Study of prognostic predictors for non-small cell lung cancer

Mesoporous SBA-15 Silica-Loaded Nano-formulation of Quercetin: A Probable Radio-Sensitizer for Lung Carcinoma

Lung cancer is considered as one of the most serious disease worldwide. The progress of drug carriers based on nonmaterial, which selectively hold chemotherapeutic agents to cancer cells, has become a major focus in biomedical research. This study aimed to evaluate the growth inhibition and apoptosis induction of the human lung cancer cells (A-549) by Q-loaded SBA-15 conjugate system. Mesoporous silica nanoparticles (SBA-15) as host materials for transporting therapeutics medicaments were fabricated for targeted drug delivery toward lung cancer. With the objective of increasing bioavailability and aqueous solubility of flavonoids, SBA-15 was successfully loaded with the quercetin (Q)-a major flavonoid and characterized with the help of Fourier-transform infrared spectroscopy (FTIR) and transmission electron microscopy (TEM). The biological investigation on A549 cell line confirmed that the efficacy of Q-SBA-15 is much higher than only Q. Moreover, the apoptotic pathway of synthesized Q-SBA-15 NPs examined that the Q-SBA-15-mediated apoptosis via PI3K/AKT/mTOR signaling pathway. Thus, the newly conjugated Q-SBA-15 system improved the apoptotic fate through caspase-mediated apoptosis via PI3K/AKT/mTOR signaling pathway and hence, it can be potentially employed as an anticancer agent for lung cancer.

Survival analysis and factors affecting survival in patients who presented to the medical oncology unit with non-small cell lung cancer

Background/aim

This study aimed to investigate the effect of clinical and pathological indicators at the time of the diagnosis on overall survival in patients recently diagnosed with non-small cell lung cancer.

Materials and methods

The study population consisted of patients who were diagnosed at the Faculty of Medicine at Isparta Süleyman Demirel University Hospital between January 1, 2010 and December 31, 2017 and presented to the medical oncology outpatient clinic.

Results

A total of 518 patients were evaluated, including 260 patients with squamous cell carcinoma, 207 patients with adenocarcinoma, 50 patients with non-small cell lung cancer-not otherwise specified, and 1 patient with large cell carcinoma. The average life expectancy was found to be 11.50 ± 1.40 months in patients with squamous cell carcinoma, 12.60 ± 1.59 months in patients with adenocarcinoma, and 8.70 ± 1.87 months in the other patients. The estimated 5-year relative survival rate for non-small cell lung cancer was 8% (7% for men and 18% for women). In the multivariate analysis, sex being male (HR, 2.41; P < 0.001), a performance status >2 (HR, 1.70; P < 0.001), the stage of cancer (HR, 1.37; P = 0.045), the presence of bone or liver metastasis (HR, 1.44, P = 0.009, HR, 1.57; P = 0.016, respectively), and the patient not having received radiotherapy (HR, 3.25; P < 0.001) or chemotherapy (HR, 1.85; P = 0.001) were defined as statistically significant predictive factors that reduced the overall survival.

Conclusions

In this study, sex, stage, performance status, the presence of liver or bone metastases, and treatment had an effect on overall survival.

Quercetin Enhances Chemosensitivity to Gemcitabine in Lung Cancer Cells by Inhibiting Heat Shock Protein 70 Expression

Quercetin is a bioflavonoid known for antioxidation and antiproliferation activities. We demonstrated that quercetin inhibited cancer cell growth and sensitized cancer cells to gemcitabine treatment by promoting apoptosis via inhibiting heat shock protein 70 expression. Our results suggest that quercetin might have potential to increase sensitivity to chemotherapy and that heat shock protein 70 could be a new target for lung cancer treatment.

BACKGROUND

Quercetin is a bioflavonoid with antiproliferative and proapoptotic activity in various cancer cells. However, little is known about the mechanism by which quercetin inhibits cancer growth or its potential role as a chemosensitizer in lung cancer cells. We investigated whether quercetin-induced inhibition of heat shock protein 70 (HSP70) is involved in its anticancer activity and whether it could modulate the responsiveness of lung cancer cells to chemotherapy.

MATERIALS AND METHODS

Various concentrations of quercetin and gemcitabine, either alone or in combination, were applied to lung cancer cells (A549 and H460 cells). We evaluated cell viability with the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide salt assay, apoptotic activity by determining caspase-3 and caspase-9 activities, and HSP70 expression using Western blot analysis after treatment.

RESULTS

Quercetin reduced cell viability and suppressed HSP70 expression in both cell lines dose-dependently. Adding a fixed quercetin dose enhanced gemcitabine-induced cell death, which was related to increased caspase-3 and caspase-9 activities. Combination treatment with quercetin and gemcitabine downregulated HSP70 expression more prominently than treatment with quercetin or gemcitabine alone.

CONCLUSION

Quercetin-induced HSP70 inhibition was involved in growth inhibition and sensitization to chemotreatment in lung cancer cells. Quercetin might have potential as a chemosensitizer in lung cancer treatment.

HER2 and lung cancer

In non-small-cell lung cancer (NSCLC), the identification of oncogenic driver mutations led to the definition of different clinical entities with different therapeutic opportunities, as demonstrated in patients harboring EGF receptor (EGFR) mutations or anaplastic lymphoma kinase translocations. Human EGFR2 (or HER2) has an established role as a prognostic and predictive factor in breast cancer. Although HER2 deregulation, including overexpression, amplification and mutation, has been described in NSCLC, its role as a therapy biomarker remains undefined. In the last few years, there has been a growing interest on HER2 mutation, with few anecdotal or retrospective studies suggesting a relevant role for this biomarker. This review discusses the prognostic and predictive impact of HER2 deregulation and the clinical implications of anti-HER2 strategies in NSCLC.

Relationship between programmed death-ligand 1 and clinicopathological characteristics in non-small cell lung cancer patients

OBJECTIVE

To evaluate the correlation between programmed death-ligand 1 (PD-L1) expression in primary lung cancer cells, tumor associated macrophages (TAM) and patients' clinicopathological characteristics.

METHODS

From 2008 to 2010, 208 non-small cell lung cancer patients who underwent surgery or CT-guided biopsy were recruited from Huadong Hospital, Fudan University. Immunohistochemistry staining was performed to evaluate the PD-L1 expression in both primary lung cancer cells and CD68 positive TAM. The relationship between PD-L1 expression and the clinical pathology was evaluated using χ(2) test. Spearman's rank correlations were used to determine the correlation between PD-L1 expression in tumor cells and macrophages.

RESULTS

Positive PD-L1 expression in primary cancer cells was found in 136 (65.3%) patients, which were negatively correlated with lymph node metastasis (P=0.009) and smoking history (P=0.036). Besides, TAM with PD-L1 expression (found in 116 patients) was positively associated with smoking history (P=0.034), well-differentiation (P=0.029) and negative lymph node metastasis (P=0.0096). A correlation between PD-L1 expression in primary tumor cells and non-small cell lung cancer associated macrophages was found (r=0.228, P=0.021).

CONCLUSION

PD-L1, secreted from TAM, might induce cancer cells apoptosis, and decrease lymph node metastasis.

Clinical significance and role of lymphatic vessel invasion as a major prognostic implication in non-small cell lung cancer: a meta-analysis

Background

Lymphatic vessel invasion (LVI) exerts an important process in the progression and local spread of cancer cells. However, LVI as a prognostic factor for survival in non-small cell lung cancer (NSCLC) remains controversial.

Methodology/Principal Findings

A meta-analysis of published studies from PubMed and EMBASE electronic databases was performed to quantity the effects of LVI on both relapse-free survival and overall survival for patients with NSCLC. Hazard ratios (HRs) with 95% confidence intervals (95% CIs) were used to assess the strength of these effects. This meta-analysis included 18,442 NSCLC patients from 53 eligible studies. LVI appeared in 32.1% (median; range, 2.8% to 70.9%) of tumor samples. In all, patients with LVI were 2.48 times more likely to relapse by univariate analysis (95% CI: 1.92–3.22) and 1.73 times by multivariate analysis (95% CI: 1.24–2.41) compared with those without LVI. For the analyses of LVI and overall survival, the pooled HR estimate was 1.97 (95% CI: 1.75–2.21) by univariate analysis and 1.59 (95% CI: 1.41–1.79) by multivariate analysis. Multivariate analysis showed a risk was 91% higher for recurrence (HR  = 1.91, 95% CI: 1.14–2.91) and 70% higher for mortality (HR = 1.70, 95% CI: 1.38–2.10) in LVI-positive I stage patients compared with LVI-negative I stage patients. Subgroup analyses showed similar significant adjusted risks for recurrence and death in adenocarcinomas, and a significant adjusted risk for death in studies that utilized elastic staining with or without immunohistochemistry in defining LVI.

