Vascular invasion in non-small cell lung carcinoma

Significance of Basal Cell Carcinomas Exhibiting Intravascular Invasion

ABSTRACT

Intravascular invasion of tumor cells can be associated with metastasis in many cancers. Basal cell carcinomas (BCCs), however, rarely metastasize; therefore, the clinical impact of intravascularly invasive BCC (IVBCC) is currently unclear. Because of these facts and the rarity of IVBCC, questions have arisen on whether IVBCC truly exists. We present 4 cases of IVBCC: one case with obvious tumor islands within immunolabeled blood vessels in the context of advanced disease and 3 cases found incidentally during Mohs micrographic surgery. We discuss the difficulty in studying IVBCC, the idea that it could be due to artifact, and the lack of direct clinical-pathological correlation. Given these challenges, we propose diagnostic criteria for IVBCC to decrease ambiguity for pathological diagnosis. Such criteria may facilitate further studies on the clinical significance of IVBCC.

Lymphangiosis carcinomatosa independently affects long-term survival of Non-Small Cell Lung Cancer patients

OBJECTIVE

The significance of postoperatively diagnosed Lymphangiosis Carcinomatosa (L1) as an independent risk factor for long-term survival in Non-Small Cell Lung Cancer (NSCLC) remains controversial. We analyzed the effect of L1 on postoperative survival in stage I, II and III NSCLC-patients.

METHODS

We investigated all consecutive patients with NSCLC between January 2012 and December 2019 who underwent an anatomical resection and radical lymphadenectomy at our institute. L1-were compared to L0-patients. All patients received adjuvant chemotherapy in accordance with European guidelines. 3- and 5- year survival rates and median-survival were assessed. To investigate whether L1 is an independent risk factor, we carried out a multivariate cox regression and a pair-match analysis looking at different properties such as TNM.

RESULTS

A total of 641 patients (L0: 74%; L1: 26%) were analyzed. Baseline characteristics were comparable between groups. The mean age was 65.3 ± 10.2 years and 64.9 ± 9.4 years in the L0 and L1-groups respectively (p-value = 0.703). 58.5% of L0-patients were male (L1: 62.7%; p-value = 0.351). Overall survival in the L1-group was significantly shorter compared to the L0-group (L1: 42.3 ± 2.8; L0: 67.6 ± 2.1 months; p-value<0.0001). We confirmed this finding in a pair-matched analysis (L0: 73.9 ± 4.7 months; L1: 42.2 ± 4.2; p-value = 0.009). 3- and 5-year survival were significantly shorter for L1-patients (3-year: L0: 65.9%; L1: 35.9%; p-value<0.0001) (5-year: L0: 34.9%; L1: 7.5%; p-value<0.0001).

CONCLUSION

L1 is an independent risk factor for long-term survival of patients with NSCLC. This cohort supports that the L0/L1 status should be included in pathological reports. We suggest to further include L0/L1-status in guideline recommendations for NSCLC patients.

Artery-first vs vein-first surgical technique for segmentectomy of non-small cell lung cancer: A protocol for systematic review and meta-analysis

BACKGROUND

Surgery for lung cancer squeezes the tumor, further promoting the circulation of tumor cells, which may be one of the reasons for lung cancer metastasis and recurrence. In theory, the potential risk of tumor cell proliferation can be minimized if the outflow veins are ligated first (via veins first [V-first]) rather than arteries first (via arteries first [A-first]). However, due to the lack of sufficient evidence, this technical concept has not been widely accepted as a standard in surgical oncology in the current guidelines. This systematic review and meta-analysis will be used to determine which techniques will yield longer patient survival and benefit patients during segmentectomy.

METHODS

We will search PubMed, Web of Science, Embase, Cancerlit, the Cochrane Central Register of Controlled Trials, and Google Scholar databases for relevant clinical trials published in any language before January 1, 2021. Randomized controlled trials (RCTs), quasi-RCTs, propensity score-matched comparative studies, and prospective cohort studies of interest, published or unpublished, that meet the inclusion criteria will be included. Subgroup analysis of the type of operation, tumor pathological stage, and ethnicity will be performed.

RESULTS

The results of this study will be published in a peer-reviewed journal.

CONCLUSION

As far as we know, this study will be the first meta-analysis to compare the efficacy of the vein-first and artery-first surgical technique of segmentectomy for patients diagnosed with resectable non-small cell lung cancer. Due to the nature of the disease and intervention methods, RCTs may be inadequate, and we will carefully consider inclusion in high-quality, non-RCTs, but this may result in high heterogeneity and affect the reliability of the results.INPLASY registration number: INPLASY202080062.

Lymphatic and vascular invasion in oral squamous cell carcinoma: Implications for recurrence and survival in a population-based cohort study

OBJECTIVE

Numerous studies analyzed lymphovascular invasion (LVI) in various malignant diseases, however, little is known about the role of lymphatic invasion (LI) as well as vascular invasion (VI) in oral squamous cell carcinoma (OSCC). The aim of this study is to illuminate the role of LI and VI in a population-based cohort study.

