Revolution in lung cancer: new challenges for the surgical pathologist

miR-939, as an important regulator in various cancers pathogenesis, has diagnostic, prognostic, and therapeutic values: a review

BACKGROUND

MicroRNAs (miRNAs or miRs) are highly conserved non-coding RNAs with a short length (18-24 nucleotides) that directly bind to a complementary sequence within 3'-untranslated regions of their target mRNAs and regulate gene expression, post-transcriptionally. They play crucial roles in diverse biological processes, including cell proliferation, apoptosis, and differentiation. In the context of cancer, miRNAs are key regulators of growth, angiogenesis, metastasis, and drug resistance.

MAIN BODY

This review primarily focuses on miR-939 and its expanding roles and target genes in cancer pathogenesis. It compiles findings from various investigations. MiRNAs, due to their dysregulated expression in tumor environments, hold potential as cancer biomarkers. Several studies have highlighted the dysregulation of miR-939 expression in human cancers.

CONCLUSION

Our study highlights the potential of miR-939 as a valuable target in cancer diagnosis, prognosis, and treatment. The aberrant expression of miR-939, along with other miRNAs, underscores their significance in advancing our understanding of cancer biology and their promise in personalized cancer care.

Identification of potential biomarkers for lung adenocarcinoma

Lung adenocarcinoma (LUAD) is the most predominant subtype of lung cancers and is one of the leading causes of cancer related mortality worldwide. Despite the advancements in the field of cancer diagnostics and therapeutics, detection at an early stage using reliable biomarkers is an unmet clinical need for a plethora of cancers, including LUAD, thus attributing to poor prognosis. In view of this, to identify potential biomarkers and therapeutic candidate genes, the expression of all known human genes was screened in the publicly available 'The Cancer Genome Atlas' (TCGA) samples of LUAD patients which resulted in the identification of overexpressed genes. Further analysis of these genes across various patient sample datasets revealed that ZNF687, ODR4, PBXIP1, PYGO2, METTL3, PIGM and RAD1 are consistently more highly expressed in LUAD. Higher expression of these genes either alone or in combination is correlated with poor survival of LUAD patients. Hence, in this study we propose that these identified genes could serve as potential candidates as gene signatures or biomarkers for LUAD that require further investigation in large cohorts of LUAD samples.

The dual PI3K/mTOR inhibitor BEZ235 restricts the growth of lung cancer tumors regardless of EGFR status, as a potent accompanist in combined therapeutic regimens

Background

Lung cancer is the most common cause of cancer-related mortality worldwide despite diagnostic improvements and the development of targeted therapies, notably including epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs). The phosphoinositide 3-kinase (PI3K)/AKT/mechanistic target of rapamycin (mTOR) signaling has been shown to contribute to tumorigenesis, tumor progression, and resistance to therapy in most human cancer types, including lung cancer. Here, we explored the therapeutic effects of co-inhibition of PI3K and mTOR in non-small-cell lung cancer (NSCLC) cells with different EGFR status.

Methods

The antiproliferative activity of a dual PI3K/mTOR inhibitor BEZ235 was examined by the WST-1 assay and the soft agar colony-formation assay in 2 normal cell lines and 12 NSCLC cell lines: 6 expressing wild-type EGFR and 6 expressing EGFR with activating mutations, including exon 19 deletions, and L858R and T790 M point mutations. The combination indexes of BEZ235 with cisplatin or an EGFR-TKI, BIBW2992 (afatinib), were calculated. The mechanisms triggered by BEZ235 were explored by western blotting analysis. The anti-tumor effect of BEZ235 alone or combined with cisplatin or BIBW2992 were also studied in vivo.

Results

BEZ235 suppressed tumor growth in vitro and in vivo by inducing cell-cycle arrest at G1 phase, but without causing cell death. It also reduced the expression of cyclin D1/D3 by regulating both its transcription and protein stability. Moreover, BEZ235 synergistically enhanced cisplatin-induced apoptosis in NSCLC cells by enhancing or prolonging DNA damage and BIBW2992-induced apoptosis in EGFR-TKI–resistant NSCLC cells containing a second TKI-resistant EGFR mutant.

