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Personalized drug screening of patient-derived tumor-like cell clusters based on specimens obtained from percutaneous transthoracic needle biopsy in patients with lung malignancy: a real-world study

BMC Cancer volume 25, Article number: 649 (2025) Cite this article

Abstract

Background

Patient-derived xenografts and organoids were the most common patient-derived tumor models in vitro that were utilized in personalized drug screening, and the establishment rate and duration required to be improved. Patient-derived tumor-like cell clusters (PTCs) could be established within ten days for drug screening, with high establishment rate and accuracy in predicting clinical outcomes. This study aims to explore the accuracy of PTCs based on specimens obtained from percutaneous transthoracic needle biopsy (PTNB) in lung malignancy (LM) patients, and to investigate the predictors for the success of PTC culture.

Materials and methods

This retrospective cohort study included LM patients who underwent image-guided PTNB, and the specimens were used for PTC culture, which was followed by personalized drug screening of chemotherapy and molecular targeted therapy, and the accuracy was validated by previous or further treatments. The predictors of the success of PTC culture were identified by univariable and multivariable analyses.

Results

A total of 68 LM patients were enrolled, consisting of 57, 7, and 4 patients with non-small cell lung cancer, small cell lung cancer, and lung metastases, respectively. Pneumothorax was the predominant adverse event for PTNB, with an incidence rate of 20.6% (14/68). PTC models based on PTNB specimens were established successfully for 56 patients in 3.8 ± 2.3 days, with an 82.4% success rate. Five patients had not received treatments before or after PTC culture. PTC drug screening reveals 88.2% (45/51) overall consistency in predicting clinical outcomes. Necrotic area over half of the tumor (hazard ratio, 0.121; 95% confidence interval, 0.025–0.598; P = 0.010) was identified as the negative predictor for the success of PTC culture.

Conclusions

PTC culture based on PTNB specimens could be established in 82.4% of LM patients, with a high accuracy in predicting clinical outcomes. Excessive necrosis in the tumor may predict the failure of PTC culture. Image-guided PTNB targeting enhanced or fluorodeoxyglucose‌ avid regions on images might contribute to improving the success rate of PTC culture.

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Introduction

Lung malignancy (LM) consists of primary lung cancer and lung metastases, and the former maintains the leading neoplasm of cancer incidence and mortality worldwide [1]. Precise acquisition of tumor samples is critical to pathological diagnoses, genomic testing, and treatment decision-making. Image-guided percutaneous transthoracic needle biopsy (PTNB) is proposed as one of the methods for LM diagnoses, with the advantages of precise lesion targeting, high accuracy of diagnoses, minimal invasiveness, and few adverse events (AEs) [2, 3].

The improvements in molecular targeted therapy and chemotherapy have increased the median overall survival (OS) of primary lung cancer to 13.0 months [4]. Despite all this, the response to anticancer therapies varied extensively owing to the phenotypic and genotypic heterogeneity of LM [5]. Therefore, the development of patient-derived tumor models (PDMs) in vitro and their application in personalized drug screening has become an area of research interest. Patient-derived xenografts (PDXs) are preclinical models generated by transplanting and culturing tumor tissue/cells in animal hosts, which could generalize histologic features and genomic alterations, and become a potent tool for precise oncology [6]. The engraftment rates of lung cancer PDXs were 24.5–89%, and developing them usually takes 2.6-8 months; thereby, limiting their large-scale application [7,8,9,10]. Patient-derived organoids (PDOs) refer to 3D cell clusters cultured from stem cells, and organized into parental organ/tissue-like structures spontaneously, with establishment rates of up to 87.5% in developing lung cancer organoids (LCOs) [11]. Although 83.3% overall consistency in predicting clinical outcomes of chemotherapeutics and tyrosine kinase inhibitors (TKIs) was found, the 4–6 weeks of established duration might limit its applicability of guiding the first-line treatments [12]. Patient-derived tumor-like cell clusters (PTCs) were 3D clusters generated in Matrigel-free conditions, and were self-assembled by primary tumor cells and endogenous stromal cells [13]. A previous study demonstrated that PTCs could allow for drug screening for non-small cell lung cancer (NSCLC) within 10 days, with an 81% success rate in model establishments and 89% overall consistency in predicting clinical outcomes [14].