METHODS

We retrospectively analyzed 745 primarily resected OSCC patients in Eastern Bavaria for histopathologically verified LI and VI. Overall survival (OS) and recurrence-free survival (RFS) were calculated, whereas analysis was performed by uni- and multivariate statistics. Mean follow-up time was 7.4 years.

RESULTS

LI was found in 115 patients (15.4%), VI was diagnosed in 23 cases (3.1%). LI correlated significantly with distinct anatomical sites (p = 0.004), increasing pT-classification (p < 0.001), lymph node involvement (p < 0.001), higher grading (p < 0.001), advanced UICC-stages (p < 0.001) and adjuvant therapies (p < 0.001). Similar results were found for VI. Survival analysis resulted in a significantly decreased five-year OS and RFS in patients with diagnosed LI (OS: 41.1%, RFS: 38.3%) in contrast to LI-negative cases (OS: 66.8%, RFS: 59.7.7%, p < 0.001). Analogous outcomes were seen for patients with VI. Additionally, LI was identified as a predictive parameter, indicating individual patients' response to adjuvant therapies.

CONCLUSION

This population-based cohort study underlines the unfavorable aspect of LI and VI on outcome in OSCC. Including LI and VI in existing staging systems could help to stratify patients' risk for adverse outcome and consecutively determine adjuvant treatment in malignant disease.

A case of cerebral infarction due to pleomorphic carcinoma of the lung

Background:

With the increase in endovascular treatment, reports of embolism other than thrombus are scattered, but intracranial tumorigenic embolism is rare and difficult to diagnose. Here, we describe a case of a tumorigenic embolism in a patient with lung cancer whose invasion into the vascular system was not detected on preoperative whole-body imaging.

Case Description:

A 66-year-old man who was hospitalized to undergo radiotherapy for pulmonary carcinoma suddenly developed left hemiplegia. He exhibited atrial fibrillation, and emergent radiographic examination revealed a right middle cerebral artery occlusion. Urgent mechanical embolectomy was performed, with successful revascularization. The excised embolus had a unique morphology and was pathologically diagnosed as a cerebral embolism caused by pleomorphic pulmonary carcinoma.

Conclusion:

Tumor-derived cerebral embolism is extremely rare, but it is necessary to consider it as a potential source of embolism during differential diagnosis in patients with malignant tumors.

Vein-first vs artery-first surgical technique for lobectomy of non-small cell lung cancer: A protocol for systematic review and meta-analysis

BACKGROUND

The operation of lung cancer may squeeze the tumor and further promote the spread of tumor cells to the circulation, which may be one of the reasons for the metastasis and recurrence of lung cancer. The potential risk of tumor cell dissemination can theoretically be minimized if the effluent veins were ligated first (via the vein-first [V-first] technique), instead of having the artery ligated first (via the artery-first [A-first] technique). However, this technical concept has not yet been widely accepted as a standard of surgical oncology in current guidelines owing to a lack of sufficient evidence. This systematic review and meta-analysis will be performed to determine which technique during lobectomy will achieve longer patient survival and be more beneficial for patients.

METHODS

We will search PubMed, Web of Science, EMBASE, Cancerlit, the Cochrane Central Register of Controlled Trials, and Google Scholar databases for relevant clinical trials published in any language before October 1, 2020. Randomized controlled trials (RCTs), quasi-RCTs, propensity score-matched comparative studies, and prospective cohort studies of interest, published or unpublished, that meet the inclusion criteria will be included. Subgroup analysis of the type of operation, tumor pathological stage, and ethnicity will be performed. INPLASY registration number: INPLASY202050060.

RESULTS

The results of this study will be published in a peer-reviewed journal.

CONCLUSION

As far as we know, this study will be the first meta-analysis to compare the efficacy of the vein-first and artery-first surgical technique of lobectomy for patients diagnosed with resectable non-small cell lung cancer. Due to the nature of the disease and intervention methods, randomized controlled trials may be inadequate, and we will carefully consider inclusion in high-quality, non-randomized controlled trials, but this may result in high heterogeneity and affect the reliability of the results.

Elastin and collagen IV double staining: A refined method to detect blood vessel invasion in breast cancer

Blood vessel invasion (BVI) is a prognostic indicator in various cancers. Elastic stain, which highlights blood vessel walls, is commonly used to detect BVI. In the breast, however, its diagnostic usefulness is limited because it also highlights some intraductal carcinoma components, which often mimic BVI. In this study, we aimed to improve BVI detection in breast cancer and developed a double staining: Victoria blue for elastin and immunohistochemistry for collagen IV. Collagen IV fibers were retained along the basement membranes of intraductal carcinoma components, whereas they were rearranged or lost in BVI. From these observations, we defined BVI as the presence of tumor cells inside an elastic ring with a rearrangement or loss of collagen IV fibers. Using these criteria, we found BVI in 148 cases (49%) among 304 cases of primary operable invasive breast carcinoma, and the presence of BVI correlated significantly with poor prognosis. By contrast, we detected BVI in 94 cases (31%) or 14 cases (5%) by elastic van Gieson or CD31 immunostaining among the same cases, respectively, with no statistically significant association with prognosis. Thus, elastin and collagen IV double staining facilitates the detection of BVI in breast cancer and is useful to predict prognosis.