Conclusions

The dual PI3K/mTOR inhibition by BEZ235 is an effective antitumor strategy for enhancing the efficacy of chemotherapy or targeted therapy, even as a monotherapy, to restrict tumor growth in lung cancer treatment.

Electronic supplementary material

The online version of this article (10.1186/s13046-019-1282-0) contains supplementary material, which is available to authorized users.

A group of long noncoding RNAs identified by data mining can predict the prognosis of lung adenocarcinoma

Long noncoding RNAs (lncRNA) are reported to be potential cancer biomarkers. This study aims to find new lncRNA biomarker relevant to lung adenocarcinoma. Gene expression profile and clinical data of lung adenocarcinoma and lung squamous cell carcinoma patients were downloaded from the UCSC Xena database. These data were analyzed to identify potential lncRNA prognostic biomarkers, and the candidate lncRNAs were analyzed and verified with association analysis, meta-analysis, survival analysis, gene ontology analysis, gene set enrichment analysis, and other statistical methods. A group of 5 lncRNAs was identified from the 1965 differentially expressed (fold-change >2) genes. Four of these 5 lncRNAs were expressed at a lower level in lung adenocarcinoma tissues and the other one at a higher level (P < .0001). A risk score model was constructed using a linear combination of the expression levels of these lncRNAs. High-risk patients showed poorer overall survival (hazard ratio [HR] = 2.14; 95% confidence interval [CI], 1.67-3.06, P < .0001), disease-free survival (HR = 1.84; 95% CI, 1.26-2.35, P = .0007), and recurrence-free survival (HR = 1.51; 95% CI, 1.02-2.40, P = .04). The 5-fold cross-validation and subsequent meta-analysis further verified that patients in the low-risk group had better survival (95% CI, 0.74-1.79, Z = 4.72, P < .00001). Furthermore, both univariate and multivariate Cox regression analyses revealed that the prognostic value of these 5 lncRNAs was independent of other clinical prognostic factors. Further analysis indicated that these 5 lncRNAs might be associated with tumor metastasis. Taken together, our study suggests new prognostic lncRNA biomarkers for lung adenocarcinoma.

A six-microRNA panel in plasma was identified as a potential biomarker for lung adenocarcinoma diagnosis

Differently expressed microRNAs (miRNAs) in the plasma of lung adenocarcinoma (LA) patients might serve as biomarkers for LA detection. MiRNA expression profiling was performed using Exiqon panels followed by the verification (30 LA VS. 10 healthy controls (HCs)) with quantitative reverse transcription polymerase chain reaction (qRT-PCR) in the screening phase. Identified miRNAs were confirmed through training (42 LA VS. 32 HCs) and testing stages (66 LA VS. 62 HCs) by using qRT-PCR based absolute quantification methods. A total of six up-regulated plasma miRNAs (miR-19b-3p, miR-21-5p, miR-221-3p, miR-409-3p, miR-425-5p and miR-584-5p) were identified. The six-miRNA panel could discriminate LA patients from HCs with areas under the receiver operating characteristic curve of 0.72, 0.74 and 0.84 for the training, testing and the external validation stage (33 LA VS. 30 HCs), respectively. All the miRNAs identified except miR-584-5p were significantly up-regulated in LA tissues. MiR-19-3p, miR-21-5p, miR-409-3p and miR-425-5p showed high expression in arterial plasma with borderline significance. Additionally, miR-19-3p, miR-21-5p and miR-221-3p were significantly up-regulated in exosomes extracted from LA peripheral plasma samples. In conclusion, we identified a six-miRNA panel in peripheral plasma which might give assistance to the detection of LA at least for Asian population to a certain extent.