PDMs can be developed in samples obtained from surgical resection, PTNB, pleural or abdominal fluids, and circulating tumor cells, and the establishment rates were correlated with the number of intratumoral viable cells [12,13,14,15]. When surgical samples were available to develop lung cancer PDXs, the establishment rates were 24.5–50%, while that of 58–87% for developing LCOs [7, 8, 16]. Nevertheless, approximately 75% of lung cancer patients are diagnosed at an advanced stage [1], which leads to the limited development of PDMs due to contraindications to surgery for those patients. Although PDOs or PTCs developed from pleural effusion can maintain molecular characteristics and tumor heterogeneity, malignant pleural effusion occurred in only approximately 40% of NSCLC [4, 14], which cannot become a universal method in developing PDMs for advanced-stage patients. Few studies have utilized PTNB specimens to establish PTC models for LM. Therefore, this study was conducted to explore the accuracy of personalized drug screening of PTCs based on PTNB specimens in LM patients, and to investigate the predictors for the success of PTC culture.

Materials and methods

Patient criteria

This retrospective, single-center, real-world, cohort study was conducted per the Declaration of Helsinki (as revised in 2013), and was approved by the institutional review board. LM patients who underwent PTNB and whose specimens were used for pathological diagnoses and/or oncogenes mutations and PTC culture between November 2021 and February 2024 at our institution were enrolled. Informed consent for PTC culture and personalized drug screening was obtained. Inclusion criteria were: (a) age ≥ 18 years; (b) tumor subtypes of NSCLC, small cell lung cancer (SCLC) or lung metastases; (c) targeted tumor diameter ≥ 1 cm; and (c) Eastern Cooperative Oncology Group (ECOG) performance status of 0–3. Exclusion criteria were: (a) incomplete data; (b) glass-ground opacity nodules; and (c) lost to follow-up.

Tumor subtypes were confirmed and oncogenes mutations were investigated in PTNB. Positron emission tomography (PET) or contrast-enhanced computed tomography (CT) was undertaken to assist the tumor staging via the clinical TNM staging system (eighth edition) [17].

PTNB procedures and management of AEs

The PTNB procedures followed the Society of Interventional Radiology guideline [2], and were performed via a coaxial cannula by several experienced interventional radiologists (S.X., Z.-X.B., Y.-M.L., X.-G.L., with > 5 years of experience in PTNB for LM) under the guidance of CT (CT590; GE Healthcare, USA). The indications of PTNB were to identify the pathological diagnoses and/or oncogenes mutations for the guidance of further treatments in LM patients. The single-gene testing or next-generation sequence was chosen according to the tumor cell proportion of specimens. When PTNB specimens were adequate for pathological diagnoses and/or oncogenes mutations, the redundant specimens were used for PTC culture. After adequate local anesthesia, a 15 or 16 G coaxial introducer needle (Argon Medical Devices, USA) was first introduced into the tumor, and then the stylet was replaced with a 16 or 18 G full-core biopsy needle (BioPince; Argon) through the cannula. The multiple directions of biopsy and at least 3–4 times of throw were performed to obtain adequate specimens, avoiding puncturing the necrotic area implied on CT and/or PET images as much as possible. PTC culture was performed on at least two pieces of specimens. The throw length of biopsy instruments was classified as 1.3, 2.3, and 3.3 cm, respectively, and was selected within the maximum tumor diameter and avoided damaging adjacent structures and potential intra-tumoral vessels. The rapid on-site evaluation was performed to inspect the specimens visually and guarantee the length of specimens utilized for PTC culture should be longer than 50% of the throw length of biopsy instruments. The specimens were preserved in Tissue Saver and transported to undergo PTC culture as soon as possible. Finally, a repeat CT scan was performed to detect the potential AEs. and.