Conclusions/Significance

The present study indicates that LVI appears to be an independent poor prognosticator in surgically managed NSCLC. NSCLC patients with LVI would require a more aggressive treatment strategy after surgery. However, large, well-designed prospective studies with clinically relevant modeling and standard methodology to assess LVI are required to address some of these important issues.

Monte Carlo role in radiobiological modelling of radiotherapy outcomes

Radiobiological models are essential components of modern radiotherapy. They are increasingly applied to optimize and evaluate the quality of different treatment planning modalities. They are frequently used in designing new radiotherapy clinical trials by estimating the expected therapeutic ratio of new protocols. In radiobiology, the therapeutic ratio is estimated from the expected gain in tumour control probability (TCP) to the risk of normal tissue complication probability (NTCP). However, estimates of TCP/NTCP are currently based on the deterministic and simplistic linear-quadratic formalism with limited prediction power when applied prospectively. Given the complex and stochastic nature of the physical, chemical and biological interactions associated with spatial and temporal radiation induced effects in living tissues, it is conjectured that methods based on Monte Carlo (MC) analysis may provide better estimates of TCP/NTCP for radiotherapy treatment planning and trial design. Indeed, over the past few decades, methods based on MC have demonstrated superior performance for accurate simulation of radiation transport, tumour growth and particle track structures; however, successful application of modelling radiobiological response and outcomes in radiotherapy is still hampered with several challenges. In this review, we provide an overview of some of the main techniques used in radiobiological modelling for radiotherapy, with focus on the MC role as a promising computational vehicle. We highlight the current challenges, issues and future potentials of the MC approach towards a comprehensive systems-based framework in radiobiological modelling for radiotherapy.

Blood vessel invasion as a strong independent prognostic indicator in non-small cell lung cancer: a systematic review and meta-analysis

Background and Objective

Blood vessel invasion plays a very important role in the progression and metastasis of cancer. However, blood vessel invasion as a prognostic factor for survival in non-small cell lung cancer (NSCLC) remains controversial. The aim of this study is to explore the relationship between blood vessel invasion and outcome in patients with NSCLC using meta-analysis.

Methods

A meta-analysis of published studies was conducted to investigate the effects of blood vessel invasion on both relapse-free survival (RFS) and overall survival (OS) for patients with NSCLC. Hazard ratios (HRs) with 95% confidence intervals (95% CIs) were used to assess the strength of this association.

Results

A total of 16,535 patients from 52 eligible studies were included in the systematic review and meta-analysis. In total, blood vessel invasion was detected in 29.8% (median; range from 6.2% to 77.0%) of patients with NSCLC. The univariate and multivariate estimates for RFS were 3.28 (95% CI: 2.14–5.05; P<0.0001) and 3.98 (95% CI: 2.24–7.06; P<0.0001), respectively. For the analyses of blood vessel invasion and OS, the pooled HR estimate was 2.22 (95% CI: 1.93–2.56; P<0.0001) by univariate analysis and 1.90 (95% CI: 1.65–2.19; P<0.0001) by multivariate analysis. Furthermore, in stage I NSCLC patients, the meta-risk for recurrence (HR = 6.93, 95% CI: 4.23–11.37, P<0.0001) and death (HR = 2.15, 95% CI: 1.68–2.75; P<0.0001) remained highly significant by multivariate analysis.

Conclusions

This study shows that blood vessel invasion appears to be an independent negative prognosticator in surgically managed NSCLC. However, adequately designed large prospective studies and investigations are warranted to confirm the present findings.

Expression and clinical significance of leptin, the functional receptor of leptin (OB-Rb) and HER-2 in non-small-cell lung cancer: a retrospective analysis

BACKGROUND

The human epidermal growth factor receptor 2 (HER-2) and leptin/OB-R system have been reported to be intertwined in several cancer types. However, limited research has been conducted with regard to this interaction in lung cancers. In this study, we investigated the relationship between the expression levels of these proteins and the development, progression and prognosis of non-small-cell lung cancer (NSCLC).

METHODS

The expression of leptin, OB-Rb and HER-2 was evaluated in 100 NSCLC specimens by immunohistochemistry, with normal lung tissue as controls. The relationships between their expression levels and clinicopathological factors were evaluated by correlation analysis. Univariate and multivariate analyses were used to determine the associations between the expression levels of these proteins and the survival of NSCLC patients.

RESULTS

Leptin was expressed in 71 and 25% (P < 0.05) of NSCLC and normal lung tissues, respectively, while OB-Rb was expressed in 62 and 31% (P < 0.05), respectively. Overexpression of HER-2 was detected in 53% of NSCLC tissues versus 0% of normal lung tissues (P < 0.05). A significant association was found between the expression levels of leptin and OB-Rb (P = 0.024), and between tumor-node-metastasis (TNM) stage and HER-2 expression (P = 0.003). Univariate survival analysis showed that TNM stage (P < 0.001) and leptin expression (P = 0.009) influenced survival time. Multivariate analysis suggested that TNM stage [hazard ratio (HR) 1.63, 95% confidence interval (CI) 1.30-2.04, P < 0.001] and leptin expression (HR 1.69, 95% CI 1.01-2.80, P = 0.044) were independent prognostic factors for NSCLC.

CONCLUSIONS

The expression of leptin, OB-Rb and HER-2 was significantly higher in NSCLC tissues than in normal lung tissues. The expression of leptin is an independent prognostic factor for NSCLC.

Factors associated with the development of brain metastases: analysis of 975 patients with early stage nonsmall cell lung cancer

BACKGROUND

The risk of developing brain metastases after definitive treatment of locally advanced nonsmall cell lung cancer (NSCLC) is approximately 30%-50%. The risk for patients with early stage disease is less defined. The authors sought to investigate this further and to study potential risk factors.

METHODS

The records of all patients who underwent surgery for T1-T2 N0-N1 NSCLC at Duke University between the years 1995 and 2005 were reviewed. The cumulative incidence of brain metastases and distant metastases was estimated by using the Kaplan-Meier method. A multivariate analysis assessed factors associated with the development of brain metastases.

RESULTS

Of 975 consecutive patients, 85% were stage I, and 15% were stage II. Adjuvant chemotherapy was given to 7%. The 5-year actuarial risk of developing brain metastases and distant metastases was 10%(95% confidence interval [CI], 8-13) and 34%(95% CI, 30-39), respectively. Of patients developing brain metastases, the brain was the sole site of failure in 43%. On multivariate analysis, younger age (hazard ratio [HR], 1.03 per year), larger tumor size (HR, 1.26 per cm), lymphovascular space invasion (HR, 1.87), and hilar lymph node involvement (HR, 1.18) were associated with an increased risk of developing brain metastases.

CONCLUSIONS

In this large series of patients treated surgically for early stage NSCLC, the 5-year actuarial risk of developing brain metastases was 10%. A better understanding of predictive factors and biological susceptibility is needed to identify the subset of patients with early stage NSCLC who are at particularly high risk.

Prognostic value of epidermal growth factor receptor expression in operable non-small cell lung carcinoma

Background and aim

Increased expression of the epidermal growth factor receptor (EGFR) in non-small cell lung cancer (NSCLC), supporting the tumor growth by a possible endocrine mechanism, affects patient survival negatively. We designed a study to test EGFR expression by immunohistochemistry (IHC) in resected stage I-II NSCLC and to correlate its overexpression with survival.

Methods

EGFR expression was evaluated in 98 consecutive NSCLC patients after complete resection (53 squamous cell carcinomas, 40 adenocarcinomas, 5 large cell carcinomas: stage I, 57 (58%) and stage II, 41 (42%). IHC was used to examine the expression of EGFR in resected lung tumor samples obtained from these patients, who had no pre- or post-operative chemotherapy or radiotherapy. Univariate and multivariate analyses were performed for factors influencing patient survival.

Results

EGFR was expressed in 51 (52%) of 98 NSCLC samples. More squamous tumors (61%) were EGFR-positive than adenocarcinomas (38%) (p = 0.038). There was a statistically significant correlation between EGFR expression and stage (p = 0.04). No difference was found between EGFR positive and negative tumors in the 5-year overall survival (57% vs. 73%, p = 0.13).

Conclusion

The level of EGFR expression in tumors was not a successful predictor of survival in resected NSCLC.

Usefulness of dynamic contrast enhanced computed tomography in patients with non-small-cell lung cancer scheduled for radiation therapy

OBJECTIVE

The goal of this study was to investigate the local tumor blood supply parameters relative tumor blood volume (rTBV) and transfer coefficient (K(trans)) measurable with dynamic contrast enhanced computed tomography (DCE-CT) in patients with non-small-cell lung cancer (NSCLC) scheduled for radiation therapy (RT).

MATERIALS AND METHODS

rTBV and K(trans) were measured before RT in 31 patients with clinically inoperable NSCLC (Stages I-III), which received (n=19) or did not receive (n=12) induction chemotherapy (IChT). Possible links between rTBV and K(trans) and time-to-progression (TTP), overall survival (OS) and maximum standardized uptake value (SUV(max)) from fluorodeoxyglucose positron emission tomography as well as histology were analyzed.

