A grading system of lung adenocarcinomas based on histologic pattern is predictive of disease recurrence in stage I tumors

Collagen type I induces EGFR-TKI resistance in EGFR-mutated cancer cells by mTOR activation through Akt-independent pathway

Primary resistance to epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) is a serious problem in lung adenocarcinoma patients harboring EGFR mutations. The aim of this study was to examine whether and how collagen type I (Col I), the most abundantly deposited matrix in tumor stroma, affects EGFR-TKI sensitivity in EGFR-mutant cells. We evaluated the EGFR-TKI sensitivity of EGFR-mutated cancer cells cultured with Col I. Changes in the activation of downstream signaling molecules of EGFR were analyzed. We also examined the association between the Col I expression in tumor stroma in surgical specimens and EGFR-TKI response of postoperative recurrence patients with EGFR mutations. Compared to cancer cells without Col I, the survival rate of cancer cells cultured with Col I was significantly higher after EGFR-TKI treatment. In cancer cells cultured with and without Col I, EGFR-TKI suppressed the levels of phosphorylated (p-)EGFR, p-ERK1/2, and p-Akt. When compared to cancer cells without Col I, expression of p-P70S6K, a hallmark of mTOR activation, was dramatically upregulated in cancer cells with Col I. This activation was maintained even after EGFR-TKI treatment. Simultaneous treatment with EGFR-TKI and mTOR inhibitor abrogated Col I-induced resistance to EGFR-TKI. Patients with Col I-rich stroma had a significantly shorter progression-free survival time after EGFR-TKI therapy (238 days vs 404 days; P < .05). Collagen type I induces mTOR activation through an Akt-independent pathway, which results in EGFR-TKI resistance. Combination therapy using EGFR-TKI and mTOR inhibitor could be a possible strategy to combat this resistance.

Predictors of recurrence and survival of pathological T1N0M0 invasive adenocarcinoma following lobectomy

BACKGROUND

This retrospective research was designed to investigate the relationship between pT1N0M0 invasive adenocarcinoma (IADC) harboring solid (SOL) and/or micropapillary (MIP) components and its prognosis following lobectomy.

METHODS

Clinical data of pT1N0M0 IADC patients were retrospectively collected from Shanghai Chest Hospital. Survival curves were plotted by Kaplan-Meier methods. Multivariable cox regressions were conducted to discover the independent risk factors of recurrence-free survival (RFS) and overall survival (OS), through which nomograms were performed to visualize the risk of recurrences and outcomes in personalized information.

RESULTS

Totally, 1965 patients were enrolled, including 248 harboring SOL/MIP and 1717 not. IADC demonstrated worse 5-year RFS (81.9 vs. 92.2%, p < 0.001) and OS (85.7 vs. 94.4%, p < 0.001) when harboring SOL and/or MIP components. And this status became an independent factor associated with poorer RFS (HR 2.445, 95% CI 1.565-3.821, p < 0.001) and OS (HR 2.139, 95% CI 1.180-3.878, p = 0.012) instead of novel classification of IADC predominant patterns. No difference existed between SOL/MIP predominant and minor patterns. In addition, age > 60, smoking, post-chemotherapy and T1b were all indicating poorer RFS and smoking was also related with worse OS. The c-indexes of nomograms were 0.723 for RFS (95% CI, 0.662-0.784) and 0.703 for OS (95% CI, 0.629-0.777) respectively.

CONCLUSIONS

Once the pT1N0M0 IADC harboring SOL/MIP, it strongly indicated the worse clinical recurrence and survival outcome, no matter whether the SOL and/or MIP was predominant. Smoking was correlated with worse prognosis for those patients. Age > 60 and stage T1b also indicated poorer RFS. Whether post-chemotherapy was harmful to pT1N0M0 IADC patients needed further research.

Lymphovascular Invasion Increases the Risk of Nodal and Distant Recurrence in Node-Negative Stage I-IIA Non-Small-Cell Lung Cancer

OBJECTIVES

Despite complete surgical resection, 30-40% of patients with stage I-IIA non-small-cell lung cancer (NSCLC) have recurrences. We aimed to elucidate the effect of lymphovascular invasion (LVI) on the prognosis and patterns of recurrence in patients with pathologically confirmed T1-2N0 NSCLC.

METHODS

We evaluated 381 patients who underwent complete resection and were diagnosed with pathologic T1-2N0 NSCLC between March 2000 and January 2012. Local recurrence, nodal recurrence, and distant metastasis were defined and analyzed.

RESULTS

LVI was present in 72 patients (18.9%). The 5-year disease-free survival (DFS) for all patients was 69.9%. Patients with LVI showed a significant decrease in 5-year DFS (47.3 vs. 74.4%, p < 0.001). LVI was a significant prognostic predictor in multivariate analysis (p = 0.003). The patients with LVI showed a significantly increased 5-year cumulative incidence of nodal recurrence (22.5 vs. 8.7%, p < 0.001) and distant metastasis (30.4 vs. 14.9%, p = 0.004). However, no difference was shown between the two groups in the 5-year cumulative incidence of local recurrence (p = 0.416).

CONCLUSIONS

LVI is a negative prognostic factor in patients with stage I-IIA NSCLC. The presence of LVI significantly increases the risk of nodal and distant recurrence.

Cell of origin markers identify different prognostic subgroups of lung adenocarcinoma

Strong prognostic markers able to stratify lung adenocarcinoma (ADC) patients are lacking. We evaluated whether a six-immunohistochemical markers panel (TTF1, SP-A, Napsin A, MUC5AC, CDX2 and CK5), defining the putative neoplastic "cell of origin," allows to identify prognostic subgroups among lung ADC. We screened a large cohort of ADC specimens (2003-2013) from Torino Institutional Repository identifying: (i) marker positivity by immunohistochemistry, (ii) main morphological appearance by light microscopy, (iii) presence of "hotspot" mutations of candidate genes by Sequenom technology. To evaluate possible predictors of survival and time to recurrence, uni- and multivariable-adjusted comparisons were performed. We identified 4 different subgroups: "alveolar," "bronchiolar," "mixed" and "null type." Alveolar-differentiated ADC were more common in young (P=.065), female (P=.083) patients, frequently harboring EGFR-mutated (P=.003) tumors with acinar pattern (P<.001). Bronchiolar-differentiated ADC were more associated with mucinous and solid pattern (P<.001), higher degree of vascular invasion (P=.01) and KRAS gene mutations (P=.07). Bronchiolar, mixed, and null types were independent negative predictors for overall survival, and the latter two had a shorter time to recurrence. This "Cell of Origin" classifier is more predictable than morphology and genetics and is an independent predictor of survival on a multivariate analysis.

Prognostic prediction of clinical stage IA lung cancer presenting as a pure solid nodule

Background

Clinical stage IA lung cancer presenting as a ground glass opacity (GGO) on imaging is known to be associated with a good prognosis. Conversely, the prognosis of lung cancer presenting as a pure solid nodule is less favorable. The purpose of this study was to identify the predictive factors affecting prognosis in pure solid nodule lung cancer.

Methods

A total of 328 consecutive patients undergoing curative resection of clinical stage IA pure solid nodule lung cancer were reviewed retrospectively. Recurrence, survival and risk factors for nodal upstaging were analyzed.

Results

Of the 328 patients, 277 patients (84.6%) underwent lobectomy (or greater) and 51 patients (15.6%) underwent sublobar resection. Mediastinal lymph node dissection or sampling was performed in 278 patients (84.8%). The 5-year recurrence-free survival rate was 70.0% and the disease-specific survival rate was 86.5%. Intraoperative mediastinal lymph node dissection was the only significant related factor for recurrence and cancer-related death in a multivariate analysis [hazard ratio (HR) =0.485, P=0.020; HR =0.342, P=0.014]. A total of 217 patients underwent lobectomy with mediastinal lymph node dissection and nodal upstaging occurred in 36 patients (16.6%). There were no significant predictive factors for nodal upstaging in a multivariate analysis. Visceral pleural invasion, lymphovascular invasion, and small cell carcinoma histology were the only identified risk factors for nodal upstaging (HR =3.858, P=0.006; HR =8.792, P<0.001; HR =45.908, P=0.017).