The AEs were evaluated per the National Cancer Institute Common Terminology Criteria for Adverse Events, version 5.0 [18]. Chest tube placement was performed for severe pneumothorax or hemothorax and was removed when these AEs resolved. Symptomatic treatments were administered for grade-2 AEs or below, such as analgesia, hemostasis, etc.

Protocols of PTC culture

PTNB specimens were conditioned in ice-cold PBS with 10 mM HEPES and 100 U/mL penicillin-streptomycin (Thermo Fisher Scientific), with necrotic and adipose tissues being removed as much as possible. Specimens were minced into small pieces and digested in 5 ml PBS/EDTA 1 mM containing collagenase I (Thermo Fisher Scientific) 200 U/mL for one hour. Dissociated cells were selected and collected by 40 μm filters. Then, the centrifugation (300 × g, 4 °C) was continued for 10 min, followed by the cell pellets being re-suspended in PTC growth medium and seeded at the concentration of 105 cells/cm2. The components of PTC growth medium were described previously [14]. The obtained cells were cultured in an incubator at 37 °C, 5% CO2, and the PTC growth medium was refreshed every 2–3 days. Cell culture plates were handled with air plasma, and coated with CYTOP solution (Asahi-glass, CTL 809 M). Then, a 96-well plate (Corning, CLS9102-50EA) was handled with air plasma for two minutes, and 20 µL 1% CYTOP solution was added to cover the bottom in each well, which was removed after a 20-minute incubation at room temperature. The 96-well plates were placed in a fume hood until all the solvents of CYTOP solution were evaporated. PTCs were collected by centrifugation (300 × g, 4 °C) for 10 min. PTNB specimens and PTCs were washed with cold PBS, and fixed in PBS containing 4% paraformaldehyde overnight. The pellets were paraffin-embedded, and 5-mm-thick paraffin sections were generated. The protocols of histology, immunohistochemistry, IF staining, DNA/RNA extraction and sequencing, genetic testing of PTCs and parental specimens were performed as described previously [13, 14]. According to the previous results, no exceeding 20 regimens of drugs could be screened when the number of clusters was within 1000. Therefore, the failure of PTC culture was defined when no typical cancer cell clone was formed or the amounts of clusters were inadequate to perform only one regimen of drug screening.

PTC drug screening

PTCs ≥ 40 μm were collected (40-mm filters, BD Falcon), centrifuged (300 × g), washed with PBS, and re-suspended with the LM growth medium. Then, 100 mL of the medium containing 30–50 PTCs was seeded into a Teflon-modified chip (GX-01, GeneX Health). Next, 50 mL of the LM PTC growth medium containing the drug was added to the chip, which was incubated at 37 °C and 5% CO2. PTC cell viability was investigated by several experienced laboratory technicians who were uninformed about the treatments and outcomes of LM patients [13, 14]. The drugs tested in PTC models consist of TKIs and single or dual chemotherapeutics, and the concentrations and exposure time were described previously [13, 14].

Further treatments and validation of PTC drug screening

For patients with targetable mutations on oncogene screening, the TKIs were administered as the first-line treatment, with gefitinib (250 mg qd), icotinib (125 mg tid), afatinib (40 mg qd) or osimertinib (80 mg qd) administered for EGFR mutations, crizotinib (250 mg bid) or alectinib (600 mg bid) administered for ALK mutation, and savolitinib (600 mg qd) administered for MET-14 mutation. Systemic chemotherapy was administered as the first-line treatment for SCLC or oncogenes-wild NSCLC, with pemetrexed or paclitaxel plus platinum administered for adenocarcinoma, gemcitabine or paclitaxel plus platinum administered for squamous cell carcinoma (SCC), and etoposide plus platinum administered for SCLC. Bronchial artery infusion chemotherapy (BAI) was considered for LM patients who were intolerant to systemic chemotherapy, which was evaluated by the multidisciplinary treatment team, with identical protocols of drug selection as systemic chemotherapy. The BAI procedures for lung cancer were described previously [19,20,21]. It was up to the patient to decide upon standard therapy or based on the results of PTC drug screening for patients who showed significant differences between PTC drug screening and current guidelines.