RESULTS

NSCLC showed a wide range of rTBV and K(trans) values as estimated by DCE-CT (6.4±0.6ml/100ml and 18.2±1.5ml/100ml/min correspondingly). A significant difference in rTBV values in patients with IChT (4.6±0.6ml/100ml) and without IChT (7.5±0.9ml/100ml; p=0.023), depending on the number of cycles of the IChT and the clinical stage was found. A negative correlation between rTBV and TTP was revealed only in RT patients up-staged by FDG-PET/CT from stage III to stage IV (n=7, r=-0.96, p=0.0006). An inverse correlation between K(trans) and TTP (n=24, r=-0.53, p=0.008) was observed in all RT patients. No relevant correlation was detected between rTBV, K(trans) and SUV(max) or histologic subtypes and grading.

CONCLUSIONS

Tumor blood supply parameters derived from DCE-CT are useful to characterize tumor vascularization before radiotherapy in patients with NSCLC and data on outcome prediction are supplemented.

Increased MET gene copy number negatively affects survival of surgically resected non-small-cell lung cancer patients

PURPOSE

To investigate the prognostic role of genomic gain for MET and epidermal growth factor receptor (EGFR) genes in surgically resected non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

This retrospective study included 447 NSCLC patients with available tumor tissue from primary lung tumor and survival data. EGFR and MET status was evaluated by fluorescent in situ hybridization (FISH) in tissue microarray sections.

RESULTS

EGFR FISH results were obtained in 376 cases. EGFR gene amplification and high polysomy (EGFR FISH+) were observed in 10.4% and 32.4% of cases, respectively. EGFR FISH-positive patients had a nonsignificant shorter survival than EGFR FISH-negative patients (P = .4). Activating EGFR mutations were detected in 9.7% of 144 stage I-II disease with no impact on survival. MET FISH analysis was performed in 435 cases. High MET gene copy number (mean > or = 5 copies/cell) was observed in 48 cases (MET+, 11.1%), including 18 cases with true gene amplification (4.1%). MET+ status was associated with advanced stage (P = .01), with grade 3 (P = .016) and with EGFR FISH+ result (P < .0001). No patient with activating EGFR mutation resulted MET+. In the whole population, MET-positive patients had shorter survival than MET-negative patients (P = .005). Multivariable model confirmed that MET-negative patients had a significant reduction in the risk of death than MET-positive patients (hazard ratio, 0.66; P = .04).

CONCLUSION

MET increased gene copy number is an independent negative prognostic factor in surgically resected NSCLC. EGFR gene gain does not impact survival after resection.

Sex-specific aspects of tumor therapy

There is increasing evidence that sex-specific differences in toxicity profiles and outcome after radiotherapy are accumulating in medical oncology, and that treatment strategies may require some modification. Furthermore, sex-specific differences in the sensitivity to genotoxic and therapeutical agents are also of general concern for risk estimation. This review is focussed on the specific influence of sex on these endpoints covering both a clinical and a biological point of view. In this paper, the literature was systematically reviewed with respect to sex-specific differences in tumor and normal tissue sensitivity after exposure to ionizing radiation, as well as to the relevant underlying molecular and cellular mechanisms. Although a number of data on sex-specific differences are available and remarkable differences on clinical, molecular, and cellular levels have been reported, a firm conclusion on any existing sex-specific differences is not yet possible. Future studies are required and should be focussed on this aspect of individual radiosensitivity.

Adjuvant chemotherapy of cisplatin, 5-fluorouracil and leucovorin for complete resectable esophageal cancer: a case-matched cohort study in east China

It is still controversial whether adjuvant chemotherapy of cisplatin, 5-fluorouracil and leucovorin can increase the overall survival of esophageal cancer patients, and which subgroup of patients get most benefits from it. Between 1998 and 2004, 66 esophageal cancer patients with adjuvant chemotherapy and 160 well-matched patients without chemotherapy were included in this study. Nine markers were measured in the protein level to analyze prognostic significance. In the whole group, adjuvant chemotherapy did not improve the survival of esophageal cancer patients. There was also no significant difference for survival in stage I (P=0.59 and P=0.59), stage II (P=0.28 and P=0.28) and stage III patients (P=0.144 and P=0.06) between the observation and the chemotherapy group. Chemotherapy was most effective for the patients who had metastases in cervical and/or celiac lymph nodes (IV subgroup). One and 3-year disease-free survival and overall survival were significantly better than for those who did not receive the chemotherapy(P=0.038, and 0.016, respectively). Bcl-2 expression was a bad prognostic factor, and was more predictive in the adjuvant chemotherapy group than in the no-chemotherapy group. Adjuvant chemotherapy significantly improved the treatment result of stage IV patients compared with the observation group. Bcl-2 could be used to analyze prognosis and guide the adjuvant treatment.

Intrapulmonary metastasis in resected pathologic stage IIIB non–small cell lung cancer: Possible contribution of aerogenous metastasis to the favorable outcome

OBJECTIVE

Non-small cell lung cancer with pulmonary metastasis in the primary lobe (PM+) is classified as pathologic stage IIIB. Although stage IIIB PM+ indicates a poor prognosis, this stage includes various subgroups with heterogeneous clinical outcomes. The objective of this study was to extract a subgroup of patients with stage IIIB PM+ non-small cell lung cancer with a better prognosis and assess their biological characteristics and metastatic mechanisms.

METHODS

We reviewed 122 cases of surgically resected stage IIIB PM+ non-small cell lung cancer and extracted a subgroup with a favorable outcome by univariate analysis of clinicopathologic factors. The 15 cases without lymph node metastasis and vessel invasion (PM+/N-/VI-) were extracted as the most favorable group. We assessed the clinicopathologic features of the PM+/N-/VI- group in comparison with the other patients with stage IIIB PM+ disease.

RESULTS

The disease-specific survival of the PM+/N-/VI- group was significantly better than that of the other stage IIIB PM+ group. Microscopic characteristics of the metastatic lesions suggesting that the cancer cells had invaded via the aerogenous route were seen in 86.7% of the PM+/N-/VI- group, as opposed to only 9.4% of the other PM+ cases. Furthermore, in all 4 patients in the PM+/N-/VI- group who had a recurrence, the relapse involved intrapulmonary metastasis, rather than distant organ metastasis.

CONCLUSIONS

Stage IIIB PM+ cases via the airway route were enriched in the PM+/N-/VI- group and had an extremely good survival. This group should be recognized as having local disease, and if relapse occurs in the remnant lobe, it may be possible to achieve a cure by local therapy.

Novel therapies targeting signaling pathways in lung cancer

Despite advances in chemotherapy, the prognosis for advanced non-small-cell lung cancer (NSCLC) remains dismal. Increasing understanding of the biological processes responsible for lung carcinogenesis has led to development of new therapeutic strategies targeting this disease at a molecular level. This article examines the molecular events believed to lead to cellular changes in lung cancer, and how knowledge of these is used to develop new agents used individually or in combination with available cytotoxic drugs to improve survival. Finally, it explores how a deeper understanding of the embryonic signaling pathways responsible for airway epithelial repair and tumorogenesis, such as Hedgehog (Hh), Notch, and Wingless (Wnt), can lead to the development of newer and more specific therapies for lung cancer.

Gene Expression Profiles from Needle Biopsies Provide Useful Signatures of Non-Small Cell Lung Carcinomas

Gene expression profiles from DNA microarrays can provide molecular signatures that improve tumor classification, prognosis, and treatment options. While much of this work has focused on isolation of RNA from the resected tumor, fewer studies have utilized RNA from fine needle aspirates (FNA). In this pilot study we examined whether the gene signatures obtained from FNA samples would correlate with signatures taken from the resected tumor. Based on NSCLC gene expression profiles obtained from eleven sets of FNA and tumor samples we obtained a high concordance of FNA profiles matching their matched tumor sample. These results suggest that FNA samples may provide informative gene expression signatures regarding the potential aggressiveness of non-small-cell lung carcinomas.

Immunohistochemical markers of prognosis in non-small cell lung cancer: a review and proposal for a multiphase approach to marker evaluation

Characteristics of the tumour that affect and predict the survival outcome of patients with cancer are prognostic markers for cancer. In non-small cell lung carcinoma (NSCLC), stage is the main determinant of prognosis and the basis for deciding options for treatment. Patients with early-stage tumour are treated by complete surgical resection, which is curative in 40-70% of patients. That there are other factors important in determining the biology of these tumours, especially genes that have a role in metastasis, is indicated. Such factors could potentially be used to further classify patients into groups according to substages that may be treated differently. During the past decade, a large number of proteins that are putatively important in carcinogenesis and cancer biology have been studied for their prognostic value in NSCLC, but none of them have been proved to be sufficiently useful in clinical diagnosis. Several markers (epidermal growth factor receptor, human epidermal growth factor receptor 2, Ki-67, p53 and Bcl-2) have been studied exhaustively. Ki-67, p53 and Bcl-2 are suggested to be important but weak prognostic markers, by meta-analyses of the results. Cyclin E, vascular endothelial growth factor A, p16(INK4A), p27(kip1) and beta-catenin are promising candidates, but require further study in large randomised clinical trial samples by using standardised assays and scoring systems. Some issues and inconsistencies in the reported studies to date are highlighted and discussed. A guideline for a multi-phase approach for conducting future studies on prognostic immunohistochemistry markers is proposed here.