Conclusions

There were no definite factors predictive of prognosis in clinical stage IA pure solid nodule lung cancer. Only accurate pathologic staging and adequate intraoperative lymph node dissection were shown to be related to prognosis.

Progress in the Management of Early-Stage Non-Small Cell Lung Cancer in 2017

The landscape of care for early-stage non-small cell lung cancer continues to evolve. While some of the developments do not seem as dramatic as what has occurred in advanced disease in recent years, there is a continuous improvement in our ability to diagnose disease earlier and more accurately. We have an increased understanding of the diversity of early-stage disease and how to better tailor treatments to make them more tolerable without impacting efficacy. The International Association for the Study of Lung Cancer and the Journal of Thoracic Oncology publish this annual update to help readers keep pace with these important developments. Experts in the care of early-stage lung cancer patients have provided focused updates across multiple areas including screening, pathology, staging, surgical techniques and novel technologies, adjuvant therapy, radiotherapy, surveillance, disparities, and quality of life. The source for information includes large academic meetings, the published literature, or novel unpublished data from other international oncology assemblies.

Classification and Pathology of Lung Cancer

Advancement in the understanding of lung tumor biology enables continued refinement of lung cancer classification, reflected in the recently introduced 2015 World Health Organization classification of lung cancer. In small biopsy or cytology specimens, special emphasis is placed on separating adenocarcinomas from the other lung cancers to effectively select tumors for targeted molecular testing. In resection specimens, adenocarcinomas are further classified based on architectural pattern to delineate tissue types of prognostic significance. Neuroendocrine tumors are divided into typical carcinoid, atypical carcinoid, small cell carcinoma, and large cell neuroendocrine carcinoma based on a combination of features, especially tumor cell proliferation rate.

Is MPP a good prognostic factor in stage III lung adenocarcinoma with EGFR exon 19 mutation?

Epidermal growth factor receptor (EGFR) is a transmembrane glycoprotein encoded by a gene located in the short arm of chromosome 7. This study aimed to investigate the clinicopathologic characteristics of classic EGFR exon mutation in Chinese patients with TMN stage III lung adenocarcinoma who received radical surgery. A total of 1,801 lung adenocarcinomas were analyzed for mutations in EGFR; 35% exhibited mutation of classic EGFR exons. Clinical and pathologic characteristics of patients with EGFR exon 19 mutation were compared with those who harbored EGFR exon 21 mutation. Patients with EGFR exon 19 mutation had a higher overall survival (OS, p=0.023) than those harboring EGFR exon 21 mutation. Our results demonstrated that patients with a micropapillary pattern (MPP) pathologic type in EGFR exon 19 mutation had a higher OS (p=0.022), and patients with exon 19 mutation were more sensitive to EGFR–tyrosine kinase inhibitors (p=0.032). The results of the current study can be used in decision-making regarding the treatment of patients with classic EGFR exon mutations.

A two-stage approach of gene network analysis for high-dimensional heterogeneous data

Gaussian graphical models have been widely used to construct gene regulatory networks from gene expression data. Most existing methods for Gaussian graphical models are designed to model homogeneous data, assuming a single Gaussian distribution. In practice, however, data may consist of gene expression studies with unknown confounding factors, such as study cohort, microarray platforms, experimental batches, which produce heterogeneous data, and hence lead to false positive edges or low detection power in resulting network, due to those unknown factors. To overcome this problem and improve the performance in constructing gene networks, we propose a two-stage approach to construct a gene network from heterogeneous data. The first stage is to perform a clustering analysis in order to assign samples to a few clusters where the samples in each cluster are approximately homogeneous, and the second stage is to conduct an integrative analysis of networks from each cluster. In particular, we first apply a model-based clustering method using the singular value decomposition for high-dimensional data, and then integrate the networks from each cluster using the integrative $\psi$-learning method. The proposed method is based on an equivalent measure of partial correlation coefficients in Gaussian graphical models, which is computed with a reduced conditional set and thus it is useful for high-dimensional data. We compare the proposed two-stage learning approach with some existing methods in various simulation settings, and demonstrate the robustness of the proposed method. Finally, it is applied to integrate multiple gene expression studies of lung adenocarcinoma to identify potential therapeutic targets and treatment biomarkers.

Prognostic Impact of the Findings on Thin-Section Computed Tomography in stage I lung adenocarcinoma with visceral pleural invasion

Visceral pleural invasion (VPI) in stageI lung adenocarcinoma is an independent negative prognostic factor. However, no studies proved any morphologic pattern could be referred to as a prognostic factor. Thus, we aim to investigate the potential prognostic impact of VPI by extracting high-dimensional radiomics features on thin-section computed tomography (CT). A total of 327 surgically resected pathological-N0M0 lung adenocarcinoma 3 cm or less in size were evaluated. Radiomics signature was generated by calculating the contribution weight of each feature and validated using repeated leaving-one-out ten-fold cross-validation approach. The accuracy of proposed radiomics signature for predicting VPI achieved 90.5% with ROC analysis (AUC, 0.938, sensitivity, 90.6%, specificity, 93.2%, PPV: 91.2, NPV: 92.8). The cut-off value allowed separation of patients in the validation data into high-risk and low-risk groups with an odds ratio 12.01. Radiomics signature showed a concordance index of 0.895 and AIC value of 88.9% with regression analysis. Among these radiomics features, percentile 10%, wavEnLL_S_2, S_0_1_SumAverage represented as independent factors for determining VPI. Results suggested that radiomics signature on CT exhibited as an independent prognostic factor in discriminating VPI in lung adenocarcinoma and could potentially help to discriminate the prognosis difference in stage I lung adenocarcinoma.

Expression of PD-L1 correlates with pleomorphic morphology and histological patterns of non-small-cell lung carcinomas

AIMS

As immunomodulatory therapy is being integrated into treatment regimens for non-small-cell lung carcinoma, we aimed to prospectively collect data on the immunohistochemical profile of tumours assessed in our institution and to correlate this with morphological tumour features.

METHODS AND RESULTS

Immunohistochemistry for programmed death-ligand 1 (PD-L1) was considered to be adequate when >100 tumour cells were seen microscopically. When adequate, PD-L1 staining was scored as <1%, ≥1-49% or ≥50% positive membrane staining within tumour cells only. There were 197 assessable cases, of which 87% of those with pleomorphic features (n = 39) showed ≥50% positivity for PD-L1 expression, as compared with only 33% of cases without pleomorphic features (P < 0.05) (90% versus 25% in resected cases). Further correlation of PD-L1 expression with architectural patterns within the tumours was performed in 74 adenocarcinoma resections. All invasive mucinous adenocarcinomas scored <1%. All lepidic components in non-mucinous adenocarcinoma resections scored <1%. Thirty-five per cent of the acinar/papillary components and 53% of the solid/micropapillary components were positive for PD-L1 expression.

CONCLUSIONS

There are significant differences in PD-L1 expression in relation to histological patterns, with particularly high levels in those with pleomorphic features and low/undetectable levels in invasive mucinous adenocarcinomas and the lepidic components of non-mucinous adenocarcinomas. Assessment of PD-L1 expression in a resected adenocarcinoma with a lepidic component may therefore not be reliable when immumodulatory therapy for recurrent disease is being considered, and either re-biopsy or limiting assessment to the invasive component may be more appropriate.

Pathologic stratification of operable lung adenocarcinoma using radiomics features extracted from dual energy CT images

PURPOSE

To evaluate the usefulness of surrogate biomarkers as predictors of histopathologic tumor grade and aggressiveness using radiomics data from dual-energy computed tomography (DECT), with the ultimate goal of accomplishing stratification of early-stage lung adenocarcinoma for optimal treatment.

RESULTS

Pathologic grade was divided into grades 1, 2, and 3. Multinomial logistic regression analysis revealed i-uniformity and 97.5th percentile CT attenuation value as independent significant factors to stratify grade 2 or 3 from grade 1. The AUC value calculated from leave-one-out cross-validation procedure for discriminating grades 1, 2, and 3 was 0.9307 (95% CI: 0.8514-1), 0.8610 (95% CI: 0.7547-0.9672), and 0.8394 (95% CI: 0.7045-0.9743), respectively.