CT scans were performed every 2 to 4 months, which established treatment response and was classified as complete response (CR), partial response (PR), stable disease, or progressive disease (PD) according to Response Evaluation Criteria in Solid Tumors version 1.1 [22]. Objective response rate (ORR) was the rate sum of CR and PR. 1–2 measurable target lesions were evaluated, including the primary lesion > 10 mm or lymph nodes short axis ≥ 15 mm. The non-measurable lesions were not considered for the evaluation despite identical responses as target lesions were shown [13, 14]. The follow-up period was at least six months.

Previous studies described drug effects (criteria), cell viability cutoff, and drug efficacy concentration (\(\:{E}_{C}\) value), which determined the cancer cell killing efficiency of PTC drug screening and was calculated as 1- [remnant cell viability after drug screening], and was classified as strong resistance (0%), resistance (1–10%), stability (11–30%), effective killing (31–70%), and strong killing (71–100%) [13, 14].

The accuracy of PTC drug screening was validated by the consistency between the cancer cell killing efficiency of PTC and the optimal response of the adopted drug regimens within six months of previous or further treatments.

Statistical analyses

Categoric variables are described as frequencies and percentages, and continuous variables are described as mean ± standard deviation (SD). SPSS 25.0 (IBM, USA) was used for statistical analyses. Demographic characteristics, AEs, pathological diagnosis, genomic information, treatment history, and details of PTC drug screening were evaluated. There were 11 potential predictors of the success of PTC culture that were investigated by univariable and multivariable logistic regression analyses. Variables with P-valve < 0.05 in the univariable analyses were entered as candidate variables into the multivariable analyses, and the entered variables were confirmed as predictors when they showed statistical significance, with a P-value < 0.05 being considered as statistical significance.

Results

Demographic characteristics

A total of 68 LM patients of one ethnicity were enrolled (42 males, 26 females; 70.0 years [SD ± 12.5]; Fig. 1); of these, 56 patients (82.4%) have established the PTC models successfully, including 45, 7, and 4 patients with the subtypes of NSCLC, SCLC, and adenoid cystic carcinoma (ACC) lung metastases, respectively. The timeline of PTC culture and drug screening is presented in Fig. 2. Detailed demographic characteristics are shown in Table 1. 21 NSCLC patients (46.7%, 21/45) harbored oncogenes mutations, and EGFR was the predominant mutation, with an incidence of 57.1% (12/21). Details of the oncogenes mutations in NSCLC according to PTC models PTNB specimens are presented in Fig. 3, which was identical to the genotypes of PTNB specimens (100%).

Fig. 1
figure 1

Patient selection flowchart. PTNB = Percutaneous transthoracic needle biopsy. PTC = Patient-derived tumor-like cell clusters. SCLC = Small cell lung cancer. NSCLC = Non-small cell lung cancer

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Fig. 2
figure 2

An overview of the timeline of personalized PTC drug screening based on PTNB specimens. PTC = Patient-derived tumor-like cell clusters. PTNB = Percutaneous transthoracic needle biopsy

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Table 1 Demographic characteristics of LM patients who underwent PTNB and received PTC culture
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Fig. 3
figure 3

Scale maps of the oncogenes mutations in NSCLC according to the PTC models. NSCLC = Non-small cell lung cancer. PTNB = Percutaneous transthoracic needle biopsy. PTC = Patient-derived tumor-like cell clusters

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AEs

Detailed AEs are shown in Table 2. The overall incidence rate of AEs in LM patients who underwent PTNB was 26.5% (18/68). Pneumothorax was the predominant AE, with an incidence rate of 20.6% (14/68). Chest tube placement was performed for six patients (8.8%) with moderate or severe pneumothorax, and was maintained for 2.0 ± 1.1 days. No one has experienced severe AEs.