The Role of c-erbB-2 Expression on the Survival of Patients with Small-Cell Lung Cancer

The aim of this study was to determine the incidence and role of c-erbB-2 overexpression as a predictive/prognostic marker in small-cell lung carcinoma (SCLC). We performed a retrospective study on subjects with a biopsy-proven diagnosis of SCLC. A chart review for demographic and clinical data was performed on patients with SCLC diagnosed between 1998 and 2004. c-erbB-2 overexpression was evaluated using immunohistochemistry performed on archival paraffin-embedded specimens. Sixty-seven patients with SCLC were identified (6 females, 61 males; median age- 56.5 yr, range-34-75) all of whom had adequate tissue specimens available for c-erB-2 testing. Of the 67 specimens, 12 (17.9%) showed c-erbB-2 overexpression. Seventy-five of the cases were positive for c-erbB-2, had extensive disease. The median overall survival of patients with SCLC whose tumors were positive and negative for c-erbB-2 were 8 +/- 0.9 months (95%CI 6.3-9.7) and 11 +/- 1.5 months (95%CI 8.0-14.0), respectively. c-erbB-2 overexpression detected using immunohistochemistry is observed in 17.9% of patients with SCLC and has statistically significant prognostic value. Our findings suggest that c-erbB-2 may be a potential target for site-specific immunotherapy in SCLC. Considering one technique examined, further molecular investigation is needed to confirm these preliminary findings.

Epidermal growth factor receptor mutations in non-small cell lung cancer: a basic science discovery with immediate clinical impact

A large body of preclinical work suggested that the epidermal growth factor receptor (EGFR) would be a successful target for therapy against non-small cell lung cancer (NSCLC), and this led to the development of oral, selective EGFR tyrosine kinase inhibitors (TKI) that improve symptoms and survival in patients with advanced NSCLC. However, not all patients benefit from this treatment, and there has been great interest in identifying the molecular correlates that predict for response to these agents. The recent detection of somatic mutations in EGFR that predict for response to the EGFR tyrosine kinase inhibitors has excited the scientific community. This discovery has far-reaching implications, not only for lung cancer patients treated with an EGFR TKI but also for future drug development in all malignancies.

Prognostic factors in non-small cell lung cancer surgery

AIMS

Complete surgical resection of primary tumours remains the treatment with the greatest likelihood for survival in early-stage non-small cell lung cancer (NSCLC). Although TNM stage is the most important prognostic parameter in NSCLC, additional parameters are required to explain the large variability in postoperative outcome. The present review aims at providing an overview of the currently known prognostic markers for postoperative outcome.

METHODS

We performed an electronic literature search on the MEDLINE database to identify relevant studies describing the risk factors in NSCLC surgery. The references reported in all the identified studies were used for completion of the literature search.

RESULTS

Poor pulmonary function, cardiovascular disease, male gender, advanced age, TNM stage, non-squamous cell histology, pneumonectomy, low hospital volume and little experience of the surgeon were identified as risk factors for postoperative outcome. However, with the exception of TNM stage and extent of resection, the literature demonstrates conflicting results on the prognostic power of most factors. The role of molecular biological factors, neoadjuvant treatment and adjuvant treatment is not well investigated yet.

CONCLUSIONS

The advantage of knowing about the existence of comorbidity and prognostic risk factors may provide the clinician with the ability to identify poor prognostic patients and establish the most appropriate treatment strategy. The assessment of prognostic factors remains an area of active investigation and a promising field of research in optimising therapy of NSCLC patients.

Survival impact of epidermal growth factor receptor overexpression in patients with non-small cell lung cancer: a meta-analysis

BACKGROUND

It is thought that overexpression of epidermal growth factor receptor (EGFR) in non-small cell lung cancer (NSCLC) might compromise patient survival, presumably by promoting tumour growth by an autocrine mechanism. However, conflicting results have been reported from various laboratories, and the clinical importance of EGFR overexpression remains unsettled.

METHODS

A meta-analysis of previous studies was performed to quantitatively review the effects of EGFR overexpression on survival in patients with NSCLC using a DerSimonian-Laird random effects model. Eighteen studies including 2972 patients were subjected to final analysis.

RESULTS

Overall, positivity for EGFR overexpression differed between histological types: 39% in adenocarcinomas, 58% in squamous cell carcinomas, 38% in large cell carcinomas, and 32% in cancers in a miscellaneous category (p<0.0001). The combined hazard ratio (HR) was 1.14 (95% CI 0.97 to 1.34; p = 0.103), indicating that EGFR overexpression has no significant impact on survival. When only the 15 immunohistochemistry based studies were considered, the combined HR was 1.08 (95% CI 0.92 to 1.28; p = 0.356), again suggesting that EGFR overexpression has no impact on survival. Heterogeneity testing indicated that there was heterogeneity between studies but publication bias was absent, which suggests that the summary statistics obtained may approximate the actual average.

CONCLUSIONS

EGFR overexpression was not associated with poorer survival in patients with NSCLC. Specific mutations of the EGFR gene will need further study in terms of survival implications.

Association of HER-2 overexpression with prognosis in nonsmall cell lung carcinoma: a metaanalysis

BACKGROUND

Prognostic implications of overexpression of the HER-2 gene in nonsmall cell lung carcinoma (NSCLC) are a matter of controversy. Many conflicting results have been reported from different laboratories.

METHODS

A metaanalysis of published studies was performed for this quantitative review of the effects of HER-2 overexpression on survival among patients with NSCLC. Of 44 articles initially selected, 20 articles fulfilled eligibility criteria. DerSimonian-Laird random effects analysis was used to estimate the effects of HER-2 overexpression on survival differences (the survival rate among patients without HER-2 overexpression minus the survival rate among patients with HER-2 overexpression) at endpoints of 1 years, 3 years, and 5 years after resection of NSCLC.

RESULTS

In total, 2579 patients were included in the final analysis. Overall, HER-2 positivity differed according to histologic type and included 38% of patients with adenocarcinoma, 16% of patients with squamous cell carcinoma, and 18% of patients with large cell carcinoma (P < 0.0001). The combined survival differences in patients with NSCLC at 1 year, 3 years, and 5 years, respectively, were 2.7% (95% confidence interval [95% CI], 1.3-6.7%; P = 0.1787), 15.2% (95% CI, 5.8-24.5%; P = 0.0015), and 16.4% (95% CI, 7.9-14.8%; P = 0.0001), suggesting significant poorer survival at 3 years and 5 years among patients with HER-2 overexpression. In patients with adenocarcinoma, the combined survival difference at 5 years was 26.0% (95% CI, 16.0-36.1%; P < 0.0001), suggesting a particularly strong survival impact for HER-2 overexpression.

CONCLUSIONS

A significant, unfavorable prognostic effect of HER-2 overexpression in NSCLC was evident from the metaanalysis. However, because several studies that found no significant difference were excluded by the current eligibility criteria, caution is needed in interpreting the results.

Current Management of Advanced Non-Small Cell Lung Cancer: Targeted Therapy

Lung cancer is one of the most frequent causes of cancer-related death in the United States. For patients with advanced non-small cell lung cancer (NSCLC), chemotherapy, alone or in combination with radiation therapy, is considered the standard treatment. Although this treatment may result in a modest improvement in patient survival, overall prognosis of these patients remains dismal, and the treatment is nonspecific, nonselective, and toxic. Therefore, new therapeutic strategies are needed. During the past decade, several molecules that contribute to lung cancer progression and metastasis have been identified. Growth factors and proangiogenic factors have been the focus of intense research in cancer since therapeutic approaches for their inhibition do exist. The role of these factors was studied in different organs and tumors and was found to be phenotypically distinct. Several molecular targeted therapies have shown efficacy and had been approved for treatment of specific cancers. Most advanced in clinical research for lung cancer are targeted therapies that inhibit the epidermal growth factor receptor (EGFR) and the vascular endothelial growth factor (VEGF) signaling pathways. Others are signaling pathway inhibitors. The first targeted therapy for lung cancer is gefitinib, an EGFR inhibitor, which was approved in several countries in 2003. Goals of molecular targeted therapy studies include the following: better understanding of the exact role of particular growth factors in specific tumors; establishment of new clinical study designs for biological agents; and tailoring appropriate combinations of conventional chemotherapy and/or radiotherapy with biological therapy for specific patients. Achievement of these goals will hopefully lead to incorporation of biological therapy into the current anticancer arsenal, for the benefit of lung cancer patients.