Prognostic significance of venous invasion in node-negative head and neck squamous cell carcinoma

BACKGROUND

Venous invasion (VI) is not frequently evaluated on routine histologic examination of head and neck squamous cell carcinoma (HNSCC), and the prognostic significance is largely unknown. Studies have shown that extramural venous invasion is an adverse prognostic factor in colorectal carcinoma. To our knowledge, this is the first study evaluating the prognostic significance of venous invasion in node-negative (without clinical or pathologic evidence of lymph node involvement) HNSCC, utilizing the elastic stain.

METHODS

A total of 105 consecutive lymph node-negative (N0) HNSCC were evaluated for the presence of venous channel invasion by tumor utilizing the elastin stain. Clinical, demographic, and follow-up data were recorded.

RESULTS

Of 37 patients with venous invasion, 19% had loco-regional recurrence, as opposed to 12% of those without. Univariate analysis revealed statistically significant decreased recurrence-free survival in the presence of venous invasion (log-rank [Mantel-Cox] test P-value .025).

CONCLUSION

Identification of VI is greatly aided by elastic stain. In patients with node-negative HNSCC, presence of VI resulted in decreased recurrence-free survival on univariate analysis. The impact of VI as a prognostic marker should be further evaluated.

Effect of Vein-First vs Artery-First Surgical Technique on Circulating Tumor Cells and Survival in Patients With Non-Small Cell Lung Cancer: A Randomized Clinical Trial and Registry-Based Propensity Score Matching Analysis

Importance

It is important to develop a surgical technique to reduce dissemination of tumor cells into the blood during surgery.

Objective

To compare the outcomes of different sequences of vessel ligation during surgery on the dissemination of tumor cells and survival in patients with non-small cell lung cancer.

Design, Setting, and Participants

This multicenter, randomized clinical trial was conducted from December 2016 to March 2018 with patients with non-small cell lung cancer who received thoracoscopic lobectomy in West China Hospital, Daping Hospital, and Sichuan Cancer Hospital. To further compare survival outcomes of the 2 procedures, we reviewed the Western China Lung Cancer database (2005-2017) using the same inclusion criteria.

Interventions

Vein-first procedure vs artery-first procedure.

Main Outcomes and Measures

Changes in folate receptor-positive circulating tumor cells (FR+CTCs) after surgery and 5-year overall, disease-free, and lung cancer-specific survival.

Results

A total of 86 individuals were randomized; 22 patients (25.6%) were younger and 64 (74.4%) older than 60 years. Of these, 78 patients were analyzed. After surgery, an incremental change in FR+CTCs was observed in 26 of 40 patients (65.0%) in the artery-first group and 12 of 38 (31.6%) in the vein-first group (P = .003) (median change, 0.73 [interquartile range (IQR), -0.86 to 1.58] FU per 3 mL vs -0.50 [IQR, -2.53 to 0.79] FU per 3 mL; P = .006). Multivariate analysis confirmed that the artery-first procedure was a risk factor for FR+CTC increase during surgery (hazard ratio [HR], 4.03 [95% CI, 1.53-10.63]; P = .005). The propensity-matched analysis included 420 patients (210 with vein-first procedures and 210 with artery-first procedures). The vein-first group had significantly better outcomes than the artery-first group for 5-year overall survival (73.6% [95% CI, 64.4%-82.8%] vs 57.6% [95% CI, 48.4%-66.8%]; P = .002), disease-free survival (63.6% [95% CI, 55.4%-73.8%] vs 48.4% [95% CI, 40.0%-56.8%]; P = .001), and lung cancer-specific survival (76.4% [95% CI, 67.6%-85.2%] vs 59.9% [95% CI, 50.5%-69.3%]; P = .002). Multivariate analyses revealed that the artery-first procedure was a prognostic factor of poorer 5-year overall survival (HR, 1.65 [95% CI, 1.07-2.56]; P = .03), disease-free survival (HR, 1.43 [95% CI, 1.01-2.04]; P = .05) and lung cancer-specific survival (HR = 1.65 [95% CI, 1.04-2.61]; P = .03).

Conclusions and Relevance

Ligating effluent veins first during surgery may reduce tumor cell dissemination and improve survival outcomes in patients with non-small cell lung cancer.

Trial Registration

ClinicalTrials.gov identifier: NCT03436329.

Quantitative vessel tortuosity: A potential CT imaging biomarker for distinguishing lung granulomas from adenocarcinomas

Adenocarcinomas and active granulomas can both have a spiculated appearance on computed tomography (CT) and both are often fluorodeoxyglucose (FDG) avid on positron emission tomography (PET) scan, making them difficult to distinguish. Consequently, patients with benign granulomas are often subjected to invasive surgical biopsies or resections. In this study, quantitative vessel tortuosity (QVT), a novel CT imaging biomarker to distinguish between benign granulomas and adenocarcinomas on routine non-contrast lung CT scans is introduced. Our study comprised of CT scans of 290 patients from two different institutions, one cohort for training (N = 145) and the other (N = 145) for independent validation. In conjunction with a machine learning classifier, the top informative and stable QVT features yielded an area under receiver operating characteristic curve (ROC AUC) of 0.85 in the independent validation set. On the same cohort, the corresponding AUCs for two human experts including a radiologist and a pulmonologist were found to be 0.61 and 0.60, respectively. QVT features also outperformed well known shape and textural radiomic features which had a maximum AUC of 0.73 (p-value = 0.002), as well as features learned using a convolutional neural network AUC = 0.76 (p-value = 0.028). Our results suggest that QVT features could potentially serve as a non-invasive imaging biomarker to distinguish granulomas from adenocarcinomas on non-contrast CT scans.