Molecular profiling of lung cancer specimens and liquid biopsies using MALDI-TOF mass spectrometry

BACKGROUND

Identification of predictive molecular alterations in lung adenocarcinoma is essential for accurate therapeutic decisions. Although several molecular approaches are available, a number of issues, including tumor heterogeneity, frequent material scarcity, and the large number of loci to be investigated, must be taken into account in selecting the most appropriate technique. MALDI-TOF mass spectrometry (MS), which allows multiplexed genotyping, has been adopted in routine diagnostics as a sensitive, reliable, fast, and cost-effective method. Our aim was to test the reliability of this approach in detecting targetable mutations in non-small cell lung cancer (NSCLC). In addition, we also analyzed low-quality samples, such as cytologic specimens, that often, are the unique source of starting material in lung cancer cases, to test the sensitivity of the system.

METHODS

We designed a MS-based assay for testing 158 mutations in the EGFR, KRAS, BRAF, ALK, PIK3CA, ERBB2, DDR2, AKT, and MEK1 genes and applied it to 92 NSCLC specimens and 13 liquid biopsies from another subset of NSCLC patients. We also tested the sensitivity of the method to distinguish low represented mutations using serial dilutions of mutated DNA.

RESULTS

Our panel is able to detect the most common NSCLC mutations and the frequency of the mutations observed in our cohort was comparable to literature data. The assay identifies mutated alleles at frequencies of 2.5-10%. In addition, we found that the amount of DNA template was irrelevant to efficiently uncover mutated alleles present at high frequency. However, when using less than 10 ng of DNA, the assay can detect mutations present in at least 10% of the alleles. Finally, using MS and a commercial kit for RT-PCR we tested liquid biopsy from 13 patients with identified mutations in cancers and detected the mutations in 4 (MS) and in 5 samples (RT-PCR).

CONCLUSIONS

MS is a powerful method for the routine predictive tests of lung cancer also using low quality and scant tissues. Finally, after appropriate validation and improvement, MS could represent a promising and cost-effective strategy for monitoring the presence and percentage of the mutations also in non-invasive sampling.

Peripheral lung adenocarcinomas harboring epithelial growth factor receptor mutations with microRNA-135b overexpression are more likely to invade visceral pleura

Lung adenocarcinoma, characterized by its early and aggressive local invasion and high metastatic potential, is the most frequently observed histological type of non-small-cell lung cancer (NSCLC). Visceral pleural invasion (VPI) caused by peripheral lung adenocarcinomas is closely associated with the poor prognosis of patients with NSCLC. The association between VPI and some clinicopathological characteristics has been observed in the past few decades. However, the molecular mechanism of VPI in lung adenocarcinomas is unknown. In the present, the expression level of microRNA (miR-)135b and epidermal growth factor receptor (EGFR) mutations using the reverse transcription-quantitative polymerase chain reaction and DNA sequencing, respectively. In addition, the present study aimed at exploring the association between the miR-135b level, EGFR mutations and VPI in peripheral lung adenocarcinoma. The results of the present study demonstrated that miR-135b was significantly upregulated in lung adenocarcinoma compared with adjacent normal tissue and positively associated EGFR mutations in peripheral lung adenocarcinoma. Furthermore, it was identified that lung adenocarcinomas with EGFR mutations and miR-135b overexpression were more likely to invade visceral pleura. Taken together, these findings indicate that miR-135b overexpression is positively associated with mutations to EGFR, which may promote the development of peripheral lung adenocarcinomas by the formation of VPI. This indicates that the two factors may serve as prognostic markers and molecular targets for the treatment of peripheral lung adenocarcinomas.