Expression of E-cadherin and nm23 is associated with the clinicopathological factors of human non-small cell lung cancer in China

E-cadherin, a calcium-dependent cell-cell adhesion molecule, functions as maintenance of epithelial integrity. nm23, encoded by non-metastatic 23 gene, plays a key role in differentiation of many kinds of epithelium. Loss or dysfunction of E-cadherin and nm23 was frequently identified in many types of human cancers and is considered to correlate with invasive/metastatic phenotype. We previously reported that defective expression of E-cadherin might play a role in the development of the malignant phenotype in non-small cell lung cancer (NSCLC) [Q.Y. Fei, H.T. Zhang, X.F. Chen, et al., Defected expression of Ecadherin in non-small cell lung cancer, Lung Cancer 37 (2002) 147-152]. In an attempt to evaluate the significance of E-cadherin and nm23 in human non-small cell lung cancer, we performed mRNA expression and genetic structure analyses of the E-cadherin and nm23 genes in 54 NSCLCs and 46 normal lung tissues. The mRNA expression was determined by semi-quantitative RT-PCR, and genetic structure was examined through PCR-SSCP followed by sequencing. Although no mutation of the E-cadherin and nm23 genes was detected, the results obtained in the present study showed that reduction of E-cadherin and nm23 mRNA expression remarkably correlated with low histological differentiation, increasing stage as well as lymph node metastases (P<0.05). These data provide us with support for the idea that dysfunction of E-cadherin and nm23 has a role in progression of NSCLC and that the examination of E-cadherin and nm23 expression can provide experimental evidence for clinical treatment.

Clinical significance of biological differences between cavitated and solid form of squamous cell lung cancer

Recently, Kolodziejski et al. [Kołodziejski LS, Dyczek S, Duda K, Goralczyk KJ, Wysocki MW, Lobaziewicz W. Cavitated tumor as a clinical subentity in squamous cell lung cancer patients. Neoplasma 2003;50:66--73] have shown, that patients with cavitated form of squamous cell lung cancer (c-SqCLC) treated by surgery had shorter survival than patients with solid form (s-SqCLC) despite having similar stage, histological features and causes of deaths. Therefore, we decided to check if tumour biological features are responsible for the difference in patients' response. The aim of the study was to assess tumour proliferation rate (MIB-1 labelling index, MIB-1 LI), tumour proliferation pattern and expression of epidermal growth factor receptor (EGFR labelling index, EGFR LI) in solid and cavitated SqCLCs. A total of 81 patients with SqCLC were analysed; 18 c-qCLC (with cavity identified at X-ray examination) and 63 s-SqCLC. Expression of Ki-67 protein (MIB-1 LI) and proliferation pattern based on this staining and EGFR LI was visualized in formalin-fixed paraffin-embedded sections, using immunohistochemistry. s-SqCLC showed faster proliferation than c-SqCLC. Mean MIB-1 LI for the first group was higher-39.2% (range, 12.7--65.6) than for the second group--26.1% (range, 7.1--45.6) (P=0.000). In c-SqCLC subgroup, eight tumours with intermediate type of proliferation, six with random and four with mixed pattern were identified. However, in the s-SqCLC there were 18 with intermediate, 22 with random and 22 with mixed type of proliferation. The difference between architecture of proliferation and histological grade was seen (P=0.040). Mean EGFR LI did not differ between c-SqCLC (31.1%) and s-SqCLC (29.3%); however, median value was non-significantly lower for c-SqCLC (14.0%) than in s-SqCLC (21.0%). Univariate Kaplan-Meier analysis revealed that patients with s-SqCLC and a lower pTNM, faster tumour proliferation (MIB-1 LI>39%) and 13%</=EGFR LI<80% had significantly longer survival. Cox multivariate analysis performed for the whole analysed group showed that proliferation rate, expression of EGF receptor (EGFR LI); pTNM and form of SqCLC were significant in respect of patients' survival. However, when the analysis was performed separately for s-SqCLC and c-SqCLC it appeared that biological parameters (EGFR LI and proliferation pattern) were significant only for solid and not for cavitated SqCLC form. For the latter, only clinical (TNM) and pathological stage (pTNM) appeared to be important and therefore adjuvant systemic chemotherapy after surgery may be more indicated.

The role of RAS oncogene in survival of patients with lung cancer: a systematic review of the literature with meta-analysis

The proto-oncogene RAS, coding for a 21 kDa protein (p21), is mutated in 20% of lung cancer. However, the literature remains controversial on its prognostic significance for survival in lung cancer. We performed a systematic review of the literature with meta-analysis to assess its possible prognostic value on survival. Published studies on lung cancer assessing prognostic value of RAS mutation or p21 overexpression on survival were identified by an electronic search. After a methodological assessment, we estimated individual hazard ratios (HR) estimating RAS protein alteration or RAS mutation effect on survival and combined them using meta-analytic methods. In total, 53 studies were found eligible, with 10 concerning the same cohorts of patients. Among the 43 remaining studies, the revelation method was immunohistochemistry (IHC) in nine and polymerase chain reaction (PCR) in 34. Results in terms of survival were significantly pejorative, significantly favourable, not significant and not conclusive in 9, 1, 31, 2, respectively. In total, 29 studies were evaluable for meta-analysis but we aggregated only the 28 dealing with non-small-cell lung cancer (NSCLC) and not the only one dealing with small-cell-lung cancer (SCLC). The quality scores were not statistically significantly different between studies with or without significant results in terms of survival, allowing us to perform a quantitative aggregation. The combined HR was 1.35 (95% CI: 1.16–1.56), showing a worse survival for NSCLC with KRAS2 mutations or p21 overexpression and, particularly, in adenocarcinomas (ADC) (HR 1.59; 95% CI 1.26–2.02) and in studies using PCR (HR 1.40; 95% CI 1.18–1.65) but not in studies using IHC (HR 1.08; 95% CI 0.86–1.34). RAS appears to be a pejorative prognostic factor in terms of survival in NSCLC globally, in ADC and when it is studied by PCR.

Coexpression of epidermal growth factor receptor with related factors is associated with a poor prognosis in non-small-cell lung cancer

The epidermal growth factor receptor (EGFR) is commonly expressed in non-small-cell lung cancer (NSCLC) and promotes a host of mechanisms involved in tumorigenesis. However, EGFR expression does not reliably predict prognosis or response to EGFR-targeted therapies. The data from two previous studies of a series of 181 consecutive surgically resected stage I–IIIA NSCLC patients who had survived in excess of 60 days were explored. Of these patients, tissue was available for evaluation of EGFR in 179 patients, carbonic anhydrase (CA) IX in 177 patients and matrix metalloproteinase-9 (MMP-9) in 169 patients. We have previously reported an association between EGFR expression and MMP-9 expression. We have also reported that MMP-9 (P=0.001) and perinuclear (p)CA IX (P=0.03) but not EGFR expression were associated with a poor prognosis. Perinuclear CA IX expression was also associated with EGFR expression (P<0.001). Multivariate analysis demonstrated that coexpression of MMP-9 with EGFR conferred a worse prognosis than the expression of MMP-9 alone (P<0.001) and coexpression of EGFR and pCA IX conferred a worse prognosis than pCA IX alone (P=0.05). A model was then developed where the study population was divided into three groups: group 1 had expression of EGFR without coexpression of MMP-9 or pCA IX (number=21); group 2 had no expression of EGFR (number=75); and group 3 had coexpression of EGFR with pCA IX or MMP-9 or both (number=70). Group 3 had a worse prognosis than either groups 1 or 2 (P=0.0003 and 0.027, respectively) and group 1 had a better prognosis than group 2 (P=0.036). These data identify two cohorts of EGFR-positive patients with diametrically opposite prognoses. The group expressing either EGFR and or both MMP-9 and pCA IX may identify a group of patients with activated EGFR, which is of clinical relevance with the advent of EGFR-targeted therapies.

Epidermal growth factor receptor as a target to improve treatment of lung cancer

Despite considerable efforts to reduce tobacco use, lung cancer remains the most common cancer in both men and women. Recent advances in radiation therapy and chemotherapy for lung cancer have yielded encouraging results, but survival in patients with locally advanced non-small-cell lung cancer (NSCLC) remains poor. As more and more molecular changes and their importance in malignant tissues continue to be characterized, approaches to target those aberrant pathways are being actively explored. The epidermal growth factor receptor (EGFR) is commonly overexpressed in NSCLC, particularly squamous cell carcinoma, and has been implicated in the development and progression of this disease, although a clear correlation with prognosis has not been established. Several different strategies have been developed to target and block the EGFR and its downstream effects, and some of them have been intensively studied in preclinical and clinical studies as a single-agent approach or in combination with radiation therapy or chemotherapy. In this article, we review the role of EGFR in lung cancer, as well as preclinical and clinical data on strategies to interfere with EGFR signaling alone or in combination with chemotherapy, radiation, or both.