MATERIALS AND METHODS

A total of 80 patients with 91 clinically and radiologically suspected stage I or II lung adenocarcinoma were prospectively enrolled. All patients underwent DECT and F-18-fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT, followed by surgery. Quantitative CT and PET imaging characteristics were evaluated using a radiomics approach. Significant features for a tumor aggressiveness prediction model were extracted and used to calculate diagnostic performance for predicting all pathologic grades.

CONCLUSIONS

Quantitative radiomics values from DECT imaging metrics can help predict pathologic aggressiveness of lung adenocarcinoma.

Quantitative image variables reflect the intratumoral pathologic heterogeneity of lung adenocarcinoma

We aimed to compare quantitative radiomic parameters from dual-energy computed tomography (DECT) of lung adenocarcinoma and pathologic complexity.

A total 89 tumors with clinical stage I/II lung adenocarcinoma were prospectively included. Fifty one radiomic features were assessed both from iodine images and non-contrast images of DECT datasets. Comprehensive histologic subtyping was evaluated with all surgically resected tumors. The degree of pathologic heterogeneity was assessed using pathologic index and the number of mixture histologic subtypes in a tumor. Radiomic parameters were correlated with pathologic index. Tumors were classified as three groups according to the number of mixture histologic subtypes and radiomic parameters were compared between the three groups.

Tumor density and 50^th through 97.5^th percentile Hounsfield units (HU) of histogram on non-contrast images showed strong correlation with the pathologic heterogeneity. Radiomic parameters including 75^th and 97.5^th percentile HU of histogram, entropy, and inertia on 1-, 2- and 3 voxel distance on non-contrast images showed incremental changes while homogeneity showed detrimental change according to the number of mixture histologic subtypes (all Ps < 0.05).

Radiomic variables from DECT of lung adenocarcinoma reflect pathologic intratumoral heterogeneity, which may help in the prediction of intratumoral heterogeneity of the whole tumor.

Nuclear localization of B7-H4 in pulmonary adenocarcinomas presenting as a solitary pulmonary nodule

PURPOSE

Although the pathogenicity of B7-H4 in cancer is well established, its role in pulmonary adenocarcinoma, especially lesions presenting as solitary pulmonary nodules (SPNs), remains unclear.

METHODS

40 cases of pulmonary adenocarcinoma presenting with SPN were enrolled during year 2012-2015. The B7-H4 expression and its subcellular distribution in pulmonary adenocarcinoma presenting with SPN were analyzed by immunohistochemistry, further its correlation with Ki-67 expression and CT feature. In vitro, the B7-H4 expression in the cytoplasmic and nucleus fractions of lung cancer cell lines was determinate by western blotting.

RESULTS

Immunostaining revealed B7-H4 in the cytoplasm of cells from all 40 SPN samples studied. No surface localization of B7-H4 was detected, but in 18 samples the nuclear membranes were B7-H4-positive. Moreover, patients with more poorly differentiated and invasive adenocarcinomas showed greater localization of B7-H4 to the nuclear membrane. The percentage of lesions with ground-glass opacity was significantly greater among samples negative for nuclear membrane B7-H4. Most importantly, there was a statistically significant relationships between the Ki-67 index and B7-H4 positivity of the nuclear membrane. This suggests tumors exhibiting higher nuclear membrane B7-H4 have greater proliferative potential. Western blotting confirmed both cytoplasmic and nuclear B7-H4 localization in lung adenocarcinoma cell lines.

CONCLUSIONS

Taken together, our study provides a new insight into the tumorigenicity of B7-H4 in lung adenocarcinoma. We suggest that in pulmonary adenocarcinoma presenting with SPN, nuclear membrane localization of B7-H4 within the tumor cells is associated with increased malignancy.

Mitosis count and number of cancer cells in cases of primary pulmonary adenocarcinoma: Correlations among phosphorylated histone 3, number of cancer cells, nuclear grade, pathologic features and prognosis

Immunohistochemistry findings for the phosphorylated form of histone 3 (pHH3) have been shown to be a reliable mitosis-specific marker. We evaluated the correlation between pHH3-stained mitotic figures (PHMFs) and clinical outcome, and compared the results with findings for numbers of PHMFs and cancer cells. The primary tumor was obtained from 113 patients with pulmonary adenocarcinomas (≤2 cm maximum dimension). All specimens were stained with pHH3, then the number of cancer cells in each was determined. Cases with a cancer-cell index ≥1000 showed worse recurrence-free survival as compared to those with a value <1000 (P < 0.001). Also, cases with a pHH3 index ≥0.27 showed worse recurrence-free survival as compared to <0.27 (P = 0.001) and cases with a pHH3/cancer-cell index ≥0.001 showed worse recurrence-free survival as compared to <0.001 (P = 0.002). Multivariate analysis demonstrated that pHH3/cancer-cell index was significantly correlated with prognosis, but not Ki-67 index. The number of cancer cells was also strongly correlated with progression of Noguchi's classification and WHO pathologic type. pHH3/cancer-cell index was correlated with prognosis, and those were useful for prognostic evaluation of pulmonary adenocarcinoma patients. Furthermore, cancer cell number was correlated with Noguchi's classification and WHO pathologic type.

Analysis of the immune microenvironment in resected non-small cell lung cancer: the prognostic value of different T lymphocyte markers

The prognosis of non-small cell lung cancer (NSCLC) remains poor and heterogeneous and new biomarkers are needed. As the immune system plays a pivotal role in cancer, the study of immune-related markers may provide valuable prognostic information of NSCLC. In 122 formalin-fixed, paraffin-embedded tumor tissue samples from early-stage NSCLC, tumor and tumor-near stromal areas were microdissected and gene expression levels of conventional and regulatory T cell markers were assessed by quantitative polymerase chain reaction. Also, the presence of infiltrating CD4+, CD8+, and FOXP3+ cells in tumor samples was assessed by immunohistochemistry. The relative proportion of conventional and regulatory T cells present in the tumor environment was assessed and found to be key to understand the importance that the immune system analysis has in the prognostics of NSCLC patients. The presence of CD8+ cells in the tumor compartment was associated with better outcome, whereas the presence of FOXP3+ cells was associated with worse overall survival. The negative prognostic value of combined biomarkers, indicating high levels of FOXP3 in the stroma and low levels of CD4 or CD8 in tumors, was observed at mRNA level and was validated by immunohistochemistry.In conclusion, the proportion of T helper and cytotoxic cells vs. regulatory T cells in different locations of the tumor microenvironment have opposite prognostic impacts in resected NSCLC.

The morphological changes of bronchovascular bundles within subsolid nodules on HRCT correlate with the new IASLC classification of adenocarcinoma

AIM

To observe the morphological changes of bronchovascular bundles within subsolid nodules on high-resolution (HR) computed tomography (CT) and analyse the correlation with the new adenocarcinoma classification.

MATERIALS AND METHODS

Two hundred and sixteen lesions (absent consolidation on mediastinal window) were reviewed retrospectively. CT features including dimensions, contour, morphological changes of the blood vessels, and bronchi/bronchioles, vacuole signs, and their correlation with histopathology were evaluated.

RESULTS

Excluding nine non-cancerous lesions, 34 pre-invasive lesions (PILs) including 15 atypical adenomatous hyperplasias (AAHs) and 19 adenocarcinomas in situ (AISs), 21 minimally invasive adenocarcinomas (MIAs), and 152 invasive adenocarcinomas (IACs) were analysed. Lepidic, acinar, and papillary patterns were identified in this cohort of adenocarcinomas. IACs were grouped into three types: type I (lepidic pattern ≥80%, n=47), type II (lepidic pattern ≥50%, <80%, n=67), and type III (lepidic pattern <50%, n=38). The contour of lesions, and morphological changes in vessels and bronchi/bronchioles significantly correlated with the classification of PIL, MIA, and IACs (p=0.000, p=0.000, and p=0.017, respectively). In IACs, the prevalence of vascular abnormalities on HRCT significantly correlated with (p=0.000) the proportion of non-lepidic pattern (23.40% in type I, 58.21% in type II, and 76.32% in type III); the prevalence of bronchial/bronchiolar abnormalities was higher (p=0.008) in type II/III (20.95%) compared with type I (6.38%).