DISC1 overexpression promotes non-small cell lung cancer cell proliferation

Neuropsychiatric disorder-associated disrupted-in-schizophrenia-1 (DISC1) activates Wnt/β-catenin signaling by inhibiting glycogen synthase kinase 3 beta (GSK3β) phosphorylation, and may promote neural progenitor cell and pancreatic β-cell proliferation. The present study found that DISC1 promotes non-small cell lung cancer (NSCLC) cell growth. Western blotting and immunohistochemistry analyses showed that DISC1 was highly expressed in NSCLC cell lines and patient tissues. DISC1 expression was negatively associated with phosphorylated (p-) GSK3β, but positively correlated with a more invasive tumor phenotype and predicted poor NSCLC patient prognosis. siRNA-mediated DISC1 silencing increased p-GSK3β expression and decreased expression of β-catenin and Cyclin D1, while DISC1 upregulation produced the opposite results. DISC1 knockdown also reduced NSCLC cell proliferation rates in vitro. These results suggest that DISC1 promotes NSCLC growth, likely through GSK3β/β-catenin signaling, and that DISC1 may function as an oncogene and novel anti-NSCLC therapeutic target.

High expression levels of MAGE-A9 are correlated with unfavorable survival in lung adenocarcinoma

A variety of melanoma-associated antigen-A (MAGE-A) protein are commonly detected in lung cancers. Their biological function is not well characterized but may involve cell cycle progression and the regulation of apoptosis. We hypothesized that MAGE-A9 is involved in the regulation of apoptosis. To test this hypothesis, we evaluated MAGE-A9 protein expression by immunohistochemical staining and we assessed the relationship between the expression of MAGE-A9 and clinical pathological parameters. In addition, we investigated the effect of MAGE-A9 down-regulation in lung adenocarcinoma. The results showed that a high expression level of MAGE-A9 protein in lung adenocarcinoma tumor cells was related to larger tumor diameter (P = 0.013) and poor differentiation (P = 0.029). Cox regression analysis revealed that the expression of MAGE-A9 in lung adenocarcinoma tumor cells (P < 0.001) is an independent prognostic factor in five-year survival rates. NSCLC cells with silenced MAGE-A9 had decreased cell proliferation, migration and invasion in cell culture compared to corresponding control cells. The NSCLC cells showing down-regulated MAGE-A9 induced the expression of apoptosis-associated proteins. In addition, MAGE-A9 was associated with resistance to conventional chemotherapeutic agents. Our findings provide evidence that MAGE-A9 could be a potential therapeutic target in NSCLC.

An Expression Signature as an Aid to the Histologic Classification of Non-Small Cell Lung Cancer

PURPOSE

Most non-small cell lung cancers (NSCLC) are now diagnosed from small specimens, and classification using standard pathology methods can be difficult. This is of clinical relevance as many therapy regimens and clinical trials are histology dependent. The purpose of this study was to develop an mRNA expression signature as an adjunct test for routine histopathologic classification of NSCLCs.

EXPERIMENTAL DESIGN

A microarray dataset of resected adenocarcinomas (ADC) and squamous cell carcinomas (SCC) was used as the learning set for an ADC-SCC signature. The Cancer Genome Atlas (TCGA) lung RNAseq dataset was used for validation. Another microarray dataset of ADCs and matched nonmalignant lung was used as the learning set for a tumor versus nonmalignant signature. The classifiers were selected as the most differentially expressed genes and sample classification was determined by a nearest distance approach.

RESULTS

We developed a 62-gene expression signature that contained many genes used in immunostains for NSCLC typing. It includes 42 genes that distinguish ADC from SCC and 20 genes differentiating nonmalignant lung from lung cancer. Testing of the TCGA and other public datasets resulted in high prediction accuracies (93%-95%). In addition, a prediction score was derived that correlates both with histologic grading and prognosis. We developed a practical version of the Classifier using the HTG EdgeSeq nuclease protection-based technology in combination with next-generation sequencing that can be applied to formalin-fixed paraffin-embedded (FFPE) tissues and small biopsies.

CONCLUSIONS

Our RNA classifier provides an objective, quantitative method to aid in the pathologic diagnosis of lung cancer. Clin Cancer Res; 22(19); 4880-9. ©2016 AACR.