Table 2 Details of AEs in LM patients who underwent PTNB
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PTC culture and drug screening

Details of PTC culture and drug screening are presented in Table 3. PTC models were successfully established in 3.8 ± 2.3 days for 56 LM patients, and it takes an additional one week for drug screening for all patients, with 9.3 ± 3.7 regimens being capable of screening according to the amounts of clusters. PTC models preserve the histological features of parental tissues obtained from PTNB in all subtypes (Figs. 4 and 5). The drug-response profile of PTC drug screening for chemotherapy or molecular targeted therapy is shown in Fig. 6. The maximum cancer cell killing efficiency of drug regimens was 42.7 ± 16.9%.

Table 3 Details of PTC culture and drug screening
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Fig. 4
figure 4

The H&E stain and representative PTC phenotypes of PTNB specimens in NSCLC patients. a, b. A 76-year-old male patient had a mass in the upper lobe of the right lung and enlarged hilar lymph nodes, with the tumor subtype of adenocarcinoma. CT-guided PTNB was performed to obtain specimens for PTC culture. c. The H&E stain showed the tumor cells had a polygonal morphology. The predominant growth pattern of the tumor was solid-type and lacked other recognizable patterns. d. PTC culture showed the cell clusters have diameters ranging from 40–90 micrometers, which are varied in size and exhibit irregular shapes. e, f. An 82-year-old male patient had a mass in the lower lobe of the right lung and enlarged mediastinal lymph nodes, with the tumor subtype of squamous cell carcinoma. CT-guided PTNB was performed to obtain specimens for PTC culture. g. The H&E stain showed the tumor was made up of large, hyperchromatic, and pleomorphic squamous cells arranged in nests, and presented with keratinization and intercellular bridge. h. PTC culture showed the diameters of cell clusters range from 40 to 100 micrometers, and the masses are regularly shaped with smooth boundaries, being surrounded by a large number of scattered cells. PTC = Patient-derived tumor-like cell clusters. PTNB = Percutaneous transthoracic needle biopsy. NSCLC = Non-small cell lung cancer. CT = Computed tomography

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Fig. 5
figure 5

The H&E stain and representative PTC phenotypes of PTNB specimens in SCLC and ACC lung metastases patients. a, b. A 49-year-old male patient had a giant mass in the upper lobe of the left lung and enlarged mediastinal lymph nodes, with the tumor subtype of SCLC. CT-guided PTNB was performed to obtain specimens for PTC culture. c. Sheets of small round to fusiform cells were observed in the H&E stain, with scant cytoplasm, hyperchromatic nuclei, inconspicuous nucleoli, and salt and pepper-like granular nuclear chromatin. d. PTC culture showed the clusters’ sizes range from 40 to 120 micrometers, and sporadically distributed. e, f. A 53-year-old female patient had multiple pulmonary metastases, with the tumor subtype of ACC. CT-guided PTNB was performed for the maximum lesions in the lower lobe of the right lung, to obtain specimens for PTC culture. g. The H&E stain showed the tumor consisted of ductal cells and myoepithelial cells. The tumor cells were in a cribriform growth pattern, and the microcysts contained an accumulation of blue or pink-colored material. h. PTC culture showed the cells constitute relatively large clusters, with a maximum diameter of up to 400 micrometers. The cell clusters are tightly packed, and vacuole-like cavities can be observed in some areas, which may contain mucous-like substances. PTC = Patient-derived tumor-like cell clusters. PTNB = Percutaneous transthoracic needle biopsy. SCLC = Small cell lung cancer. ACC = Adenoid cystic carcinoma. CT = Computed tomography

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Fig. 6
figure 6

The drug-response profile of PTC drug screening for chemotherapy or molecular targeted therapy in LM patients. PTC = Patient-derived tumor-like cell clusters. LM = Lung malignancy

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Further treatments and validation