CONCLUSIONS

The morphological changes of vessels and bronchi/bronchioles within the subsolid nodules on HRCT help to differentiate IAC from PIL and MIA, and are more common in non-lepidic predominant adenocarcinomas.

BRMS1 Expression in Surgically Resected Lung Adenocarcinoma Predicts Future Metastases and Is Associated with a Poor Prognosis

INTRODUCTION

Expression of breast cancer metastasis suppressor 1 gene (BRMS1) is decreased in NSCLC cells and tumors. We hypothesized that intratumoral breast cancer metastasis suppressor 1 (BRMS1) expression is associated with lung adenocarcinoma (LUAD) histologic subtypes and overall survival (OS) and disease-free survival (DFS) in patients undergoing resection for early-stage LUAD.

METHODS

Patients (N = 1030) who underwent complete resection for LUAD with tissue available for histologic evaluation were identified. Tissue microarrays were constructed, and immunostaining was performed and scored for intensity of BRMS1 expression. OS and DFS were estimated (by the Kaplan-Meier method) and compared between groups (by the log-rank test), stratified by stage. Hazard ratios (HRs) for hazard of death and recurrence were estimated using univariable and multivariable Cox proportional hazards models. OS and DFS nomograms were created, and model performance was examined.

RESULTS

Intratumoral BRMS1 expression was high in 632 patients (61%) and low in 398 (39%). Low BRMS1 expression was associated with higher pathologic T stage (p = 0.001), larger tumor size (p ≤ 0.0001), greater lymphatic (p = 0.032) and vascular (p = 0.001) invasion, LUAD histologic subtype (p = 0.001), and intermediate and high architectural tumor grade (p = 0.003). Low BRMS1 expression was an independent predictor of worse OS (HR = 1.35, 95% confidence interval: 1.10-1.65, p = 0.004) and DFS (HR = 1.27, 95% confidence interval: 1.05-1.54, p = 0.012). OS and DFS nomograms showed excellent predictive performance based on discrimination and calibration.

CONCLUSIONS

Among patients with surgically resected LUAD, OS and DFS were significantly worse in cases with low intratumoral BRMS1 expression. Our findings suggest that BRMS1 is an independent biomarker with prognostic significance in surgically resected LUAD.

Pathologic N0 Status in Clinical T1N0M0 Lung Adenocarcinoma is Predictable by the Solid Component Proportion with Quantitative CT Number Analysis

Correctly predicting pathologic regional node-negative (pN₀) disease in patients with lung cancer before operation may avoid unnecessary mediastinal lymph node dissection (MLND). In this study, we analyze the value of the radiographic and histopathological features of primary tumors for predicting pN₀ status in cT₁N₀M₀ lung adenocarcinoma and to establish an optimal surgical strategy for avoiding MLND in cT₁N₀M₀ lung adenocarcinoma patients. We retrospectively investigated the histopathological and radiographic data of 348 surgically resected cT₁N₀M₀ lung adenocarcinoma patients with systematic lymph node dissection from January 2005 to December 2012. Histopathological features and radiographic features were analyzed. Multivariable analysis was used to identify significant predictors of pN₀ disease. Our results showed that pN₀ disease was detected in 306 patients (87.9%) among the 348 patients with cT₁N₀M₀ lung adenocarcinoma. A decreasing trend of the pN₀ disease proportion was observed with both increasing histological grade and decreased differentiation (P < 0.001). In multivariable analysis, the solid component proportion was a significant predictor of pN₀ disease. Among 110 patients with a solid component proportion of no more than 21.3%, mediastinal lymph node involvement was not observed. Patients who meet this criterion may be successfully managed with lung resection without MLND.

[The 2015 classification of lung adenocarcinomas: Reproducibility in a Tunisian department specialised in thoracic pathology]

INTRODUCTION

The new classification of lung cancer contains modifications of terminology and a new subdivision of the tumors with the most relevant modifications concerning the group of adenocarcinomas. The latter has been increasing and represents nowadays the most frequent type. Our aim was to assess the reproducibility of the new classification through the experience of a Department of Pathology specialized in thoracic pathology.

METHODS

Our study included initially 106 cases diagnosed as adenocarcinomas and reviewed by 2 pathologists and 1 referee. Five cases were ruled out because they corresponded to squamous carcinoma according to the immunohistochemical findings. The same number of slides was reviewed without a limit of time. Statistical analysis was performed using the SPSS software. The Kappa index was estimated and a second coefficient: rho was analyzed.

RESULTS

A total concordance was noticed in 82 cases (81.2%) and a discordance was noticed in 19 cases (18.8%). The agreement degree was good with an index Kappa estimated to 0.743 and a rho index reaching 0.763.

CONCLUSION

Our study highlights the good reproducibility of the 2015 WHO classification of lung cancer among a trained team. Whereas, in order to improve the reproducibility of such a classification, even in non specialised departments, a training of the pathologists is necessary in order to highlight the prognostic impact of this classification.

High expression of monocarboxylate transporter 4 predicts poor prognosis in patients with lung adenocarcinoma

Monocarboxylate transporter 4 (MCT-4) serves a key function in transporting lactate across the plasma membrane in various types of human cancer. Evidence indicates that MCT-4 expression is associated with non-small cell lung cancer; however, the distribution and clinical significance of MCT-4 in the lung adenocarcinoma (AC) subtype remain unknown. Thus, the aim of the present study was to explore the clinicopathological significance and prognostic values of MCT-4 expression in lung AC. Quantum dots-based immunofluorescence histochemistry was performed to observe the expression of MCT-4 in 146 specimens of lung AC and corresponding normal lung tissues. MCT-4 protein and mRNA were detected by western blotting and reverse transcription-quantitative polymerase chain reaction from 30 fresh samples of lung AC and corresponding normal lung tissues. Of the 146 samples, 25 (17.1%) exhibited high and 121 (82.9%) exhibited low MCT-4 expression. MCT-4, at the protein and mRNA level, was significantly increased in tumor specimens compared with corresponding normal lung tissue (P<0.05). MCT-4 protein expression was significantly associated with depth of invasion (P=0.034). A survival curve analysis indicated that high MCT-4 expression in lung AC was associated with a decreased overall survival rate (P=0.001). Multivariate analysis demonstrated that high MCT-4 level was an independent prognostic factor (hazard ratio, 3.192; 95% confidence interval, 1.804–5.646; P=0.001) for patients with lung AC. The results have demonstrated that high MCT-4 expression is significantly associated with the poor prognosis and disease progression of patients with lung AC. Therefore, MCT-4 may be a candidate therapeutic target in lung AC.

A Grading System Combining Tumor Budding and Nuclear Diameter Predicts Prognosis in Resected Lung Squamous Cell Carcinoma

For lung squamous cell carcinomas, there are no histologic findings that have been universally accepted as prognostic factors. Tumor budding and nuclear grade have been recognized as prognostic factors in other carcinomas. In this study, we investigated whether pathologic findings could determine clinical outcome in Japanese patients with lung squamous cell carcinomas. Tumor slides from surgically resected lung squamous cell carcinomas (1999 to 2012) were reviewed (n=216). Tumors were evaluated for histologic subtypes, differentiation, tumor budding, nuclear diameter, and mitosis. Recurrence-free survival (RFS) and overall survival (OS) were analyzed using the log-rank test and the Cox proportional hazards model. Tumor budding and large nuclei were independent prognostic factors of a worse RFS (P<0.001 and P=0.002, respectively) and a worse OS (P<0.001 and P=0.038, respectively) on multivariate analysis after adjustment for pathologic stage and lymphatic invasion. However, histologic subtypes, differentiation, and mitotic count did not correlate with prognosis. A grading system combining tumor budding and nuclear diameter was an independent prognostic factors of a worse RFS (grade 2 vs. 1, hazard ratio [HR]=2.91; P<0.001, and grade 3 vs. 1, HR=7.60, P<0.001) and a worse OS (grade 2 vs. 1, HR=2.15; P=0.014, and grade 3 vs. 1, HR=4.54, P<0.001). We found that a grading system combining tumor budding and nuclear diameter was a significant prognostic factor among Japanese patients with resected lung squamous cell carcinoma.

