2, ethylene and alkyl iodides over nickel-based catalyst.

The catalytic conversion of carbon dioxide (CO2) and olefins into acrylates has been a long standing target, because society attempts to synthesize commodity chemicals in a more economical and sustainable fashion. In this work, two alkylation reaction pathways were investigated to explore the role of methylene linkage (-CH2-) on the formation of alkyl acrylate from coupling of CO2 and ethylene, catalyzed by a nickel catalyst in the presence of different alkyl iodides. The energy barrier of Ni-O bond cleavage decreases with increasing methylene linkage of alkyl iodides, which may be due to NPA charge transfer of alkyl iodides. Meanwhile, the O1 (ester sp3 O atom) attack route leading to the formation of alkyl acrylate competes with the O2 (carboxylic sp2 O atom) attack route in terms of energy barriers. Further studies on the fluoro-substituted alkyl acrylates show that neither CF3I nor CF3CH2I is effective in releasing trifluoroalkyl acrylates from the nickellacycle, which explains why only negligible amounts of the desired product were detected in the experiment. In addition, we investigated the non-productive pathways leading to byproducts, such as propionic acid, propionates and ion pair complexes, etc. By comparing the results obtained with CH3I, the use of C2H5I as an electrophilic reagent may stabilize the non-productive intermediates. The methylene linkage has little effect on the main productive pathway. However, it has a significant influence on the side reactions, which is detrimental to the formation of alkyl acrylate in competing with the main productive pathway.

Expert consensus on the diagnosis and treatment of RET gene fusion non-small cell lung cancer in China.

The rearranged during transfection (RET) gene is one of the receptor tyrosine kinases and cell-surface molecules responsible for transmitting signals that regulate cell growth and differentiation. In non-small cell lung cancer (NSCLC), RET fusion is a rare driver gene alteration associated with a poor prognosis. Fortunately, two selective RET inhibitors (sRETi), namely pralsetinib and selpercatinib, have been approved for treating RET fusion NSCLC due to their remarkable efficacy and safety profiles. These inhibitors have shown the ability to overcome resistance to multikinase inhibitors (MKIs). Furthermore, ongoing clinical trials are investigating several second-generation sRETis that are specifically designed to target solvent front mutations, which pose a challenge for first-generation sRETis. The effective screening of patients is the first crucial step in the clinical application of RET-targeted therapy. Currently, four methods are widely used for detecting gene rearrangements: next-generation sequencing (NGS), reverse transcription-polymerase chain reaction (RT-PCR), fluorescence in situ hybridization (FISH), and immunohistochemistry (IHC). Each of these methods has its advantages and limitations. To streamline the clinical workflow and improve diagnostic and treatment strategies for RET fusion NSCLC, our expert group has reached a consensus. Our objective is to maximize the clinical benefit for patients and promote standardized approaches to RET fusion screening and therapy.

Chinese expert consensus on the diagnosis and treatment of malignant pleural mesothelioma.

Malignant pleural mesothelioma (MPM) is a malignant tumor originating from the pleura, and its incidence has been increasing in recent years. Due to the insidious onset and strong local invasiveness of MPM, most patients are diagnosed in the late stage and early screening and treatment for high-risk populations are crucial. The treatment of MPM mainly includes surgery, chemotherapy, and radiotherapy. Immunotherapy and electric field therapy have also been applied, leading to further improvements in patient survival. The Mesothelioma Group of the Yangtze River Delta Lung Cancer Cooperation Group (East China LUng caNcer Group, ECLUNG; Youth Committee) developed a national consensus on the clinical diagnosis and treatment of MPM based on existing clinical research evidence and the opinions of national experts. This consensus aims to promote the homogenization and standardization of MPM diagnosis and treatment in China, covering epidemiology, diagnosis, treatment, and follow-up.

Correlation between immunotherapy biomarker PD-L1 expression and genetic alteration in patients with non-small cell lung cancer.