Vascular invasion is an adverse prognostic factor in resected non-small-cell lung cancer

Lung cancer is a leading cause of death, and there is a need for better prognostic factors in treatment decisions. Vascular invasion is a known negative prognosticator, but it is not clear how to evaluate this feature. Here, we studied the prevalence and prognostic impact of blood and lymphatic vascular invasion (BVI, LVI), tumour grade, necrosis, inflammation and pleural invasion on cancer-specific survival (LCSS) and time to recurrence (TTR) in non-small-cell lung cancer (NSCLC). A total of 438 patients surgically treated for NSCLC (1993-2010) were examined, including 213 adenocarcinomas (AC), 135 squamous cell carcinomas (SCC) and 90 other NSCLC. BVI and LVI were found in 25% and 21% of the cases, with reduced LCSS and TTR for both markers in AC and SCC (p < 0.005 for all). BVI and LVI remained independent prognostic factors for LCSS and TTR in separate multivariate models for AC and SCC. Combined BVI/LVI (7%) showed significantly reduced LCSS and TTR (p < 0.001), also by multivariate analysis. Our results support that BVI and LVI are valuable for prognostic staging. Vascular invasion identifies a group of patients at higher risk of recurrence and lung cancer-related death, and this could influence stratification of patients for treatment and follow-up.

Application of novel quantitative techniques for fluorodeoxyglucose positron emission tomography/computed tomography in patients with non-small-cell lung cancer

AIM

Flurodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) is routinely used in non-small-cell lung cancer. This study aims to assess the prognostic value of quantitative FDG-PET/CT parameters including standard uptake value (SUV), metabolic tumor volume (MTV) and total lesional glycolysis (TLG) in non-small-cell lung cancer.

METHODS

A retrospective review of 92 nonsurgical patients with pathologically confirmed stage I-III non-small-cell lung cancers treated with radical dose radiotherapy (≥50 Gy) was conducted. Metabolically active tumor regions on FDG-PET/CT scans were contoured manually. SUV, MTV and TLG were calculated for primary, nodal and whole-body disease. Univariate and multivariate (adjusting for age, sex, disease stage and primary tumor size in centimeters) Cox regression modeling were performed to assess the association between these parameters and both overall and progression-free survival (PFS).

RESULTS

On univariate analysis, overall survival (OS) was significantly associated with primary MTV (P = 0.03), whole-body MTV (P = 0.02), whole-body maximum SUV (P = 0.05) and whole-body TLG (P = 0.03). PFS was significantly associated with primary MTV (P = 0.01), primary TLG (P = 0.04), whole-body MTV (P < 0.01) and whole-body TLG (P = 0.01). On multivariate analysis, OS was significantly associated with whole-body MTV (P = 0.05). PFS was significantly associated with whole-body MTV (P = 0.02) and whole-body TLG (P = 0.05).

CONCLUSIONS

Whole-body MTV was significantly associated with overall and PFS, and whole-body TLG was significantly associated with PFS on multivariate analysis. These two parameters may be significant prognostic factors independent of other factors such as stage. SUV was not significantly associated with survival on multivariate analysis.

Omics Profiling in Precision Oncology

Cancer causes significant morbidity and mortality worldwide, and is the area most targeted in precision medicine. Recent development of high-throughput methods enables detailed omics analysis of the molecular mechanisms underpinning tumor biology. These studies have identified clinically actionable mutations, gene and protein expression patterns associated with prognosis, and provided further insights into the molecular mechanisms indicative of cancer biology and new therapeutics strategies such as immunotherapy. In this review, we summarize the techniques used for tumor omics analysis, recapitulate the key findings in cancer omics studies, and point to areas requiring further research on precision oncology.

Necrosis and apoptotic index as prognostic factors in non-small cell lung carcinoma: a review

Necrosis and apoptosis represent two pathogenetically distinct types of cell death. Necrosis is associated with pathologic conditions while apoptosis is a physiological process of programmed cell death, which is associated with normal tissue growth and is frequently impaired in various forms of cancer. Tumor necrosis and apoptotic index (AI) have been previously evaluated as prognostic biomarkers in lung cancer, but their exact clinical value remains unclear. The aim of this study was to perform a systematic review of the MEDLINE literature on the prognostic significance of these histopathological markers in patients with non-small cell lung carcinoma (NSCLC). Although a substantial body of evidence suggests that tumor necrosis may be a strong predictor of aggressive tumor behavior and reduced survival in patients with NSCLC, the independent prognostic value of this biomarker remains to be firmly established. Furthermore, previous data on the prognostic significance of apoptotic index in NSCLC are relatively limited and largely controversial. More prospective studies are necessary in order to further validate tumor necrosis and AI as prognostic markers in NSCLC.