A Clinicopathological Study of Small Lung Adenocarcinoma 1 cm or Less in Size: Emphasis on Histological Subtypes Associated With Lymph Node Metastasis and Recurrence

BACKGROUND

The aim of this study was to assess the prognostic significance of the newly proposed 2015 World Health Organization (WHO) lung adenocarcinoma classification for patients undergoing resection for small (≤1 cm) lung adenocarcinoma. We also investigated whether lobectomy offers prognostic advantage over limited resection for this category of tumors.

METHODS

A retrospective study of resected pulmonary adenocarcinomas (n = 83) in sizes 1 cm or less was carried out in which comprehensive histologic subtyping was assessed according to the 2015 WHO classification on all consecutive patients who underwent lobectomy or limited resection between 2008 and 2015. Correlation between clinicopathologic parameters and the difference in recurrence between lobectomy and limited resection group was evaluated.

RESULTS

Our data show that the proposed 2015 WHO classification identifies histological subsets of small lung adenocarcinomas with significant differences in prognosis. No recurrence was noted for patients with adenocarcinoma in situ and minimally invasive adenocarcinoma. Invasive adenocarcinomas displayed high heterogeneity and the presence of micropapillary component of 5% or greater in adenocarcinomas was significantly related to lymph node involvement and recurrence ( P < .001). Stage Ia patients who underwent limited resection had a higher risk of recurrence than did those treated by lobectomy (P < .05).

CONCLUSIONS

Application of the 2015 WHO classification identifies patients with adenocarcinoma in situ and minimally invasive adenocarcinoma had excellent prognosis. Micropapillary pattern was associated with high risk of lymph node metastasis and recurrence.

Metastatic spread of solid subtype lung adenocarcinoma to the small intestine with anemia and melena: A case report

RATIONALE

Metastasis to the small intestine from a primary lung cancer is rare, and is associated with a poor prognosis. Early diagnosis of small intestine metastasis is difficult because of the low incidence of clinically apparent symptoms.

PATIENT CONCERNS

Clinical data and treatment of a 59-year-old man with small intestine metastasis from primary solid subtype lung adenocarcinoma are summarized.

DIAGNOSES

A man who was previously diagnosed with stage IIIA (T3N2M0) lung adenocarcinoma (solid subtype) came to our hospital for postoperative radiotherapy. Laboratory tests indicated anemia and melena. The patient was initially believed to have digestive ulcer and was treated with omeprazole, which proved to be ineffective. We conducted an abdominal computed tomography (CT) contrast scan and discovered a mass in the small intestine mass. Further positron emission tomography-computed tomography (PET-CT) imaging indicated the small intestine mass with fluorodeoxyglucose uptake.

INTERVENTIONS

The patient underwent an enterectomy and anastomosis. Pathological analysis confirmed the diagnosis of small intestinal metastasis from lung cancer with concomitant mesenteric lymph node metastasis.

OUTCOMES

One month after the operation, hemoglobin levels became normal, and the patient had good quality of life. However, 3 months after the operation, the patient suffered from anemia again. An abdominal CT scan indicated a new small intestine mass. Progression continued rapidly, and the patient died of hemorrhagic shock 5.5 months after the resection of the small intestine mass.

LESSONS

Although uncommon, if lung cancer patients present with anemia and melena, enteric metastasis should be part of the differential diagnosis. Abdominal CT scans and PET-CT are effective for early diagnosis. The prognosis of metastatic spread of solid subtype lung adenocarcinoma to the small intestine with mesenteric lymph node metastasis is poor. Subgroups of patients benefitting from metastasectomy and more effective systemic therapy need to be further investigated.

Evaluation of grading systems in stage I lung adenocarcinomas: a retrospective cohort study

AIMS

There is no internationally accepted grading system for lung adenocarcinoma despite the new WHO classification. The architectural grade, the Kadota grade and the Sica score were evaluated and compared with overall (OS) and disease-free survival (DFS).

METHODS

Comprehensive histological subtyping was used in a series of resected stage I lung adenocarcinoma to identify subtypes of adenocarcinomas, the architectural grade, the Kadota grade, the Sica grade, the mitotic count, nuclear atypia, the presence of lymphovascular, vascular and airway propagation, necrosis, and micropapillary or solid growth pattern in any percentage. Statistical models fitted included Kaplan-Meier estimates and Cox proportional hazard regression models.

RESULTS

261 stage I adenocarcinomas were included. The 5-year survivals of different subtypes were as follows: lepidic (n=40, OS: 92.5%; DFS 91.6%), acinar (n=54, OS: 81.8%; DFS: 68.6%), papillary (n=49, OS: 73.6%; DFS: 61.0%), solid (n=95, OS: 64.7%; DFS: 57.8%) and micropapillary (n=23, OS: 34.8%; DFS: 33.5%). Concerning the architectural grade, there were significant differences between OS and DFS of low and intermediate (pOS=0.005, pDFS<0.001), low and high (pOS<0.001, pDFS<0.001) and intermediate and high grades (pOS=0.002, pDFS<0.001). Low-grade and intermediate grade tumours did not differ in survival according to Kadota grade and Sica grade. In the multivariable model, architectural grade was found to be an independent prognostic marker. In another model, architectural pattern proved to be superior to architectural grade.

CONCLUSIONS

Of the three grading systems compared, the architectural grade makes the best distinction between the outcome of low-grade, intermediate-grade and high-grade stage I adenocarcinomas.

Clinical Relevance of Different Papillary Growth Patterns of Pulmonary Adenocarcinoma

Growth patterns of pulmonary adenocarcinoma (ADC) have high prognostic impact and are accepted as a novel classification system for this entity. However, specifically for the papillary pattern, divergent data with respect to prevalence, clinical associations, and prognostic impact have been reported. By evaluating 674 resected pulmonary ADCs containing 308 cases with a papillary component and 101 papillary predominant cases, we documented differences in the morphologic composition of papillary growth patterns and delineated 3 different types. The different types were correlated with pathologic and clinical data including survival. Type 3 papillary cases with any or predominant papillary growth were associated with extensive spread through alveolar spaces, high proliferation, higher stage, low rates of EGFR mutations, and smoking, whereas type 1 papillary tumors showed the opposite associations. The subclassification of papillary growth revealed type-specific associations for overall and disease-free survival (disease-free survival type 1: 67.1 mo, type 2: 56.8 mo, type 3: 49.9 mo, P=0.025). The presence of any papillary type 3 pattern was a predominant pattern independent predictor of worse overall survival (hazard ratio=2.5, P=0.02). For a future grading system of lung ADC, categorization of papillary growth in 1 single category might not be adequate, as this pattern contains a heterogenous mix of tumors with a divergent prognosis. We suggest that papillary pattern types should be separated to further improve the prognostic power of ADC growth pattern analysis.

Utility of Genomic Analysis in Differentiating Synchronous and Metachronous Lung Adenocarcinomas from Primary Adenocarcinomas with Intrapulmonary Metastasis

Distinguishing synchronous and metachronous primary lung adenocarcinomas from adenocarcinomas with intrapulmonary metastasis is essential for optimal patient management. In this study, multiple lung adenocarcinomas occurring in the same patient were evaluated using comprehensive histopathologic evaluation supplemented with molecular analysis. The cohort included 18 patients with a total of 52 lung adenocarcinomas. Eleven patients had a new diagnosis of multiple adenocarcinomas in the same lobe (n = 5) or different lobe (n = 6). Seven patients had a history of lung cancer and developed multiple new tumors. The final diagnosis was made in resection specimens (n = 49), fine needle aspiration (n = 2), and biopsy (n = 1). Adenocarcinomas were non‐mucinous, and histopathologic comparison of tumors was performed. All tumors save for one were subjected to ALK gene rearrangement testing and targeted Next Generation Sequencing (NGS). Using clinical, radiologic, and morphologic features, a confident conclusion favoring synchronous/metachronous or metastatic disease was made in 65% of patients. Cases that proved challenging included ones with more than three tumors showing overlapping growth patterns and lacking a predominant lepidic component. Genomic signatures unique to each tumor were helpful in determining the relationship of multiple carcinomas in 72% of patients. Collectively, morphologic and genomic data proved to be of greater value and achieved a conclusive diagnosis in 94% of patients. Assessment of the genomic profiles of multiple lung adenocarcinomas complements the histological findings, enabling a more comprehensive assessment of synchronous, metachronous, and metastatic lesions in most patients, thereby improving staging accuracy. Targeted NGS can identify genetic alterations with therapeutic implications.