Epidermal growth factor receptor (EGFR) expression in operable non-small cell lung carcinoma

This study was performed to assay the expression of epidermal growth factor receptor (EGFR) in non-small cell lung carcinoma (NSCLC), and to investigate the relationship between EGFR status and various clinicopathologic features of NSCLC, including angiogenesis and proliferative activity. The expression of EGFR, microvessel count (MVC) measured by CD31 monoclonal antibody, and proliferative activity using Ki-67 labeling index were immunohistochemically analyzed in formalin-fixed and paraffin-embedded tissue specimens from 65 patients with completely resected stage II-IIIA NSCLC. Pathologic and clinical records of all patients were retrospectively reviewed. EGFR was expressed in 18 (28%) of 65 NSCLC samples. More squamous tumors (35%) were EGFR-positive than other NSCLCs (23%) (p-value 0.308). There was a statistically significant correlation between EGFR expression and Ki-67 labeling index (p-value 0.042), but no correlation was observed between EGFR expression and tumor histology, stage, or MVC. There were no differences between EGFR positive and negative tumors in 5-yr disease-free survival (60% vs. 52%, p-value 0.5566) and 5-yr overall survival (53% vs. 45%, p-value 0.3382) rates. In conclusion, our findings suggest that NSCLC proliferative activity may be dependent on EGFR expression, but that EGFR expression had no significant impact on survival in curatively resected NSCLC.

MDM2 gene amplification: a new independent factor of adverse prognosis in non-small cell lung cancer (NSCLC)

The prognostic impact of MDM2 amplification in non-small cell lung cancer (NSCLC) remains unknown. In this study, we investigated the occurrence of MDM2 amplification in surgically treated NSCLC patients. Molecular data were correlated with clinicopathological factors and evaluated for their prognostic value. The study group included 116 NSCLC patients who underwent pulmonary resection between 1996 and 1999. MDM2 amplification was assessed by real-time PCR using hybridization probe format on a LightCycler (Roche). The calculated ratio was a MDM2 value normalized to the amplification of the housekeeping gene phenylalaninhydroxylase (PAH). Survival curves were drawn according to the Kaplan-Meier method and compared with the use of the log-rank test. Multivariate analysis was based on Cox regression analysis. MDM2 amplification was found in 24 patients (21%). There was no relationship between MDM2 amplification and clinicopathological factors, such as sex, age and stage of disease, pT, pN, histology and tumor differentiation. Median disease-free survival (DFS) in patients with and without MDM2 amplification was 3 and 31 months, and 5-year DFS 24 and 33%, respectively (log-rank, P = 0.02). Likewise, median overall survival (OS) in patients with and without MDM2 amplification was 9 and 33 months, respectively, and 5-year OS 24 and 39%, respectively (log-rank, P = 0.01). The strong prognostic relevance of MDM2 amplification for both DFS and OS was confirmed in multivariate analysis (P < 0.01 for both comparisons). Our results suggest that MDM2 gene amplification analysis provides additional prognostic information in surgically treated NSCLC patients.

Large cell neuroendocrine carcinoma of the lung: an aggressive disease potentially treatable with surgery

BACKGROUND

Assessment of clinical and pathologic features of large cell neuroendocrine carcinoma to confirm its specificity in the setting of high grade neuroendocrine pulmonary tumors.

METHODS

From 1989 to 2001, 123 patients with a neuroendocrine carcinoma were surgically treated in a curative intent at a single institution. According to the 1999 World Health Organization classification, 20 patients were reviewed as having a large cell neuroendocrine carcinoma. Clinical data as well as detailed pathologic analysis and survival were collected.

RESULTS

There were 18 men and 2 women. The median age was 62 years. Four patients had a preoperative diagnosis of large cell neuroendocrine carcinoma. The resections consisted of 14 lobectomies and 6 pneumonectomies. There was no operative death. Complications occurred in 7 patients (35%). Four patients had a stage I of the disease, 4 had stage II, 9 had stage III, and 3 had stage IV. At follow-up (median, 46 months), 13 patients died from general recurrence and 7 patients were still alive. Median time to progression was 9 months (range, 1 to 54 months). The 5-year survival rate was 36% (median, 49 months) and it seemed to be negatively influenced by the disease stage (54% for stage I-II vs 25% for stage III-IV; p = 0.07), the presence of metastatic lymph node (45% for N0/N1 vs 17% for N2; p = 0.12), or vessel invasion (66 vs 25%; p = 0.18).

CONCLUSIONS

Large cell neuroendocrine carcinoma predominantly occurred in men. An accurate tissue diagnosis was rarely obtained preoperatively. Although overall survival after resection was substantial, large cell neuroendocrine carcinoma frequently showed pathologic features of occult metastatic disease, such as lymph node or vessel invasion, or both.

Nonanatomic prognostic factors in resected nonsmall cell lung carcinoma: the importance of perineural invasion as a new prognostic marker

BACKGROUND

A number of prognostic factors have been reported for resected nonsmall cell lung carcinoma. Although none of them reported to have greater prognostic impact than the TNM staging system, which is based on anatomical descriptions of tumors, the prognoses of a significant number of patients are not in agreement with real survival of the patients. Moreover, certain histopathologic properties of the tumor (such as lymphatic and vascular invasion) could help to predict the survival of the patients.

METHODS

A retrospective study was conducted on 82 surgically resected nonsmall cell lung carcinomas, and the following prognostic factors were evaluated in univariate analysis: age, gender, clinical and surgical-pathologic T and N status, histologic type of tumor, grade of differentiation, lymphatic invasion, vascular invasion, and perineural invasion.

RESULTS

Lymphatic invasion and perineural invasion of the tumor were found to be significant prognostic factors (p = 0.02 and p = 0004). Blood vessel invasion (venous or arterial involvement) had no prognostic impact (p > 0.05). According to multivariate analyses, three factors were selected as prognostic indicators: (1) clinical N status (p = 0.027), (2) lymphatic invasion (p = 0.027) and (3) perineural invasion (p = 0.0148). By combining these factors we identified a poor prognostic subgroup of patients with stage I disease.

CONCLUSIONS

Our study showed that lymphatic vessel and perineural invasion of the tumor could be prognostic factors, along with anatomical determinants such as cN and surgical-pathologic stage of the pulmonary carcinoma.

Extensive experience of disease control with gefitinib and the role of prognostic markers

Traditionally, the efficacy of an anticancer agent has been measured by response rate. With the development of biological molecular-targeted agents, which have a different mechanism of action from conventional agents, it may be appropriate to consider alternative criteria that reflect the positive effect of these biological agents on disease control, palliation, symptom improvement and quality of life. One such targeted agent is the orally active epidermal growth factor receptor tyrosine kinase inhibitor gefitinib ("Iressa", ZD1839). This article reviews the clinical experience of patients with advanced/metastatic non-small-cell lung cancer, who have received gefitinib as part of a clinical trial or through the "Iressa" Expanded Access Programme. Disease-control rates of approximately 50% were observed in some Expanded Access Programme series, comparable with results obtained from Phase II trials. Symptom improvement was also reported. Information that will help identify those patients most likely to respond to treatment will become increasingly important. Therefore, the possible role of prognostic markers and the relationship between epidermal growth factor receptor status and response to gefitinib has been investigated. No clear association between epidermal growth factor receptor expression and response was observed. Future studies of other biomarkers in the epidermal growth factor receptor pathway should help to identify which patients are likely to benefit most from gefitinib.

Lack of prognostic implications of HER-2/neu abnormalities in 345 stage I nonsmall cell carcinomas (NSCLC) and 207 stage I-III neuroendocrine tumours (NET) of the lung

HER-2/neu oncogene activation by either gene amplification and/or protein overexpression has been documented in several human malignancies. Irrespective of protein overexpression, HER-2/neu gene amplification is rare in lung cancer and studies on its prevalence and clinicopathological implications in early stage non-small cell lung cancer (NCSLC) and neuroendocrine tumours (NET) of the lung are lacking. We evaluated HER-2/neu abnormalities in 345 Stage I NSCLC and 207 Stage I-III NET of the lung of all the diverse histological types, by using immunohistochemistry and fluorescent in situ hybridization in selected cases. Overall, HER-2/neu immunoreactivity was detected in 23% of 345 NSCLC and in 7% of 207 NET. Gene amplification was seen in only 7 (7.4%) of the immunoreactive tumours, with high-level amplification (HER-2/neu gene to chromosome 17 ratio > 4.0) in 3 adenocarcinomas, 1 squamous-cell carcinoma and 1 large-cell neuroendocrine carcinoma (LCNEC), and low-level amplification (HER-2/neu gene to chromosome 17 ratio from 2.0 to 4.0) in 1 squamous-cell carcinoma and 1 LCNEC. None of tested carcinoids and SCLC showed gene amplification. All but 1 gene amplified case exhibited 2+ or 3+ membrane labeling. No relationship was found between gene amplification or protein overexpression and patients' survival or other clinicopathological variables. HER-2/neu gene amplification and protein overexpression are not closely correlated in lung carcinomas and do not bear any prognostic implication. Among neuroendocrine tumours, LCNEC show a slightly higher prevalence of either HER-2/neu gene amplification or protein overexpression.