There were 16, 3, and 29 patients who received TKIs, systemic chemotherapy, and BAI, respectively. Five patients had not received treatments before or after PTC drug screening. One adenocarcinoma patient had the tumor stage of I B and harbored the mutation of MET-14 skipping, with savolitinib being administered and surgery or radiotherapy not being performed owing to the comorbidity of coronary heart disease and severe emphysema. Three patients have not received further treatments but received treatments previously, with the information being used for validation. There were 11 patients (19.6%, 11/56) who presented with differences between the optimal drug regimen of PTC drug screening and current guidelines; of these, three SCLC or SCC patients showed better effectiveness of TKIs than chemotherapy, one SCLC patient showed better effectiveness of gemcitabine than etoposide in platinum-based chemotherapy, four oncogenes-mutated lung adenocarcinoma patients showed better effectiveness of chemotherapy than TKIs, one oncogenes-wild lung adenocarcinoma patient showed better effectiveness of TKIs than chemotherapy, and two ACC lung metastases patients showed prominent effectiveness of chemotherapy. Four patients received the optimal drug regimen shown in PTC drug screening, and the accuracy was further validated by the response. Six patients experienced PD within six months, but the adopted drug regimens were shown to be effective according to PTC drug screening. In summary, PTC drug screening reveals 88.2% (45/51) overall consistency in predicting clinical outcomes.

Predictor of the success of PTC culture

The results of univariable and multivariable logistic regression analyses for the success of PTC culture are presented in Table 4. The univariable analyses revealed that emphysema (hazard ratio [HR], 0.150; 95% confidence interval [CI], 0.030–0.749; P = 0.021), and necrotic area over half of the tumor (HR, 0.077; 95% CI, 0.017–0.352; P = 0.001) were potential predictors. Subsequently, multivariable logistic regression analyses revealed that necrotic area over half of the tumor (HR, 0.121; 95% CI, 0.025–0.598; P = 0.010) was the negative predictor for the success of PTC culture.

Table 4 Univariable analyses and multivariable logistic regression analyses for the success of PTC culture in LM patients who underwent PTNB
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Discussion

PDMs in vitro have been applied as tumor avatars to screen anticancer drugs preclinically and have shown robust potential in guiding the treatments. Few studies have reported a satisfactory establishment rate of PDMs based on PTNB specimens in lung cancer. This real-world study found an 82.4% establishment rate of PTC models based on PTNB specimens in LM patients, which indicated the PTNB specimens were not inferior to surgical samples or pleural effusion in establishing PDMs. Four patients who presented with differences between current guidelines and PTC drug screening followed the optimal regimens of the latter, and the accuracy was validated. Fast model establishments were achieved and an 88.2% overall consistency in predicting clinical outcomes was revealed for PTC, which indicated the great potential of guiding first-line treatments. This study also demonstrated that excessive intra-tumoral necrosis may predict the failure of PTC culture, which might be attributed to the limited number of viable tumor cells, and implied that drug screening based on pleural effusion or other metastatic sites should be considered as a supplement to this condition. Moreover, this study has performed PTNB targeting to enhanced or FDG avid regions on CT or PET images as much as possible, and it contributed to a satisfactory success rate of PTC culture, which was significantly higher than that in the previous study and was not inferior to that based on surgical samples [13, 14].

Systemic chemotherapy provides an ORR of 8–60% and 20–40% for SCLC and advanced NSCLC, respectively [23, 24]. Although the ORR of third-generation TKIs reached as high as 80%, acquired resistance still develops in 9-18.9 months for EGFR-mutated advanced NSCLC [25]. Moreover, ACC seems to be insensitive to systemic chemotherapy, with an ORR of less than 33% [26]. The heterogeneity of lung cancer involves more than the different subtypes, it also exists among cells in the tumor tissue, even with identical subtypes, which causes heterogeneous drug response [5].