CD200-positive cancer associated fibroblasts augment the sensitivity of Epidermal Growth Factor Receptor mutation-positive lung adenocarcinomas to EGFR Tyrosine kinase inhibitors

Cancer associated fibroblasts (CAFs) play important roles in the chemotherapeutic process, especially through influencing the resistance of tumor cells to molecular targeted therapy. Here we report the existence of a special subpopulation of patient-specific-CAFs that augment the sensitivity of EGFR gene mutation-positive lung cancer to the EGFR-tyrosine kinase inhibitor (EGFR-TKI), gefitinib. When cocultured with EGFR mutation positive lung cancer cells, these CAFs increased the apoptic effect of gefitinib on cancer cells, whereas, in the absence of gefitinib, they did not affect cancer cell viability. The assay using different single cell-derived clones demonstrated that the aforementioned sensitizing ability is clone-specific. Microarray analysis revealed that CD200 was expressed at much higher levels in this CAFs. Knocking down of CD200 expression deprived CAFs of their sensitizing potential, suggesting that CD200 is the functional molecule responsible for the effect. Immunohistochemical analysis of samples from patients receiving postoperative gefitinib treatment revealed that the individuals whose resected lung adenocarcinomas contained CD200-positive CAFs tended to have longer progression free survival of gefitinib when they recurred after surgery. These results suggest that CD200-positive CAFs can augment the sensitivity to EGFR-TKIs and may possess far reaching applications in the therapeutic use of EGFR-TKIs.

Possible pathways used to predict different stages of lung adenocarcinoma

We aimed to find some specific pathways that can be used to predict the stage of lung adenocarcinoma.RNA-Seq expression profile data and clinical data of lung adenocarcinoma (stage I [37], stage II 161], stage III [75], and stage IV [45]) were obtained from the TCGA dataset. The differentially expressed genes were merged, correlation coefficient matrix between genes was constructed with correlation analysis, and unsupervised clustering was carried out with hierarchical clustering method. The specific coexpression network in every stage was constructed with cytoscape software. Kyoto Encyclopedia of Genes and Genomes pathway enrichment analysis was performed with KOBAS database and Fisher exact test. Euclidean distance algorithm was used to calculate total deviation score. The diagnostic model was constructed with SVM algorithm.Eighteen specific genes were obtained by getting intersection of 4 group differentially expressed genes. Ten significantly enriched pathways were obtained. In the distribution map of 10 pathways score in different groups, degrees that sample groups deviated from the normal level were as follows: stage I < stage II < stage III < stage IV. The pathway score of 4 stages exhibited linear change in some pathways, and the score of 1 or 2 stages were significantly different from the rest stages in some pathways. There was significant difference between dead and alive for these pathways except thyroid hormone signaling pathway.Those 10 pathways are associated with the development of lung adenocarcinoma and may be able to predict different stages of it. Furthermore, these pathways except thyroid hormone signaling pathway may be able to predict the prognosis.

Comparison of Prognosis of Solid and Part-Solid Node-Negative Adenocarcinoma With the Same Invasive Component Size

BACKGROUND

Our study compared the prognosis of solid node-negative adenocarcinoma sized less than 20 mm with that of part-solid node-negative adenocarcinoma with an invasive tumor size of less than 20 mm.

METHODS

From 2003 to 2012, 191 patients were selected with a diagnosis of solid or part-solid pathologic node-negative adenocarcinoma with an invasive component sized less than 20 mm. The enrolled patients were categorized into two groups: group 1 had solid adenocarcinoma consisting only of the invasive component, and group 2 had part-solid adenocarcinoma consisting of both an in situ and an invasive component. Recurrence-free survival and overall survival at 5 years were compared using Kaplan- Meier survival analysis and the log-rank test.

RESULTS

The mean size of the invasive component was 15.9 mm in group 1 (n = 92) and 15.2 mm in group 2 (n = 99; p = 0.06), and the mean total lesion size was 15.9 mm in group 1 and 21.0 mm in group 2 (p < 0.001). The median follow-up duration was 54.2 months. The 5-year overall survival rates were 90.3% in group 1 and 93.8% in group 2 (p = 0.160), and the recurrence-free survival rates were 84.0% in group 1 and 93.7% in group 2 (p = 0.037). Lymphovascular invasion and high maximum standardized uptake values were significantly more common in group 1.

CONCLUSIONS

Although the total size of the part-solid adenocarcinoma lesions was larger than that of the solid adenocarcinoma lesions, the prognosis of part-solid adenocarcinoma was better than that of solid adenocarcinoma in cases of node-negative adenocarcinoma with invasive components sized less than 20 mm.

Aberrant Signaling through the HER2-ERK1/2 Pathway is Predictive of Reduced Disease-Free and Overall Survival in Early Stage Non-Small Cell Lung Cancer (NSCLC) Patients

Background: Purpose of this study was to evaluate the contribution of the Extracellular-regulated protein kinase (ERK)-1/2 pathway to oncogenic signaling elicited by the tyrosine kinase receptor HER2 in Non-Small Cell Lung Cancer (NSCLC) and to assess the prognostic value of these oncoproteins in NSCLC patients.

Methods: Immunohistochemistry was performed to determine expression and activation of HER2 and ERK1/2 (detected by phosphorylation of Y1248 and T202/Y204, respectively) using Tissue Micro Arrays (TMA) containing matched normal and neoplastic tissues from 132 NSCLC patients. Survival analysis was carried out using the Kaplan-Meier method. Univariate and multivariate analysis were used to evaluate the prognostic value of pERK1/2, pHER2 and a combination thereof with clinical-pathological parameters such as age, lymph node status (N), size (T), stage (TNM) and grade.

Results: We found that HER2 was overexpressed in 33/120 (27%) and activated in 41/114 (36%) cases; ERK1/2 was activated in 44/102 (43%) cases. A direct association was found between pERK1/2 and pHER2 (23/41; p=0.038). In addition, patients positive for pERK1/2 and for both pHER2 and pERK1/2 showed significantly worse overall survival (OS) and disease-free survival (DFS) compared with negative patients. Univariate and multivariate analysis of patients' survival revealed that positivity for pHER2-pERK1/2 and for pERK1/2 alone were independent prognostic factors of poor survival in NSCLC patients. In particular, this association was significantly important for DFS in stage I+II patients.

Conclusion: This study provides evidence that activated ERK1/2 and/or the combined activation of HER2 and ERK1/2 are good indicators of poor prognosis in NSCLC patients, not only in unselected patients but also in early stage disease.

Orai3 is a predictive marker of metastasis and survival in resectable lung adenocarcinoma

Orai3 channel has emerged as important player in malignant transformation. Indeed, its expression is increased in cancer and favors cell proliferation and survival by permitting calcium influx. In this study, Orai3 was overexpressed in lung adenocarcinoma as compared to their matched non-tumour samples and was associated with tumoural aggressiveness. Moreover, its expression was associated with estrogen receptor alpha (ERα) expression and visceral pleural invasion in multivariate analysis. Furthermore, both the overall survival (OS) median and the metastasis free survival (MFS) median of tumors with high Orai3 expression were lower than in low Orai3 expression regardless of cancer stage (35.01 months vs. 51.11 months for OS and 46.01 months vs. 62.04 months for MFS). In conclusion, Orai3 protein level constitutes an independent prognostic marker in lung adenocarcinoma, and a novel prognostic marker that could help selecting the patients with worst prognosis to be treated with adjuvant chemotherapy in resectable stage.