PD-L1 and Lung Cancer: The Era of Precision-ish Medicine?

The success of immune checkpoint inhibitor therapy in lung cancer, both in squamous and nonsquamous non-small cell carcinoma, has led to US Food and Drug Administration approval for 2 medications that have as part of their prescribing information an associated immunohistochemistry-based companion or complementary diagnostic test for programmed death ligand-1 (PD-L1). The intense interest in drug development in this area has resulted in additional agents with associated diagnostics looming on the horizon in 2016. In the era of precision medicine, the paradigm of paired molecular target and molecular test, which serves as a model of oncogenic mutation-driven cancer therapy, is challenged by the proliferation of immunohistochemistry-based tests with different antibodies, instruments, and scoring. The difficulty inherent to targeted therapy aimed at a moving target is discussed, as well as the emerging challenges to pathologists and oncologists who seek to optimize care in this complex therapeutic arena.

Characterizing specimen quality of cell block samples in an era of personalized diagnostics: analysis of 221 lymph node fine-needle aspirations

INTRODUCTION

Cell block (CB) preparations of fine-needle aspirates (FNAs) are utilized for patient management, which requires retention of representative material on slides. Personalized medicine demands quality CB specimens. There is no standard protocol for CB preparation, often resulting in suboptimal slides. The utility of using two CB slides in lymph node (LN) FNA cases was investigated.

MATERIALS AND METHODS

We cut 10 serial sections from each CB, slides 1 and 5 are stained and considered the first and second cuts, respectively; the remaining slides are reserved for ancillary studies. Hematoxylin and eosin-stained CBs of 221 consecutive LN FNA cases were reviewed; qualitative and quantitative assessment of diagnostic value was made on sections 1 and 5.

RESULTS

Of the 221 cases, 46.1% (102) had comparable diagnostic cellularity (equally representative) on both slides, whereas 26.7% (59) and 27.1% (60) had more representative material on the first and second cuts, respectively (P = 0.52). Differences between the representativeness of first and second CB cuts of intrathoracic lymph nodes were minor (n = 192, P = 0.065). Differences between the first and the second slide representativeness of superficial (n = 22, P = 0.98) and intra-abdominal lymph nodes (n = 7, P = 0.38) are limited because of small sample sizes.

CONCLUSION

One CB cut can be suboptimal for diagnosis. In our study, inclusion of a second slide increases equal representativeness from 46.1% to 73.2%. These limited observations recognize the need for additional investigations regarding the collection and preparation of CBs.

Identifying and Assessing Interesting Subgroups in a Heterogeneous Population

Biological heterogeneity is common in many diseases and it is often the reason for therapeutic failures. Thus, there is great interest in classifying a disease into subtypes that have clinical significance in terms of prognosis or therapy response. One of the most popular methods to uncover unrecognized subtypes is cluster analysis. However, classical clustering methods such as k-means clustering or hierarchical clustering are not guaranteed to produce clinically interesting subtypes. This could be because the main statistical variability--the basis of cluster generation--is dominated by genes not associated with the clinical phenotype of interest. Furthermore, a strong prognostic factor might be relevant for a certain subgroup but not for the whole population; thus an analysis of the whole sample may not reveal this prognostic factor. To address these problems we investigate methods to identify and assess clinically interesting subgroups in a heterogeneous population. The identification step uses a clustering algorithm and to assess significance we use a false discovery rate- (FDR-) based measure. Under the heterogeneity condition the standard FDR estimate is shown to overestimate the true FDR value, but this is remedied by an improved FDR estimation procedure. As illustrations, two real data examples from gene expression studies of lung cancer are provided.