PDXs are developed in immunodeficient mice, and could maintain the inherent histologic or genetic characteristics and DNA methylation pattern of the parental tumor, which could mimic the response of anticancer drugs [6]. Hao et al. [27] found that lung cancer PDXs could retain 93% of mutations of the parental tumors. Several studies indicated that PDXs of NSCLC harboring EGFR exon 19 deletion or exon 21 p.L858R mutations showed response to TKIs, while that of EGFR exon 19 deletion and T790M mutations showed resistance to first-generation TKIs, consistent with clinical observations [28, 29]. A similar response profile was also observed in the PDXs of NSCLC harboring ALK mutation [30]. However, some drawbacks of PDXs were observed: (a) the establishment rate was limited, with 20–33%, 36–66%, and 67–83% for adenocarcinoma, SCC, and SCLC, respectively; (b) the developing process was excessively time consuming; and (c) the tumor microenvironments might change gradually with the human stromal cells being replaced by murine stromal cells [7, 31]. PDO models omit animal hosts or cell differentiation, and have higher establishment rates and shorter establishment duration when compared with PDX [11]. The efficacy of PDO drug screening was justified according to the morphological changes and reduction of tumor volume or cell viability [32]. LCOs showed an 83.3% overall consistency in predicting clinical outcomes of chemotherapeutics and TKIs in 4–6 weeks, with 76–100% and 43–46% of establishment rates for adenocarcinoma and SCC, respectively [12, 33]. Nevertheless, the most common matrix environment for LCO culture was Matrigel, and it contains over 1800 proteins, which might suppress differentiation and influence tumor growth [34]. PTCs were cultured in Matrigel-free conditions, and contained CK8/18 + epithelial cells and stromal cells, such as macrophages and fibroblast cells, which was indispensable for PTC assembly and drug screening [13]. PTCs might be a robust tool to guide first-line treatments, with 72.8–81% establishment rates, less than 2–3 weeks of cultural duration, and 89–93% overall consistency in predicting clinical outcomes of chemotherapeutics or molecular targeted therapy [13, 14]. Moreover, PTCs could maintain the phenotypes and genotypes of parent tissues [13, 14]. Meanwhile, the accuracy of predicting the outcomes of programmed cell death protein-1 (PD-1) blockade for NSCLC was also indicated in PTC models via combining assessments of cell viability and interferon-γ [14].

PTNB specimens have not only become the cornerstone of pathological diagnoses and genomic testing, but have also been attempted as the mainstay sampling sources for developing PDM in vitro in advanced-stage lung cancer, with establishment rates of 40–89%, 28–83%, and 52% for PDXs, PDOs, and PTCs, respectively [10, 14, 35, 36]. Failure of PDM establishments falls into inadequate tumor tissues or viable tumor cells. Tumor fraction was the proportion of tumor nuclei over total nuclei within a specimen, and PTNB specimen contains a median tumor fraction of approximately 30–60% [37, 38]. It was estimated that a 1-mm3 tumor tissue contains approximately 105 cells in full-length cylindrical cores [39]. The biopsy instruments used in this study provided throw lengths of 1.3, 2.3, and 3.3 cm, respectively, which did not always correspond to the actual lengths of the specimens [38]. The maximum tumor cells per idealized full cylindrical core of 16- and 18-G were 1,007,725–2,015,450 and 496,388–992,776, respectively [38]. Meanwhile, no significant difference in tumor cellularity in biopsies has been found between the central and peripheral regions of tumors [40]. However, some tumors with multiple treatments previously or a tendency of necrosis might be hypocellular, and multiple cores should be performed to obtain adequate viable tumor tissues [38]. It should be noticed that tumor size, tumor cellularity, and tumor fraction have a complicated correlation. Increasing the tumor sample does not equate to more viable tumor cells, and it might decrease tumor fraction if more non-tumorous components were contained, such as stroma. Therefore, limiting biopsy to potential regions of viable tumors seems to obtain viable tumor cell-rich specimens, which might decrease the possibility of failed establishments of PDMs.

Some limitations of this study should be acknowledged. First, patient selection bias might exist owing to the retrospective study design from a single center. Second, BAI was performed for some part of patients who were intolerant to systemic chemotherapy, and it was not recommended by current guidelines despite the effectiveness that has been indicated in previous studies [19,20,21]. Third, this study lacks the precise evaluation of tumor cell amounts in PTNB specimens, which is due to the actual lengths of specimens always incompletely corresponding with the lengths of biopsy throw. Fourth, the drug screening of anti-angiogenesis therapy or PD-1 blockade was absent in this study, despite the outcomes prediction of the latter being reported to be achieved in NSCLC PTCs previously [14]. Finally, a more sensitive radiological analysis over conventional CT or PET would be useful to detect the viable tumor cell-rich regions, such as radiomics, which were warranted to be investigated in further study.