Imaging Phenotyping Using Radiomics to Predict Micropapillary Pattern within Lung Adenocarcinoma

INTRODUCTION

Lung adenocarcinomas (ADCs) with a micropapillary pattern have been reported to have a poor prognosis. However, few studies have reported on the imaging-based identification of a micropapillary component, and all of them have been subjective studies dealing with qualitative computed tomography variables. We aimed to explore imaging phenotyping using a radiomics approach for predicting a micropapillary pattern within lung ADC.

METHODS

We enrolled 339 patients who underwent complete resection for lung ADC. Histologic subtypes and grades of the ADC were classified. The amount of micropapillary component was determined. Clinical features and conventional imaging variables such as tumor disappearance rate and maximum standardized uptake value on positron emission tomography were assessed. Quantitative computed tomography analysis was performed on the basis of histogram, size and shape, Gray level co-occurrence matrix-based features, and intensity variance and size zone variance-based features.

RESULTS

Higher tumor stage (OR = 3.270, 95% confidence interval [CI]: 1.483-7.212), intermediate grade (OR = 2.977, 95% CI: 1.066-8.316), lower value of the minimum of the whole pixel value (OR = 0.725, 95% CI: 0.527-0.98800), and lower value of the variance of the positive pixel value (OR = 0.961, 95% CI: 0.927-0.997) were identified as being predictive of a micropapillary component within lung ADC. On the other hand, maximum standardized uptake value and tumor disappearance rate were not significantly different in groups with a micropapillary pattern constituting at least 5% or less than 5% of the entire tumor.

CONCLUSION

A radiomics approach can be used to interrogate an entire tumor in a noninvasive manner. Combining imaging parameters with clinical features can provide added diagnostic value to identify the presence of a micropapillary component and thus, can influence proper treatment planning.

Expression level of CRKL and AXL combined with exon 19 deletion in EGFR and ALK status confer differential prognosis of lung adenocarcinoma subtypes

Non-small cell lung cancer (NSCLC) is a lethal cancer-related disease in population. Adenocarcinoma (AC) is subclassified into several subtypes based on the new classification by the International Association for the Study of Lung Cancer, American Thoracic Society and European Respiratory Society in 2011. Correlation between original expression of Crk-like (CRKL) and anaplastic lymphoma receptor tyrosine kinase in diverse histological components of AC and epidermal growth factor receptor (EGFR) or ALK status was evaluated by immunohistochemistry and sequencing in present study. A total of 106 cases, including 83 patients (78.3%) with mixed-type ACs, were assessed in the present study using eligible follow-up data. The ACs consisted of 32 acinar, 12 papillary, 5 mucinous, 11 micropapillary and 46 solid-predominant ACs. In total, 69.8% samples were composed of 2 or 3 histological components, with different expression levels of CRKL and AXL. ACs with EGFR mutation had a higher level of AXL expression compared with ACs without mutation (P=0.019). Multivariate survival analysis showed that AC subtypes and EGFR mutation subtypes were significantly associated with the progression-free survival (PFS) time. Acinar AC was the subtype with the most notable PFS time (30.6 months), which was significantly different from the PFS time of papillary, mucinous, micropapillary and solid-predominant ACs (hazard ratio, 0.4; 95% CI, 0.21-0.75; P=0.005). Among the ACs with exon 19 mutation, the median PFS time (28.8 months) of patients with a lower level of AXL protein expression was increased compared with the PFS time of patients with the L858R mutation and wild-type EGFR (9.1 months and 11 months, respectively; P=0.03), whereas no significant difference in ACs with an increased level of AXL expression. However, AC patients with higher level of CRKL expression had better PFS (28.8 months) than patients with the L858R mutation and wild-type EGFR (9.1 months and 11.3 months, respectively). Exon 19 deletion is an important status that is associated with an improved response to conventional chemotherapy. The identification of EGFR mutations combined with CRKL and AXL status may potentially alter the way that lung AC is treated.

Suppression of Type I IFN Signaling in Tumors Mediates Resistance to Anti-PD-1 Treatment That Can Be Overcome by Radiotherapy

Immune checkpoint therapies exhibit impressive efficacy in some patients with melanoma or lung cancer, but the lack of response in most cases presses the question of how general efficacy can be improved. In addressing this question, we generated a preclinical tumor model to study anti-PD-1 resistance by in vivo passaging of Kras-mutated, p53-deficient murine lung cancer cells (p53^R172HΔg/+K-ras^LA1/+ ) in a syngeneic host exposed to repetitive dosing with anti-mouse PD-1 antibodies. PD-L1 (CD274) expression did not differ between the resistant and parental tumor cells. However, the expression of important molecules in the antigen presentation pathway, including MHC class I and II, as well as β2-microglobulin, were significantly downregulated in the anti-PD-1-resistant tumors compared with parental tumors. Resistant tumors also contained fewer CD8⁺ (CD8α) and CD4⁺ tumor-infiltrating lymphocytes and reduced production of IFNγ. Localized radiotherapy induced IFNβ production, thereby elevating MHC class I expression on both parental and resistant tumor cells and restoring the responsiveness of resistant tumors to anti-PD-1 therapy. Conversely, blockade of type I IFN signaling abolished the effect of radiosensitization in this setting. Collectively, these results identify a mechanism of PD-1 resistance and demonstrate that adjuvant radiotherapy can overcome resistance. These findings have immediate clinical implications for extending the efficacy of anti-PD-1 immune checkpoint therapy in patients. Cancer Res; 77(4); 839-50. ©2016 AACR.

Comprehensive Computational Pathological Image Analysis Predicts Lung Cancer Prognosis

INTRODUCTION

Pathological examination of histopathological slides is a routine clinical procedure for lung cancer diagnosis and prognosis. Although the classification of lung cancer has been updated to become more specific, only a small subset of the total morphological features are taken into consideration. The vast majority of the detailed morphological features of tumor tissues, particularly tumor cells' surrounding microenvironment, are not fully analyzed. The heterogeneity of tumor cells and close interactions between tumor cells and their microenvironments are closely related to tumor development and progression. The goal of this study is to develop morphological feature-based prediction models for the prognosis of patients with lung cancer.

METHOD

We developed objective and quantitative computational approaches to analyze the morphological features of pathological images for patients with NSCLC. Tissue pathological images were analyzed for 523 patients with adenocarcinoma (ADC) and 511 patients with squamous cell carcinoma (SCC) from The Cancer Genome Atlas lung cancer cohorts. The features extracted from the pathological images were used to develop statistical models that predict patients' survival outcomes in ADC and SCC, respectively.

RESULTS

We extracted 943 morphological features from pathological images of hematoxylin and eosin-stained tissue and identified morphological features that are significantly associated with prognosis in ADC and SCC, respectively. Statistical models based on these extracted features stratified NSCLC patients into high-risk and low-risk groups. The models were developed from training sets and validated in independent testing sets: a predicted high-risk group versus a predicted low-risk group (for patients with ADC: hazard ratio = 2.34, 95% confidence interval: 1.12-4.91, p = 0.024; for patients with SCC: hazard ratio = 2.22, 95% confidence interval: 1.15-4.27, p = 0.017) after adjustment for age, sex, smoking status, and pathologic tumor stage.

CONCLUSIONS

The results suggest that the quantitative morphological features of tumor pathological images predict prognosis in patients with lung cancer.

Role of CT and PET Imaging in Predicting Tumor Recurrence and Survival in Patients with Lung Adenocarcinoma: A Comparison with the International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society Classification of Lung Adenocarcinoma

INTRODUCTION

Recently, a new lung adenocarcinoma classification scheme was published. The prognostic value of this new classification has not been elaborated together with the value of imaging biomarkers including computed tomography (CT) and positron emission tomography (PET).

METHODS

We reviewed pathologic specimens and imaging characteristics of primary tumors from 723 consecutive patients who underwent surgical resection for lung adenocarcinoma. On pathology, the predominant histologic subtype and pattern group were quantified. Tumor-shadow disappearance ratio (TDR) on CT and maximum standardized uptake value (SUVmax) on PET were assessed. The relationships between those variables and survival (overall survival [OS] and disease-free survival) were analyzed by using Kaplan-Meier curves and Cox regression analyses.