Prognostic impact of vascular and lymphovascular invasion in early lung cancer

Background

The prognostic significance of vascular and lymphatic invasion in non-small-cell lung cancer is under continuous debate. We analyzed the effect of tumor aggressiveness (lymphatic and/or vessel invasion) on survival and relapse in stage I and II non-small-cell lung cancer.

Methods

We retrospectively analyzed prospectively collected data of 457 patients with stage I and II non-small-cell lung cancer from 1998 to 2008. Specimens were analyzed for intratumoral vascular invasion and lymphovascular space invasion. Overall survival and disease-free survival were estimated using the Kaplan-Meier method, and differences were determined by the logrank test. Cox regression analysis was performed to identify independent risk factors.

Results

The incidence of intratumoral vascular invasion was 23.4%, and this correlated significantly with grade of differentiation, visceral pleural involvement, lymphovascular space invasion, and N status. The incidence of lymphovascular space invasion was 5.5%, and this correlated significantly with grade of differentiation, lymph nodes involved, and intratumoral vascular invasion. On multivariate analyses, intratumoral vascular invasion proved to be an significant independent risk factor for overall survival but not for disease-free survival. Lymphovascular space invasion was associated significantly with early tumor recurrence but not with overall survival.

Conclusions

Vascular and lymphatic invasion can serve as independent prognostic factors in completely resected non-small-cell lung cancer. Intratumoral vascular invasion and lymphovascular space invasion in early stage non-small-cell lung cancer are important factors in overall survival and early tumor recurrence. Further large scale studies with more recent patient cohorts and refined histological techniques are warranted.

Tumors of the pulmonary artery and veins

The pulmonary vasculature may be involved by different primary and secondary tumors. Poorly differentiated and undifferentiated sarcomas are the most common primary tumors of the pulmonary arteries. They tend to affect the large caliber pulmonary vessels and present with predominantly intraluminal growth. Pulmonary and mediastinal metastasis are common, and prognosis is poor. Clinical and imaging manifestations may mimic those of pulmonary embolism. Dyspnea, chest pain, cough, and hemoptysis are the most common presenting symptoms. Primary sarcomas arising from the central pulmonary veins are less common than their arterial counterpart. Secondary involvement of the pulmonary arteries and veins by primary and metastatic pulmonary malignancies is more common. Tumoral embolism may also affect the pulmonary arteries. They may develop from different intrathoracic and extrathoracic malignancies and may be indistinguishable from venous thromboembolism. It may manifest as cor pulmonale with right cardiac strain and dilated pulmonary arteries. Computed tomography, magnetic resonance imaging, and fluorodeoxyglucose positron emission tomography may help in the differentiation between these 2 conditions.

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.

Radiotherapy is effective for a primary lung cancer invading the left atrium

Atrial involvement is an uncommon feature of advanced non-small-cell lung cancer, occurring in up to 10% of patients with bronchogenic carcinoma. Additionally, cardiac metastases from other sources are documented in up to 7% of cancer patients at autopsy. Because atrial invasion can lead to systemic embolisation and/or outflow obstruction, it is treated regardless of the overall prognosis. While the gold standard treatment has historically been surgical resection, advances in radiotherapy allow for the safe treatment of cardiac disease. Here we present the case of a woman with pulmonary adenocarcinoma of the left lower lobe that progressed to invade the pulmonary vein and left atrium while maintained on standard chemotherapy. She was treated with intensity-modulated radiotherapy and had a complete response in terms of her atrial disease within 3 months. She suffered no acute toxicity or complications as a result of the radiation therapy.

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.

Overexpression of the mammalian target of rapamycin (mTOR) and angioinvasion are poor prognostic factors in early stage NSCLC: a verification study

BACKGROUND

A recent study by Dhillon et al. [12], identified both angioinvasion and mTOR as prognostic biomarkers for poor survival in early stage NSCLC. The aim of this study was to verify the above study by examining the angioinvasion and mTOR expression profile in a cohort of early stage NSCLC patients and correlate the results to patient clinico-pathological data and survival.

METHODS

Angioinvasion was routinely recorded by the pathologist at the initial assessment of the tumor following resection. mTOR was evaluated in 141 early stage (IA-IIB) NSCLC patients (67 - squamous; 60 - adenocarcinoma; 14 - others) using immunohistochemistry (IHC) analysis with an immunohistochemical score (IHS) calculated (% positive cells×staining intensity). Intensity was scored as follows: 0 (negative); 1+ (weak); 2+ (moderate); 3+ (strong). The range of scores was 0-300. Based on the previous study a cut-off score of 30 was used to define positive versus negative patients. The impact of angioinvasion and mTOR expression on prognosis was then evaluated.

RESULTS

101 of the 141 tumors studied expressed mTOR. There was no difference in mTOR expression between squamous cell carcinoma and adenocarcinoma. Angioinvasion (p=0.024) and mTOR staining (p=0.048) were significant univariate predictors of poor survival. Both remained significant after multivariate analysis (p=0.037 and p=0.020, respectively).