Programmed death-ligand 1 (PD-L1) has been widely used in immunotherapy evaluation of patients with non-small cell lung cancer (NSCLC). However, the effect is not particularly ideal, and the association between PD-L1 and genetic alterations requires more exploration. Here, we performed targeted next-generation sequencing and PD-L1 immunohistochemistry (IHC) testing for PD-L1 expression on both tumor cells (TCs) and tumor-infiltrating immune cells (ICs) in 1549 patients. Our studies showed that surgical method of resection was positively correlated with IC+, and a low tumor mutation burden (TMB) was negatively correlated with TC+. Furthermore, we found that EGFR was mutually exclusive with both ALK and STK11. In addition, the features between PD-L1 expression status and genomic alterations were characterized. These results suggest that clinical characteristics and molecular phenotypes are associated with PD-L1 expression signatures, which may provide novel insights for improving the efficiency of immune checkpoint inhibitors (ICIs) in immunotherapy.

Interface engineering of Mn3O4/Co3O4 S-scheme heterojunctions to enhance the photothermal catalytic degradation of toluene.

Transition metal oxides have high photothermal conversion capacity and excellent thermal catalytic activity, and their photothermal catalytic ability can be further improved by reasonably inducing the photoelectric effect of semiconductors. Herein, Mn3O4/Co3O4 composites with S-scheme heterojunctions were fabricated for photothermal catalytic degradation of toluene under ultraviolet-visible (UV-Vis) light irradiation. The distinct hetero-interface of Mn3O4/Co3O4 effectively increases the specific surface area and promotes the formation of oxygen vacancies, thus facilitating the generation of reactive oxygen species and migration of surface lattice oxygen. Theoretical calculations and photoelectrochemical characterization demonstrate the existence of a built-in electric field and energy band bending at the interface of Mn3O4/Co3O4, which optimizes the photogenerated carriers' transfer path and retains a higher redox potential. Under UV-Vis light irradiation, the rapid transfer of electrons between interfaces promotes the generation of more reactive radicals, and the Mn3O4/Co3O4 shows a substantial improvement in the removal efficiency of toluene (74.7%) compared to single metal oxides (53.3% and 47.5%). Moreover, the possible photothermal catalytic reaction pathways of toluene over Mn3O4/Co3O4 were also investigated by in situ DRIFTS. The present work offers valuable guidance toward the design and fabrication of efficient narrow-band semiconductor heterojunction photothermal catalysts and provides deeper insights into the mechanism of photothermal catalytic degradation of toluene.

Chinese expert consensus on the diagnosis and treatment of thymic epithelial tumors.

Thymic epithelial tumors (TETs) are a relatively rare type of thoracic tumor, accounting for less than 1% of all tumors. The incidence of TETs is about 3.93/10000 in China, slightly higher than that of European and American countries. For resectable TETs, complete surgical resection is recommended. Radiotherapy or chemotherapy may be used as postoperative adjuvant treatment. Treatment for advanced, unresectable TETs consist mainly of radiotherapy and chemotherapy, but there is a lack of standard first- and second-line treatment regimens. Recently, targeted therapies and immune checkpoint inhibitors have shown promising outcomes in TETs. Based on the currently available clinical evidences and the opinions of the national experts, the Thymic Oncology Group of Yangtze River Delta Lung Cancer Cooperation Group (East China LUng caNcer Group, ECLUNG; Youth Committee) established this Chinese expert consensus on the clinical diagnosis and treatment of TETs, covering the epidemiology, diagnosis, treatment, prognosis and follow-up of TETs.

Tunning active oxygen species for boosting Hg0 removal and SO2-resistance of Mn-Fe oxides supported on (NH4)2S2O8 doping activated coke.