Calcification in coronary arteries as quantified by CT scans correlated with tobacco consumption in patients with inoperable non-small cell lung cancer treated with three-dimensional radiotherapy

It has been shown that radiological manifestations of coronary artery sclerosis are an indirect measure of co-morbidity and predictive of survival. The aim of the present study is to evaluate the outcome and side effects after three-dimensional (3D) radiotherapy in patients with unresectable non-small cell lung cancer (NSCLC) stage I, II and IIIA, depending on coronary artery calcification, Karnofsky performance index (KI) and co-morbidity. Between 1993 and 1999, 89 patients with unresectable NSCLC were treated with 3D-radiotherapy. The median age was 66.6 years and median KI 80%. All patients had 3D-treatment planning, based on CT scans. The median total dose was 60 Gy in 2 Gy fractions five times a week. The mean follow-up period was 13.2 months and mean survival time 12.2 months. Significant prognostic factors for improved survival were KI and tumour stage. Patients with a KI<90% had a median survival of 6.5 months compared with 14 months, in patients with KI>/==" BORDER="0">90% (p<0.001). NSCLC stage I+II showed a significantly longer median survival than patients with NSCLC stage IIIA (16.5 months versus 7 months, p<0.004). A significant correlation was seen between pack-years and coronary artery calcification (p<0.05) and between age and marked coronary artery calcification. The incidence of calcification was 67% in smokers (>/==" BORDER="0">20 pack-years) and 43/58 in patients >60 years (p<0.007). Side effects, e.g. pneumonitis, did not correlate with coronary artery calcification but correlated with chronic obstructive lung disease in 19/89 patients. Conventional CT scans for 3D-treatment planning are able to detect coronary artery calcification. There is a significant correlation between age, KI, tobacco consumption and vascular calcification. Although there was a trend to worse overall survival, coronary artery calcification was not a significant predictor of progression-free and overall survival.

The role of HER-2/neu expression on the survival of patients with lung cancer: a systematic review of the literature

C-erbB-2 prognostic value for survival in patients with lung cancer remains controversial. We performed a systematic review of the literature to clarify its impact. Studies were identified by an electronic search in order to aggregate the survival results, after a methodological assessment using the scale of the European Lung Cancer Working Party. To be eligible, a study had to deal with c-erbB-2 assessment in lung cancer patients and to analyse survival according to c-erbB-2 expression. In total, 30 studies were eligible: 24 studies dealt with non-small-cell lung carcinoma (NSCLC), five with adenocarcinoma and one study dealt with small-cell carcinoma. In all, 31% of the patients were positive for c-erbB-2. According to c-erbB-2 expression, 13 studies were 'negative' (significant detrimental effect on survival), one 'positive' (significant survival improvement) and 16 not significant. Significant studies had a better subscore relative to analysis and results report than nonsignificant studies. In total, 86% of the significant studies and only 56% of the nonsignificant studies were evaluable for the meta-analysis. This suggests a possible bias in our aggregated results. For NSCLC, the hazard ratio was 1.55 (95% CI: 1.29-1.86) in favour of tumours that do not express c-erbB-2. In conclusion, the overexpression of c-erbB-2 might be a factor of poor prognosis for survival in NSCLC, but there is a potential bias in favour of the significant studies with an overestimation risk of the magnitude of the true effect of c-erbB-2 overexpression.

Heterogeneity of stage IIIA non-small cell lung cancers (NSCLC) and evaluation of late results of surgical treatment

AIMS

The aim of the study was assessment of the heterogeneity of stage IIIA non-small cell lung cancers (NSCLC) and the late results of surgical treatment.

METHODS

The study group consisted of 83 consecutive patients discharged between 1988 and 1992 undergoing radical operative treatment for stage IIIA NSCLC. Squamous cell carcinoma was diagnosed in 54 (65.1%) patients, adenocarcinoma in 23 (27.7%), large cell carcinoma in 2 (2.4%) and mixed (i.e. adenoid-squamous type) in 4 (4.8%). In respect of pTNM staging, 19 (22.9%) patients had T3N1M0, 35 (42.2%) had T2N2M0 and 29 (34.9%) had T3N2M0.

RESULTS

Overall, 13.3% of patients with stage IIIA NSCLC survived 5 years following the operation and 8.7% survived 10 years. Analysis of follow-up study indicated that this group was heterogenic. In T3N1M0 group 26.3% survived 5 years following the operation, in T2N2M0 group 14.3%, in T3N2M0 group 3.5% (P = 0.015). Of 23 patients with N2 disease and no metastases in hilar lymph nodes ('skip' metastases), 26.1% survived 5 years, whereas none of 41 patients with metastases spreading by continuity survived (P = 0.0015). If mediastinal lymph node metastases were diagnosed in one level, 25% patients survived 5 years, but if two or more levels were affected, 2.3% only (P = 0.0214): 85.7% of patients with well-differentiated (G1) cancer survived 5 years and 62.0% 10 years, whereas among those with moderately differentiated (G2) tumours, 11.8% and 8.8%, respectively. No patient survived 5 years after resection of poorly differentiated (G3) cancer (P < 0.001).

CONCLUSIONS

(1) Patients operated for stage IIIA NSCLC are a heterogeneous group, which makes it difficult to predict late results. (2) Patients operated for stage IIIA NSCLC have a better prognosis if metastases are discovered in level one mediastinal lymph nodes, particularly in the superior part of mediastinum, or if 'skip' metastases (pulmonary hilus unaffected) are discovered, as compared to those with N2 disease. (3) Poor histologic differentiation of the tumour is a bad prognostic factor.

Blood vessel invasion in resected non small cell lung carcinomas is predictive of metastatic occurrence

Prognosis of patients with non small cell lung cancer (NSCLC) remains difficult to assess, even after adjustment for pathological stage. Prognostic value of numerous biological markers has been evaluated, with conflicting results. Data of 86 patients with NSCLC treated by surgery were collected with clinical characteristics, histopathological data including tumor differentiation and status of blood and lymphatic vessel invasion and evaluation by immunohistochemistry of Rb, Bcl-2 and Ki-67 expression. Prognostic values for overall survival (OS) and event-free survival (EFS) were analyzed by the log tank test and the multivariable Cox model. Using univariable analyses, pT, pN, poor differentiation or large cell subtype were associated with a poor OS, while lymphatic and/or blood vessel invasion were associated with a short EFS. None of the molecular markers had a significant prognostic value for either outcome. In multivariable analyses, only stage remained of prognostic value for OS. Interestingly, the presence of blood vascular invasion in the tumor was significantly predictive for subsequent metastatic occurrence in stages I and II. This feature might, therefore, be relevant for administration of adjuvant therapy in completely resected NSCLC.

Prognostic factors in non-small cell lung cancer: a decade of progress

STUDY OBJECTIVES

To provide a systematic overview of the literature investigating patient and tumor factors that are predictive of survival for patients with non-small cell lung cancer (NSCLC), and to analyze patterns in the design of these studies in order to highlight problematic aspects of their design and to advocate for appropriate directions of future studies.

DESIGN

A systematic search of the MEDLINE database and a synthesis of the identified literature.

MEASUREMENTS AND RESULTS

The database search (January 1990 to July 2001) was carried out combining the MeSH terms prognosis and carcinoma, nonsmall cell lung. Eight hundred eighty-seven articles met the search criteria. These studies identified 169 prognostic factors relating either to the tumor or the host. One hundred seventy-six studies reported multivariate analyses. Concerning 153 studies reporting a multivariate analysis of prognostic factors in patients with early-stage NSCLC, the median number of patients enrolled per study was 120 (range, 31 to 1,281 patients). The median number of factors reported to be significant in univariate analyses was 4 (range, 2 to 14 factors). The median number of factors reported to be significant in multivariate analyses per study was 2 (range, 0 to 6 factors). The median number of studies examining each prognostic factor was 1 (range, 1 to 105 studies). Only 6% of studies addressed clinical outcomes other than patient survival.

CONCLUSIONS

While the breadth of prognostic factors studied in the literature is extensive, the scope of factors evaluated in individual studies is inappropriately narrow. Individual studies are typically statistically underpowered and are remarkably heterogeneous with regard to their conclusions. Larger studies with clinically relevant modeling are required to address the usefulness of newly available prognostic factors in defining the management of patients with NSCLC.