CONCLUSIONS

Our findings verify angioinvasion and mTOR expression as new biomarkers for poor outcome in patients with early stage NSCLC. mTOR expressing patients may benefit from novel therapies targeting the mTOR survival pathway.

Extratumoral vascular invasion is a significant prognostic indicator and a predicting factor of distant metastasis in non-small cell lung cancer

INTRODUCTION

Vascular invasion is thought to be a fundamental step in hematogenous metastasis. The aim of this study was to assess whether the qualitative evaluation of vascular invasion according to its location (intratumoral or extratumoral) could provide an appropriate means of predicting the prognostic outcome and potential patterns of recurrence in non-small cell lung cancer.

METHODS

We reviewed the cases of 1000 consecutive patients in whom complete resection of non-small cell lung cancer had been performed. Sections stained by the Victoria blue van Gieson method were examined for the presence of vascular invasion and the evaluation of its location (v0: absence, n = 540; v1: intratumoral, n = 428; v2: extratumoral, n = 32). Survival was estimated using the Kaplan-Meier method. To determine independent prognostic factors, univariate and multivariate analyses were conducted.

RESULTS

The study cohort included 605 men and 395 women, with a mean age of 66 years (range, 20-90 years). The 5-year overall survival rate of the vascular invasion-negative group and the vascular invasion-positive group was 82.5% and 55.1%, respectively (p < 0.001), and the 5-year overall survival rates of the v1 group and v2 groups were 55.9% and 44.0%, respectively (p = 0.010). Multivariate analysis showed that location of the vascular invasion (v0-1 versus v2) (p = 0.049), age (p = 0.030), tumor size (p = 0.004), lymph node metastasis (p < 0.001), and pleural invasion (p < 0.001) were significant prognostic factors. The proportion of patients who developed distant metastasis was significantly higher in the v2 group than in the v1 group (p = 0.026).

CONCLUSION

Evaluation of vascular invasion location was a statistically significant predictor of prognosis and potential recurrence patterns.

Prognostic value and therapeutic consequences of vascular invasion in non-small cell lung carcinoma

The prognostic relevance of blood vessel invasion (BVI) in non-small cell lung carcinoma (NSCLC) remains controversial, as is the question of whether its finding should influence therapeutic decisions after an R0 resection. One hundred and twelve cases of NSCLC were included in the study. All had been treated by potentially curative surgical resection of the primary tumor and systematic lymphadenectomy. In all cases, lymphatic metastatic spread was at its earliest stage and only one regional lymph node was involved, 27.0+/-8.9 nodes per patient being examined histologically. Most of the cases were pT2 (75.9%) and pN1 (81.3%), and all were MX/M0 and R0. 62.5% were at stage IIB, 25.9% at stage IIIA, and 9.8% at stage IIA. BVI was found in 45.5% of the tumors (V1), and 18.8% exhibited both lymphatic invasion and BVI (L1V1). Local recurrence occurred in 10.7% of the patients, distant metastasis in 24.1%, and both forms of tumor progression simultaneously in a further 7.1%. Thus 31.2% of the patients developed distant metastases by hematogenous spread (to the brain, bones, lung, adrenal, and liver, in descending order of frequency), mostly within two years of surgery. Late metastasis is not typical of NSCLC. Adenocarcinomas showed a strong tendency to be associated with a poorer prognosis than squamous cell carcinomas, probably because of their more frequent involvement of blood vessels. Five-year survival (Kaplan-Meier method) was significantly lower in V1 cases (37.2%) than in V0 cases (56.0%; p = 0.0249). Adjuvant mediastinal radiation in node-positive cases of NSCLC may prevent local recurrence but is unlikely to influence the development of distant metastases. The histological detection of BVI is of prognostic relevance and should be considered for inclusion in the staging criteria and indications for adjuvant chemotherapy.

Evaluation of extratumoral lymphatic permeation in non-small cell lung cancer as a means of predicting outcome

BACKGROUND

Lymphatic permeation (ly) has been described as a potential prognostic factor for non-small cell lung cancer (NSCLC).

METHODS

The purpose of this study was to analyze whether evaluation of the presence or absence of ly and its location (ly 0: absent, N=464; ly 1: intratumoral, N=42; ly 2: extratumoral, N=52) provides an appropriate means of predicting the outcome of NSCLC. We investigated the clinical implications of ly in 558 consecutive patients with surgically resected NSCLC.

RESULTS

Evaluation according to ly status showed that the recurrence-free survival (RFS) time of the ly 2 patients was significantly shorter than that of the ly 0 patients (P<0.0001), the ly 1 patients (P=0.0028). A significant difference in RFS time was also observed between the ly 0 patients and the ly 1 patients (P=0.0025). RFS time of the ly 0 patients was significantly longer than that of the ly 1 plus ly 2 patients (P<0.0001). We also evaluated the patients with pathological stage I disease (N=378) separately. The RFS time of the ly 2 patients (N=9) was significantly shorter than that of the ly 0 plus ly 1 patients (P<0.0001). In the nine ly 2 patients, six developed a distant metastasis within 1 year. A multivariate analysis revealed that ly status (ly 0 plus ly 1 versus ly 2) was an independent prognostic factor (P=0.0116), demonstrating the significant prognostic value of extratumoral lymphatic permeation in NSCLC.