Active oxygen species (AOS) play an essential role in modulating the activity of activated coke (AC) based samples. In this paper, AC was endowed with abundant AOS by modifying with (NH4)2S2O8 and MnOx-FeOx for Hg0 removal. (NH4)2S2O8 treatment induced abundant micropores and oxygen-containing functional groups, and thus provided more anchoring sites for the dispersion of MnOx-FeOx. The synergy of MnOx-FeOx and interaction between MnOx-FeOx and NAC support contributed to a larger surface area, highly-dispersed active components, stronger reducibility, and more metal ions with high valence of MnFe/NAC. The optimal MnFe/NAC exhibited superior Hg0 removal efficiency above 90% at 120∼180 â„ƒ, as well as excellent performance for simultaneous removal of Hg0 and NO, and 600 ppm SO2 and 8 vol.% H2O addition led to a slight deterioration. XPS and Hg-TPD revealed that mercury adsorbed on MnFe/NAC included phy-Hg, C=O-Hg, COO-Hg, and OL-HgO. Besides, the priority of AOS for Hg0 chemisorption was C=O > COO- > OL, and Hg2+ was also detected in the outlet. Moreover, the SO2-poisoning effect was ascribed to the sulfation of MnOx and the occupation of COO- and C=O, and FeOx incorporation enhanced the SO2-resistance through weakening SO2 adsorption on C=O and COO-. The motivation of O2 mainly contributed to the regeneration of AOS, especially OL. The excellent regeneration performance and stability further affirmed the application potential of MnFe/NAC for Hg0 capture from coal-fired flue gas.

Genomic characterization of thymic epithelial tumors reveals critical genes underlying tumorigenesis and poor prognosis.

Thymic epithelial tumors (TETs) are rare mediastinal tumors whose tumorigenesis mechanism is poorly understood. Characterization of molecular alterations in TETs may contribute to a better understanding of tumorigenesis and prognosis. Hybrid capture-based next-generation sequencing was performed on tumor tissues from 47 TETs (39 thymomas and 8 thymic carcinomas) to detect mutations in 315 tumor-associated genes. In total, 178 nonsynonymous mutations were identified, with a median of 3.79 per tumor in 47 TETs. Higher tumor mutation burden (TMB) level was more common in older TET patients, and significantly associated with the more advanced pathological type, especially in thymic carcinomas (TC) patients. The gene mutation profiles of B1-3, A/AB, and TC patients varied greatly. In the actionable mutations analysis, we found 32 actionable mutations in 24 genes. Among them, NFKBIA and TP53 mutations was the most frequently, which were only identified in TCs. Additionally, TCGA database analysis found that the expression of NFKBIA mRNA in the TCs were significantly higher than thymomas. TET patients with high NFKBIA expression had shorter overall survival compared with patients with low/medium NFKBIA expression, thus providing insights to consider NFKBIA as a potential prognosis biomarker and therapeutic target in TETs.

Quantitative Analysis of TP53-Related Lung Cancer Based on Radiomics.

Background: The role of TP53 mutations in the diagnosis and treatment of lung cancer has attracted increasing attention from experts worldwide. This study aimed to explore the expression of TP53 gene in lung cancer and its correlation with radiomics quantitative features. Methods: A total of 93 cases of lung cancer confirmed by pathology were selected, including 44 cases with TP53 mutations and 49 cases with TP53 wild-type. ITK-SNAP software was used to segment the pulmonary nodules, AK software was used to extract radiomic features, and a model was established to predict the type of TP53 gene mutation in lung cancer lesions. Results: A total of 852 features were extracted, and 10 features remained after feature selection. The accuracy, areas under the curve, specificity, sensitivity, positive predictive value, and negative predictive value of the logistic regression model were 0.80, 0.86, 0.89, 0.74, 0.90, and 0.71, respectively. Conclusion: TP53 gene mutations are correlated with radiomic features in lung cancer, which may have application value for TP53 therapy in the future.

Recent Progress of Carbon Dots for Air Pollutants Detection and Photocatalytic Removal: Synthesis, Modifications, and Applications.

Rapid industrialization has inevitably led to serious air pollution problems, thus it is urgent to develop detection and treatment technologies for qualitative and quantitative analysis and efficient removal of harmful pollutants. Notably, the employment of functional nanomaterials, in sensing and photocatalytic technologies, is promising to achieve efficient in situ detection and removal of gaseous pollutants. Among them, carbon dots (CDs) have shown significant potential due to their superior properties, such as controllable structures, easy surface modification, adjustable energy band, and excellent electron-transfer capacities. Moreover, their environmentally friendly preparation and efficient capture of solar energy provide a green option for sustainably addressing environmental problems. Here, recent advances in the rational design of CDs-based sensors and photocatalysts are highlighted. An overview of their applications in air pollutants detection and photocatalytic removal is presented, especially the diverse sensing and photocatalytic mechanisms of CDs are discussed. Finally, the challenges and perspectives are also provided, emphasizing the importance of synthetic mechanism investigation and rational design of structures.