RESULTS

The median follow-up period was 3.8 years. There were 137 patients (19%) with recurrence and 167 patients (23%) with metastasis after surgical resection. Among 723 patients, 35 patients (4.8%) had adenocarcinoma in situ, 34 patients (4.7%) had minimally invasive adenocarcinoma, 125 patients (17.3%) had lepidic predominant, 314 patients (43.4%) had acinar predominant, 65 patients (9.0%) had papillary predominant, 23 patients (3.2%) had micropapillary predominant, 113 patients (15.6%) had solid predominant, and 14 patients (1.9%) had variant adenocarcinomas. OS and disease-free survival rates were significantly different according to TDR on CT and SUVmax on PET, predominant subtypes, and pattern groups. On multivariate analysis, the SUVmax (p < 0.001), TDR (p = 0.038), and pattern group (p = 0.015) were independent predictors of OS.

CONCLUSIONS

TDR on CT, SUVmax on PET, and the new histologic classification schemes appear to be promising parameters for the prognostic stratification of patients with lung adenocarcinomas, allowing for the triage of patients who necessitate further staging workup and adjuvant therapy.

Pathologic heterogeneity of lung adenocarcinomas: A novel pathologic index predicts survival

Although the most predominant subtype of invasive lung adenocarcinoma has been reported to have clinical significance, a major limitation of this concept is that most tumors are mixed-subtype. Therefore, we aimed to determine the individual prognostic significance of each subtype and also attempted to establish a pathologic index that reflects the pathologic subtypes and overall heterogeneity of lung adenocarcinomas and evaluated its prognostic significance. The individual prognostic impact of each subtype was assessed from the development cohort using the disease-free survival (DFS) curve of a previous large-scale study. Hazard ratios (HRs) from the development cohort were 1, 1.025, 1.059, 1.495, and 1.160 for the lepidic, acinar, papillary, micropapillary, and solid pattern subtype, respectively. Based on the calculated HR of each subtype, four indices representing pathologic heterogeneity were developed. The first and second indices were defined as the sum of the proportions of each subtype multiplied by their HRs, with the addition of either entropy or Gini coefficient, respectively. The third index was calculated as the sum of all subtype percentages multiplied by their HRs. To emphasize heterogeneity, the fourth index was defined as the simple arithmetic sum of the scores of the subtypes multiplied by their HRs. Each subtype was assigned a score of 0 if the subtype was absent and a score of 1 if the subtype was present in a binary fashion. We applied these four pathologic indices to a validation group of 148 patients with comprehensive histologic subtyping for completely resected lung adenocarcinomas. DFS curves were plotted and predictive ability of each pathologic index was evaluated. Among the four pathologic indices, only pathologic index 3 enabled significant patient stratification in the validation cohort according to DFS (P = 0.004) and showed the highest Harrell's C index of 0.691 of all four pathologic indices. In conclusion, we estimated the HR of each subtype and generated four pathologic indices that reflect heterogeneity. One of these, index 3, the pathologic heterogeneity index based on the sum of all subtype percentages multiplied by their HR, possesses good prognostic ability for predicting survival in patients with lung adenocarcinoma.

Factors predicting organ-specific distant metastasis in patients with completely resected lung adenocarcinoma

The aim of the study is to demonstrate the relationship between clinicopathological variables and organ sites of metastasis in resected lung adenocarcinoma. The clinicopathological characteristics of 748 patients of resected lung adenocarcinoma at Taipei Veterans General Hospital between 2004 and 2012 were retrospectively reviewed. The prognostic value of clinicopathological variables for specific organ site metastasis-free survival was demonstrated. Among the 182 patients with distant metastasis, 93 (51.1%) patients developed contralateral lung metastasis, 81 (44.5%) had brain metastasis, 71 (39.0%) had bone metastasis, and 18 (8.9%) had liver metastasis during follow-up. Acinar predominant (Hazard ratio [HR], 0.468; 95% confidence interval [CI]: 0.250 to 0.877; P = 0.018) was significantly associated with less contralateral lung metastasis in multivariate analysis. Micropapillary predominant (HR, 2.686; 95% CI, 1.270 to 5.683; P = 0.010) was significantly associated with brain metastasis. Acinar predominant (HR, 0.461; 95% CI, 0.216 to 0.986; P = 0.046) was a significant prognostic factor for better contralateral lung metastasis-free survival in multivariate analysis. Micropapillary predominant (HR, 2.186; 95% CI, 1.148 to 4.163; P = 0.017) and solid predominant (HR, 4.093; 95% CI, 1.340 to 12.504; P = 0.013) were significant prognostic factors for worse brain metastasis-free survival and liver metastasis free-survival, respectively. There are significant differences in metastatic behavior between predominant pathological subtypes of lung adenocarcinoma. This information is important for patient follow-up strategy and identification of organ-specific distant metastasis. Prospective multi-institutional studies are mandatory for further validation.

Comparison of detection methods and follow-up study on the tyrosine kinase inhibitors therapy in non-small cell lung cancer patients with ROS1 fusion rearrangement

Background

The screening of ROS proto-oncogene 1, receptor tyrosine kinase(ROS1) fusion rearrangement might be potentially beneficial for an effective therapy against non-small cell lung cancer (NSCLC). However, the three main ROS1 rearrangement detection methods have limitations, and no routine protocol for the detection of ROS1 rearrangement in NSCLC is available. In this study, our aims were to compare immunohistochemistry (IHC), fluorescent in situ hybridization (FISH) and quantitative real-time polymerase chain reaction (qRT-PCR) in their ability to detect ROS1 rearrangement in NSCLC, and discuss the clinical characteristics and histopathology of the patients with ROS1 rearrangement. Moreover, the effects of tyrosine kinase inhibitors (TKIs) therapy on the patients with ROS1 rearrangement and advanced stage disease (III b–IV) were investigated.

Methods

Patients with a previously diagnosed NSCLC were recruited in this study from November 2013 to October 2015. IHC was performed using the D4D6 monoclonal antibody (mAb) in an automatic IHC instrument, while FISH and qRT-PCR were carried out to confirm the IHC results. FISH and qRT-PCR positive cases underwent direct sequencing. After detection, patients with advanced ROS1 rearranged NSCLC had received TKI therapy.

Results

Two hundred and thirty-eight patients were included in this study. ROS1 rearrangement was detected in 10 patients. The concordant rate of FISH and qRT-PCR results was 100 %, while in the FISH and IHC results high congruence was present when IHC showed a diffusely (≥60 % tumor cells) 2–3+ cytoplasmic reactivity pattern. Patients harboring ROS1 rearrangement were mostly young (8/10), females (7/10) and non-smokers (7/10) with adenocarcinoma (10/10) and acinar pattern. Most of their tumor were in intermediate grade (6/8). Among these 10 patients, three of them in stage IV with ROS1 rearrangement gained benefits from ROS1 TKI therapy.

Conclusions

IHC, FISH and qRT-PCR can reliably detect ROS1 rearrangement in NSCLC, while IHC can be used as a preliminary screening tool. These results supported the efficacy of ROS1 TKI therapy in treating advanced NSCLC patients with ROS1 rearrangement.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-016-2582-9) contains supplementary material, which is available to authorized users.

Surgical pathology of early stage non-small cell lung carcinoma

The histologic classification of non-small cell lung carcinoma (NSCLC), particularly adenocarcinoma (ADC), has undergone extensive study in recent decades, ultimately resulting in an extensively updated classification system. The 2015 World Health Organization (WHO) classification of ADC provides greatly improved prognostic information in comparison to the 2004 WHO classification. Several issues still require further investigation: lepidic predominant ADC, prognostic significance of poor prognostic subtypes such as micropapillary carcinoma, the more recently described concept of spread of tumor through airspaces (STAS), and the utility of sublobar resections. While limited resection appears to be suitable for tumors with a ground glass radiographic appearance, which typically correspond to adenocarcinoma in situ (MIS) or minimally invasive adenocarcinoma (MIA) histologically, the role of sublobar resection in radiographic solid tumors is not as clear, and the impact of histologic subtypes with a poor prognosis needs further evaluation. Squamous cell carcinoma (SCC) has not been as extensively studied and the current classification lacks subclassification with significant prognostic information.