CONCLUSIONS

These results indicate that ly status is a good prognostic marker of poorer outcome in patients with resected NSCLC.

Arterial Invasion Predicts Early Mortality in Stage I Non–Small Cell Lung Cancer

BACKGROUND

A retrospective study was performed to evaluate the association between arterial invasion and survival in patients with stage I non-small cell lung cancer.

METHODS

One hundred patients were identified who had undergone complete anatomic resection as definitive treatment for stage I non-small cell lung cancer. The tumors were reviewed for the presence or absence of arterial invasion. Five-year survival data were obtained for all patients.

RESULTS

The 100 patients had an overall 5-year survival of 61%. There were 64 stage IA patients with a 62% 5-year survival and 36 stage IB patients with a 58% 5-year survival. The 39 patients identified with arterial invasion had a 38% 5-year survival compared with a 73% 5-year survival in the 61 patients without arterial invasion (p < 0.001), with an unadjusted hazard ratio of 3.5 (p < 0.001). Multivariate analysis by stage IA versus IB and by size greater or less than 2 cm demonstrated hazard ratios of 3.5 and 4.0, respectively (p < 0.001). This difference was independent of demographic characteristics, tumor type, or grade. Subgroup analysis revealed a hazard ratio of 5.8 in patients with stage IA non-small cell lung cancer (p < 0.001) and 19.8 in patients with tumors < or = 2 cm (p = 0.006).

CONCLUSIONS

Arterial invasion is present in a substantial percentage of patients with stage I non-small cell lung cancer and is adversely associated with survival.

Metastatic chondrosarcoma to the lung with extension into the left atrium via invasion of the pulmonary veins: presentation as embolic cerebral infarction

We present a case of metastatic chondrosarcoma to the lungs that invaded the left inferior pulmonary vein, extended into the left atrium and presented with an embolic cerebral infarct. CT findings included a large mass in the left lower lobe associated with enlargement of the left inferior pulmonary vein and a lobular filling defect in the left atrium. Systemic arterial embolization and obstruction of the mitral valve may be prominent features of pulmonary tumors that have invaded the pulmonary veins.

Study of prognostic predictors for non-small cell lung cancer

BACKGROUND

The outcome of treatment in non-small cell lung cancer (NSCLC) remains poor. One of the reasons is that in many patients its biological behavior does not follow a definite pattern, and can not be accurately predicted prior to treatment. In the present study we have examined the significant prognostic predictors.

METHODS

One hundred and fifty-eight patients with NSCLC entered this study. They received surgery alone (95 cases) or combined therapy with postoperative irradiation (63 cases). Three types of data have been collected: (1) clinical characteristics: age, sex, Karnofsky performance status, weight loss, T stage, and N stage; (2) histopathology studies: histological types, tumor differentiation, status of vascular and lymphatic vessel invasions; (3) laboratory measurements by immunohistochemistry assay: oncoprotein overexpression, including pan-ras, c-myc, neu, epidermal growth factor receptor (EGFR) and p53, and tumor cell proliferation by proliferating cell nuclear antigen (PCNA).

RESULTS

For the entire group, 5-year actuarial survival, local control and distant metastasis rates were 44, 63 and 40%, respectively. In the univariate analyses, T stage, N stage and lymphatic vessel invasion correlated to survival; T stage and N stage to local control; N stage, lymphatic vessel invasion and pan-ras protein positive stain to distant metastasis. When the index of oncoprotein positive stains was used, the higher index was associated with a higher distant metastasis rate. In the multivariate analyses, T stage, N stage and lymphatic vessel invasion could be independent predictors for survival; T stage for local control; N stage, lymphatic vessel invasion and index of positive oncoprotein stains for distant metastasis.

CONCLUSIONS

Late T and N stages, lymphatic vessel invasion and multi-oncoprotein positive stains would predict poor prognoses for NSCLC.

Expression of matrix metalloproteinase (gelatinase) in T1 adenocarcinoma of the lung

The expression of matrix metalloproteinase-2 (MMP-2; 72 kDa type IV collagenase/gelatinase A) and MMP-9 (92 kDa type IV collagenase/gelatinase B) was immunohistochemically investigated in 79 T1 adenocarcinomas of the lung using non-commercial polyclonal anti-MMP-2 and -9 antibodies. Thirty-two (41%) and 22 (28%) among the 79 cases were positive in the tumor cells for MMP-2 and -9, respectively. The incidences of MMP-2 and -9 immunoreactivities were higher (64 and 45%, respectively) in poorly differentiated tumors than in well differentiated tumors (36 and 25%, respectively), and lower in bronchioloalveolar carcinoma (22 and 10%, respectively) compared with other subtypes of adenocarcinoma. The prognosis for patients with MMP-2 and/or -9 positive immunoreactivities was significantly poorer than for those with a MMP-negative tumor (P < 0.05). The degree of collagenization was divided into four grades, and tumors with a small to abundant amount of collagen (grade 2 and grade 3 fibrosis) had a higher incidence of immunoreactivity to both types of MMP. It is estimated that these expressions might be responsible for tumor invasion, metastasis, and for grade 2 and grade 3 fibrosis in T1 adenocarcinoma of the lung.