Chinese expert consensus on the multidisciplinary management of pneumonitis associated with immune checkpoint inhibitor.

Immune checkpoint inhibitors (ICIs) have successfully treated a number of different types of cancer, which is of great significance for cancer treatment. With the widespread use of ICIs in clinical practice, the increasing checkpoint inhibitor pneumonia (CIP) will be a challenge to clinicians. To guide the diagnosis and treatment of CIP, we conducted in-depth discussions based on the latest evidence, forming a consensus among Chinese experts on the multidisciplinary management of CIP.

Comparison of Gefitinib in the treatment of patients with non-small cell lung cancer and clinical effects of Osimertinib and EGFR Gene mutation.

Objectives: To compare the clinical effects of Osimertinib and Gefitinib in the treatment of non-small cell lung (NSCLC) complicated with epidermal growth factor receptor (EGFR) gene mutation. Methods: We retrospectively analyzed the clinical data of 102 patients with advanced NSCLC and EGFR gene mutations treated in the Chest Disease Diagnosis and Treatment Center of our hospital from January 2018 to January 2020. We divided the data based on the administered treatments into Osimertinib and Gefitinib groups. The disease control rate (DCR), progression free survival (PFS) and the incidence of adverse events in both groups were analyzed. Results: In the Osimertinib group, there was one patients with complete response (CR), 38 with partial response (PR), eight with stable disease (SD), and two with progressive disease (PD)/ The overall response rate (ORR) was 79.59% (39/49), and the disease control rate (DCR) was 95.92% (47/49). In the Gefitinib group, we found zero patients with CR, 37 patients with PR, 11 with SD, and five with PD. The ORR in the Gefitinib group was 69.80% (37/53) and DCR was 90.57% (48/53). There was no statistical significance between the two groups, ORR was Χ2=0.927 (P=0.336) and the DCR Χ2=0.221 (P=0.638). The median PFS of and Gefitinib groups was significantly higher in the oxitinib group, compared to the Gefitinib group (18.1 months (95% CI 15.4-20.7) and 10.7 months (95% CI 9.9-11.4), respectively, P<0.001). The incidence of adverse reactions in the Osimertinib group was 12.24% (6/49), which was significantly lower than 28.30% (15/53) in the Gefitinib group (P < 0.05). Conclusions: The clinical effect of oxitinib in the treatment of non-small cell lung cancer complicated with EGFR gene mutation is similar to that of Gefitinib. In patients with advanced NSCLC and EGFR gene mutations, oxitinib treatment is associated with significantly longer PFS and lower adverse reaction rate compared with Gefitinib treatment.

A real-world study in advanced non-small cell lung cancer with de novo brain metastasis.

Brain metastases are the major cause of life-expectancy shortened for patients with lung cancer. The prognostic value of EGFR mutation subtypes and survival benefit of EGFR-tyrosine kinase inhibitors (TKIs) in advanced non-small cell lung cancer (NSCLC) patients with de novo brain metastasis is still not clear. Here, we present a real-world study nation-wide focusing on the prognostic value of genomic and therapeutic factors in overall survival (OS) of those patients. We enrolled a total of 233 patients diagnosed with advanced NSCLC and de novo BM from multi-medical centers across China. The enrolled patients were divided into 4 groups, including EGFR 19del, EGFR L858R, EGFR wild-type, and EGFR unknown groups. The median OS of patients with EGFR mutations and all patients were 29.0 and 25.0 months, respectively. There was significant difference in OS of patients among EGFR 19del (n=76), EGFR L858R (n=94), EGFR wild-type (n=46) and EGFR unknown (n=17) groups (30.5 vs 27.5 vs 16.0 vs 25.0, P=0.025). Patients treated by icotinib showed better OS than gefitinib and erlotinib (31.0 vs 25.5 vs 26.5, P=0.02). There was a difference in OS of patients received the whole-brain radiotherapy (WBRT), stereotactic radiosurgery (SRS), or WBRT+SRS (20.0 vs 31.0 vs 30.0 months, P<0.001), respectively. In multivariate analysis, patients treated with icotinib had superior iPFS benefit than gefitinib and erlotinib (HR=0.86[95%CI (0.74-1.0)], P=0.04). Besides, the histology of non-adenocarcinomas, the number of BM (>3), and extracranial metastases status could have an independent negative impact on the OS of all patients (P<0.001). EGFR mutant NSCLC patients with de novo BM had a better OS than patients with EGFR wild type. Patients treated with icotinib had longer iPFS than gefitinib and erlotinib but not in OS. Non-adenocarcinomas, number of BM (>3) and extracranial metastases were independent negative prognostic factors in iPFS and OS of all patients. Prospective clinical trials are warranted to explore more effective multimodality in this population.