Conclusions

In conclusion, PTC culture based on PTNB specimens could be established in 82.4% of LM patients, with a high accuracy in predicting clinical outcomes. Excessive necrosis in the tumor may predict the failure of PTC culture. Image-guided PTNB targeting enhanced or fluorodeoxyglucose‌ avid regions on images might contribute to improving the success rate of PTC culture.

Data availability

The datasets used and/or analyzed in the current study are available from the corresponding author on reasonable request.

Abbreviations

AE:

Adverse event

BAI:

Bronchial artery infusion chemotherapy

CI:

Confidence interval

CR:

Complete response

CT:

Computed tomography

ECOG:

Eastern Cooperative Oncology Group

HR:

Hazard ratio

ICI:

Immune checkpoint inhibitor

LCO:

Lung cancer organoid

LM:

Lung malignancy

NSCLC:

Non-small cell lung cancer

ORR:

Objective response rate

OS:

Overall survival

PD:

Progressive disease

PD-1:

Programmed cell death protein-1

PDO:

Patient-derived organoid

PDM:

Patient-derived tumor model

PDX:

Patient-derived xenograft

PET:

Positron emission tomography

PR:

Partial response

PS:

Performance status

PTC:

Patient-derived tumor-like cell cluster

PTNB:

Percutaneous transthoracic needle biopsy

SCLC:

Small cell lung cancer

SCC:

Squamous cell carcinoma

TKI:

Tyrosine kinase inhibitor

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Acknowledgements

None.

Funding

This work was funded by the Capital’s Funds for Health Improvement and Research (CFH-2022-2-4053). Funding source had no involvements in the financial support for the conduct of the research and preparation of the article.

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Author notes

  1. Sheng Xu and Shen-Yi Yin contributed equally to this work.

Authors and Affiliations

  1. Department of Minimally Invasive Tumor Therapies Center, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, China

    Sheng Xu, Zhi-Xin Bie, Yuan-Ming Li & Xiao-Guang Li

  2. State Key Laboratory of Natural and Biomimetic Drugs, Department of Biomedical Engineering, College of Future Technology, Peking University, Beijing, 100871, China

    Shen-Yi Yin

  3. Department of Neurology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, China

    Jing Qi

  4. Department of Pathology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, China

    Yi-Dan Ma & Zheng Wang

  5. State Key Laboratory of Natural and Biomimetic Drugs, Department of Biomedical Engineering, College of Future Technology, Peking University, No.5 Yiheyuan Road, Haidian District, Beijing, 100871, China

    Jianzhong Jeff Xi

  6. Department of Minimally Invasive Tumor Therapies Center, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No.1 Da Hua Road, Dong Dan, Beijing, 100730, China

    Xiao-Guang Li

  7. Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, 9 Dongdansantiao Street, Dongcheng District, Beijing, 100730, China

    Xiao-Guang Li

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  1. Sheng Xu
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Contributions

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Sheng Xu, Shen-Yi Yin, Zhi-Xin Bie, Yuan-Ming Li, Jing Qi, Yi-Dan Ma, Zheng Wang, Jianzhong Jeff Xi, and Xiao-Guang Li. The first draft of the manuscript was written by Sheng Xu and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding authors

Correspondence to Jianzhong Jeff Xi or Xiao-Guang Li.

Ethics declarations

Ethics approval and consent to participate

This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the institutional ethics review board of Beijing Hospital, National Center of Gerontology (2021BJYYEC-272-01, approved on 11/03/2021). Informed consent for PTC culture and personalized drug screening was obtained.

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The authors declare no competing interests.

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Xu, S., Yin, SY., Bie, ZX. et al. Personalized drug screening of patient-derived tumor-like cell clusters based on specimens obtained from percutaneous transthoracic needle biopsy in patients with lung malignancy: a real-world study. BMC Cancer 25, 649 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12885-025-14069-0

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Keywords

BMC Cancer

ISSN: 1471-2407

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