Significance of demonstrable vascular space invasion for the progression of prostatic adenocarcinoma

Histologically demonstrable vascular invasion by tumor has been reported as an index of poor prognosis correlating with increased probability of metastasis in many types of cancer other than prostatic. We quantitated vascular invasion foci in 357 radical prostatectomy specimens and developed improved criteria for their diagnosis and their distinction from fixation artifact. Vascular invasion foci were found in 7% of cancers less than 4 cc in volume and 24% of larger cancers. Most foci were selectively located either near the basal end of the cancer or near the transition zone border. Correlations among multiple morphologic variables showed significant correlation of vascular invasion only with the presence of intraductal carcinoma. The only statistically significant independent predictors of disease progression (serum prostate-specific antigen elevation) were vascular invasion, carcinoma grade, and cancer volume. Our findings suggest that further study of vascular invasion foci may disclose additional information about the biologic features of local and distant spread of prostatic carcinoma.

Blood and lymphatic vessel invasion as prognostic factors for patients with primary resected nonsmall cell carcinoma of the lung with intrapulmonary metastases

BACKGROUND

The new classification of intrapulmonary metastases of lung cancer was proposed by the American Joint Committee on Cancer; however, the prognostic factors are heterogeneous and not yet fully clarified. In this study, the authors evaluated the prognostic factors for and the possible routes of intrapulmonary metastases.

METHODS

The factors influencing the prognosis of primary resected nonsmall cell lung carcinomas with intrapulmonary metastasis in the resected specimens were evaluated according to the Cox proportional hazards model using a total of 66 nonsmall cell lung carcinomas. The possible routes of tumor spread via the blood or lymphatic vessels also were evaluated.

RESULTS

The overall 5-year survival rate was 26.1%, and the statistical analysis of survival curves revealed a significant difference with regard to N classification (P = 0.042), site of intrapulmonary metastasis (P = 0.012), blood vessel invasion (P = 0.0046), and lymphatic vessel invasion (P = 0.0267); there were no significant differences in relation to age, sex, histology, differentiation, T classification, tumor size, stage, number of intrapulmonary metastases, or size of intrapulmonary metastasis. Multivariate analysis according to the Cox proportional hazards model identified a significant correlation between survival and blood vessel invasion (P = 0.044) and lymphatic vessel invasion (P = 0.042), suggesting independent prognostic significance. The correlation between site of intrapulmonary metastasis and the ratio of blood or lymphatic vessel invasion showed a significantly lower ratio of blood vessel invasion in cases with intrapulmonary metastases at sites central to the primary lesion or in different segment(s) compared with those in cases with intrapulmonary metastases at sites peripheral to the primary lesion or in ipsilateral different lobe(s), suggesting a possible lymphatic vessel route of tumor spread.

CONCLUSION

Blood vessel and lymphatic vessel invasion are important clinical factors in evaluating prognosis and the route of tumor spread in primary resected nonsmall cell carcinoma with intrapulmonary metastasis.

Expression of bcl-2 protein in stage T1N0M0 non-small cell lung carcinoma

The bcl-2 gene product (bcl-2 protein, BCLP) prevents apoptotic cell death. Via a 14;18 chromosomal translocation, BCLP is overexpressed in most follicular lymphomas as well as some other non-Hodgkin's lymphomas, and it has also been documented in other nonlymphomatous malignancies. To address the possible prognostic value of this marker in predefined subsets of non-small cell lung carcinoma (NSCLC), the authors studied 126 T1N0M0 cases seen between the years 1986 to 1991 at our institution. Patients were treated by lobectomy (105 cases) or wedge excision (21 cases) with negative margins; neuroendocrine carcinomas of all grades were specifically excluded. The mean follow-up period was 39 months. Immunostaining for BCLP was done using a monoclonal antibody (clone no. 124; DAKO, Carpinteria, CA), and the avidin-biotin-peroxidase complex (ABC) technique. The study cases included 73 adenocarcinomas (ACs) as well as 40 squamous cell (SCC), five adenosquamous (ASC), and eight large cell/poorly differentiated (LCC) carcinomas. As assessed with the Kaplan-Meier method, overall survival was 64% at 5 years (66% AC vs 59% SC). BCLP was detected in 47 of 126 cases (37%) including 32 AC (44%), 10 SCC 925%), two ASC (40%), and three LCC (38%). No significant difference in 5-year survival was noted in a comparison of all cases with BCLP expression (63%) and those without (59%). There was, however, a significant difference in the survival of grade 1 BCLP(+) cases, when compared with grade 2 or 3 BCLP(+) cases (P = .01). A nonstatistically significant trend toward increased survival was observed in BCLP(+) SCC cases (66% 5-year survival in BCLP[+] vs 45% in BCLP[-] [P = .11]). Proportional hazards analysis failed to disclose significant independent risk factors. These data suggest that bcl-2 protein immunoreactivity has limited prognostic value in the pathological evaluation of NSCLC.