Highly efficient simultaneous removal of HCHO and elemental mercury over Mn-Co oxides promoted Zr-AC samples.

MnxCoy/Zrz-AC prepared by impregnation method was investigated on the simultaneous removal of HCHO and Hg0. The samples were characterized by BET, SEM, XRD, H2 pulse chemisorption, H2-TPR, XPS, Hg-TPD and in-situ DRIFTS. Thereinto, the optimal Mn2/3Co8/Zr10-AC achieved 99.87% HCHO removal efficiency and 82.41% Hg0 removal efficiency at 240 °C, respectively. With increased surface area and pore volume, Zr-AC support facilitated higher dispersion of MnOx-CoOx. Moreover, the co-doping of MnOx-CoOx endowed the sample with more active oxygen species and higher reducibility, which further facilitated the removal of HCHO and Hg0. Chemisorption was proved to predominate in Hg0 removal, and oxidation also worked as Hg2+ was detected in outlet gas. Besides, HCHO predominated in the competition of active oxygen species, especially for lattice oxygen, thus suppressed the Hg0 removal. According to in-situ DRIFTS, HCHO removal proceeded as HCHOads → DOM → formate species → CO2 + H2O, and was boosted by active oxygen species. Furthermore, Mn2/3Co8/Zr10-AC was proved with excellent regeneration performance, indicating its potential in practical application.

Genomic Feature of a Rare Case of Mix Small-Cell and Large-Cell Neuroendocrine Lung Carcinoma: A Case Report.

BACKGROUND: Cases of both of small- (SCLC) and large-cell neuroendocrine lung carcinoma (LCNEC) were rarely reported. Although typical cases are morphologically distinct, the distinction between LCNEC and SCLC is still controversial, with some LCNECs showing close morphologies with SCLC. Here, we reported on a patient who had tumor with a mix of SCLC and LCNEC and uncovered these components' histological and genomic features. CASE PRESENTATION: A 59-year-old man was diagnosed with lung cancer and had resection surgery in our hospital. The H&E and immunohistochemistry staining revealed that the tumor had 30%-35% LCNEC and 65%-70% SCLC cells. The whole-exome sequencing (WES) identified no potentially actionable alteration in the tumor sample but found five alterations all with allele frequency over 90%, including TP53 p.R273H, MYH8 p.Q1814K, SLC17A6 p.W505L, PTPN5 p.M40I, and RB1 p.L267X. The genomic results supported that these two different components shared a similar dominant clonal origin. Furthermore, fluorescence in situ hybridization analysis revealed that the LCNECs have a higher copy number of MET than the SCLC component while without notable difference in the copy number of HER2 and TP53. Chemotherapy with pemetrexed and carboplatin was administrated for two cycles after the surgery. Although the chest CT showed remission in the lung, he was diagnosed with bone metastasis in 1 year later. Then, he received chemotherapy with etoposide and carboplatin but had severe side effect, leading to the discontinuation of the regime. Unfortunately, he returned to the local hospital with supportive care and died shortly after. CONCLUSION: Based on these observations, we proposed that LCNEC and SCLC components in this patient may have a common clonal origin with dual mutations in TP53 and RB1, while the chromosome instability may cause multiple independent conversion that leads to LCNEC or SCLC morphologies.