Proportion of ground-glass opacity on high-resolution computed tomography in clinical T1 N0 M0 adenocarcinoma of the lung: A predictor of lymph node metastasis

OBJECTIVE

In patients with clinical T1 N0 M0 lung adenocarcinoma, we investigated whether the proportion of ground-glass opacity area measured on high-resolution computed tomography was valuable for predicting the existence of lymph node metastasis, lymphatic invasion, or vascular invasion.

METHODS

Between 1994 and 1999, 111 patients with clinical stage IA adenocarcinoma underwent surgical resection of the lung at our hospital. Of these, 96 patients received high-resolution computed tomography of the chest, and they constituted the study population. The tumors were semiquantitatively classified into 5 groups on the basis of the proportion of ground-glass opacity area to whole tumor shadow on high-resolution computed tomography: group I, 0%; group II, 1% to 25%; group III, 26% to 50%; group IV, 51% to 75%; and group V, 76% to 100%. Correlations of computed tomographic findings, pathologic results of lymph node metastasis and lymphatic and vascular invasion, and the histologic subtype according to the new World Health Organization classification were examined. We also investigated the characteristics of the patients with ground-glass opacity areas on high-resolution computed tomography and their value for predicting lymph node metastasis.

RESULTS

Among the 96 patients, 15 (15.6%) had mediastinal lymph node metastases, and 3 (3.1%) had hilar node metastases. Regarding the proportion of the ground-glass opacity area of the tumors, 15 (15.6%) tumors were classified as group V, 11 (11.5%) as group IV, 9 (9.3%) as group III, 22 (22.9%) as group II, and 39 (40.6%) as group I, respectively. Of the 18 patients with lymph node metastases, no patients were found in groups IV and V, 2 (22.2%) were found in group III, 4 (18.2%) were found in group II, and 12 (30.8%) were found in group I (trend P =. 003), respectively. Twenty-six patients classified into groups IV and V also showed neither lymphatic invasion nor recurrence. All the smaller tumors (< or =2.0 cm) in group IV or V were histologically proved to be bronchioloalveolar carcinoma. Adjusted for smoking status and other characteristics, patients without ground-glass opacity on high-resolution computed tomography had a significantly increased risk of concurrent lymph node metastasis compared with those with ground-glass opacity.

CONCLUSION

In patients with clinical T1 N0 M0 adenocarcinoma, the proportion of ground-glass opacity area on thin-section computed tomography scans was a strong predictor for tumor aggressiveness and thus could be a useful index for planning limited surgical resection for these patients.

Prognostic impact of Cyfra21-1 and other serum markers in completely resected non-small cell lung cancer

PURPOSE

The aim of this prospective study was to assess the prognostic impact of serum tumor markers (Cyfra21-1, carcinoembryonic antigen, neuron-specific enolase, squamous cell carcinoma-antigen and TPAcyk) in patients with non-small cell lung cancer (NSCLC) receiving complete resection.

METHODS

Sixty-seven patients with histologically proven NSCLC and complete resection of stage I-IIIA disease were included. The serum levels of all markers were measured using commercially available immunoassays.

RESULTS

With a median follow-up of 86 months for surviving patients, those with initial Cyfra21-1 serum levels higher than 3.57 ng/ml had a significantly worse prognosis (P=0.014). The remaining serum tumor markers showed no prognostic impact. In a Cox regression model, Cyfra21-1 proved to be an independent prognostic factor for both overall survival and disease-free interval. In addition, Cyfra21-1 sustained as an independent prognostic factor in completely resected stage I/II disease.

CONCLUSIONS

With a cut-off value of 3.57 ng/ml, Cyfra 21-1 was an independent prognostic factor for survival in NSCLC-patients with complete resection. Further evaluation is needed, particularly in stage I/II disease. When the prognostic impact is confirmed with larger patient numbers this may contribute to the identification of stratification variables for future treatment approaches of NSCLC.

Prognostic relevance of proliferating cell nuclear antigen and p53 expression in non-small cell lung cancer

Prognostic value of p53 and PCNA expression in non-small cell lung cancer (NSCLC) remains controversial. In this study we determined the relevance of these abnormalities in terms of overall survival and disease-free survival in 95 NSCLC patients who underwent curative pulmonary resection. Expression of p53 was found in 44 samples (45%), expression of PCNA-in 79 samples (83%), and expression of both markers-in 35 samples (36%). There was no relationship between expression of either protein and major clinicopathological characteristics. Median survival for patients with and without p53 expression was 36 and 33 months, respectively and 5-year survival probability-29 and 37%, respectively (P=0.73). Median survival for patients with and without PCNA expression was 36 and 27 months, respectively and 5-year survival probability-35 and 25%, respectively (P=0.60). There was no significant difference in overall survival between particular groups of patients with tumors carrying four possible p53/PCNA phenotypes. In multivariate analysis including patient age, sex, tumor stage, tumor type and differentiation, p53 and PCNA expression, the only variable important for survival was stage of disease. These results suggest the lack of prognostic relevance of p53 and PCNA expression in surgically treated NSCLC patients.

Role of p53 as a prognostic factor for survival in lung cancer: a systematic review of the literature with a meta-analysis

The role of p53, as a prognostic factor for survival in lung cancer, is controversial and the purpose of the present systematic review of the literature is to determine this effect. Published studies were identified with the objective to aggregate the available survival results after a methodological assessment using a scale specifically designed by the European Lung Cancer Working Party (ELCWP). To be eligible, a study had to deal with p53 assessment in lung cancer (primary site) only, and to provide a survival comparison according to the p53 status. Among the 74 eligible papers, 30 identified p53 abnormalities as a univariate statistically significant poor prognostic factor and 56 provided sufficient data to allow survival results aggregation. There was no significant difference between the trials that either showed or did not show a prognostic effect of p53 according to the methodological score or to the laboratory technique used. The studies were categorized by histology, disease stage, treatment and laboratory technique. Combined hazard ratios suggested that an abnormal p53 status had an unfavourable impact on survival: in any stage nonsmall cell lung cancer (NSCLC) the mean (95% confidence interval) was 1.44 (1.20-1.72) (number of studies included in the subgroup was 11), 1.50 (1.32-1.70) in stages I-II NSCLC (n=19), 1.68 (1.23-2.29) in stages I-IIIB NSCLC (n=5), 1.68 (1.30-2.18) in stages III-IV NSCLC (n=9), 1.48 (1.29-1.70) in surgically resected NSCLC (n=20), 1.37 (1.02-1.85) in squamous cell carcinoma (n=9), 2.24 (1.70-2.95) in adenocarcinoma (n=9), 1.57 (1.28-1.91) for a positive immunohistochemistry with antibody 1801 (n=8), 1.25 (1.09-1.43) for a positive immunohistochemistry with antibody DO-7 (n=16), and 1.65 (1.35-2.00) for an abnormal molecular biology test (n=13). Data were insufficient to determine the prognostic value of p53 in small cell lung cancer. In each subgroup of nonsmall cell lung cancer, p53 abnormal status was shown to be associated with a poorer survival prognosis.

c-erbB-2 expression in small-cell lung cancer is associated with poor prognosis

Small-cell lung cancer (SCLC) carries a bad prognosis despite good initial response to chemotherapy. It is therefore important to identify molecular markers that influence survival as potential new therapeutic targets. In our study, expression of the tyrosine kinase c-erbB-2 (HER2/neu) receptor in tumor tissues of 107 consecutive newly diagnosed patients with primary SCLC was quantified using a monoclonal antibody directed against the c-terminal domain of c-erbB-2. A clear-cut positive expression of c-erbB-2 was observed in 13% of patients. Surprisingly, c-erbB-2 was an independent prognostic factor (RR = 2.16; p = 0.014) when a proportional-hazard model was adjusted to stage (limited vs. extensive disease) and performance status (WHO I-IV), the most relevant clinical parameters. Similarly, a significant association between c-erbB-2 and survival was obtained if a larger number of clinical parameters were included into the analysis, namely response to chemotherapy, TNM stage, lactate dehydrogenase (LDH), neuron-specific enolase (NSE), gender and age (p = 0.033). Interestingly, c-erbB-2 expression was more relevant for patients with advanced tumors. In the subgroup of patients with bad performance status (WHO II-IV), median survival of patients with undetectable c-erbB-2 expression was 274 days compared with only 23 days for patients with clear-cut positive c-erbB-2 immunohistochemistry (p = 0.0031; log-rank test). Similar results were obtained for patients with extensive disease (p = 0.028) and high TNM stages (T>2 or N>1 or M1; p < 0.068, all comparisons). In contrast, c-erbB-2 expression was not associated with survival in patients with limited disease (p = 0.97), low TNM stages (p > 0.56, all comparisons) and good performance status (p = 0.97). In conclusion, c-erbB-2 is expressed in more than 10% of SCLC. Expression of c-erbB-2 is an independent prognostic factor of survival. The effect of c-erbB-2 expression seems to become more important in advanced stages of the disease. Since c-erbB-2 is a therapeutical target in other types of cancer, further studies to identify the role of c-erbB-2 in SCLC are clearly warranted.