Transcription factor glioma-associated oncogene homolog 1 is required for transforming growth factor-β1-induced epithelial-mesenchymal transition of non-small cell lung cancer cells

Epithelial-mesenchymal transition (EMT) is the process by which epithelial cells depolarize and acquire a mesenchymal phenotype, and is a common early step in the process of metastasis. Patients with lung cancer frequently already have distant metastases when they are diagnosed, highlighting the requirement for early and effective interventions to control metastatic disease. Transforming growth factor-β1 (TGF-β1) is able to induce EMT, however the molecular mechanism of this remains unclear. In the current study, TGF-β1 was reported to induce EMT and promote the migration of non-small cell lung cancer (NSCLC) cells. A notable observation was that EMT induction was accompanied by the upregulation of human glioma-associated oncogene homolog 1 (Gli1) mRNA and protein levels. Furthermore, Gli1 levels were depleted by small interfering RNA, and the Gli1 inhibitor GANT 61 attenuated the TGF-β1-mediated induction of EMT and cell migration. The results of the current study suggest that Gli1 regulates TGF-β1-induced EMT, which may provide a novel therapeutic target to inhibit metastasis in patients with NSCLC.

Second ESMO consensus conference on lung cancer: pathology and molecular biomarkers for non-small-cell lung cancer

To complement the existing treatment guidelines for all tumour types, ESMO organises consensus conferences to focus on specific issues in each type of tumour. The Second ESMO Consensus Conference on Lung Cancer was held on 11-12 May 2013 in Lugano. A total of 35 experts met to address several questions on management of patients with non-small-cell lung cancer (NSCLC) in each of four areas: pathology and molecular biomarkers, early stage disease, locally advanced disease and advanced (metastatic) disease. For each question, recommendations were made including reference to the grade of recommendation and level of evidence. This consensus paper focuses on recommendations for pathology and molecular biomarkers in relation to the diagnosis of lung cancer, primarily non-small-cell carcinomas.

The pivotal role of pathology in the management of lung cancer

The last decade has seen significant advances in our understanding of lung cancer biology and management. Identification of key driver events in lung carcinogenesis has contributed to the development of targeted lung cancer therapies, heralding the era of personalised medicine for lung cancer. As a result, histological subtyping and molecular testing has become of paramount importance, placing increasing demands on often small diagnostic specimens. This has triggered the review and development of the first structured classification of lung cancer in small biopsy/cytology specimens and a new classification of lung adenocarcinoma from the IASLC/ATS/ERS. These have enhanced the clinical relevance of pathological diagnosis, and emphasise the role of the modern surgical pathologist as an integral member of the multidisciplinary team, playing a crucial role in clinical trials and determining appropriate and timely management for patients with lung cancer.

The state of cell block variation and satisfaction in the era of molecular diagnostics and personalized medicine

BACKGROUND

In the recent past, algorithms and recommendations to standardize the morphological, immunohistochemical and molecular classification of lung cancers on cytology specimens have been proposed, and several organizations have recommended cell blocks (CBs) as the preferred modality for molecular testing. Based on the literature, there are several different techniques available for CB preparation-suggesting that there is no standard. The aim of this study was to conduct a survey of CB preparation techniques utilized in various practice settings and analyze current issues, if any.

MATERIALS AND METHODS

A single E-mail with a link to an electronic survey was distributed to members of the American Society of Cytopathology and other pathologists. Questions pertaining to the participants' practice setting and CBs-volume, method, quality and satisfaction-were included.

RESULTS

Of 95 respondents, 90/95 (94%) completed the survey and comprise the study group. Most participants practice in a community hospital/private practice (44%) or academic center (41%). On average, 14 CBs (range 0-50; median 10) are prepared by a laboratory daily. Over 10 methods are utilized: Plasma thrombin (33%), HistoGel (27%), Cellient automated cell block system (8%) and others (31%) respectively. Forty of 90 (44%) respondents are either unsatisfied or sometimes satisfied with their CB quality, with low-cellular yield being the leading cause of dissatisfaction. There was no statistical significance between the three most common CB preparation methods and satisfaction with quality.

DISCUSSION

Many are dissatisfied with their current method of CB preparation, and there is no consistent method to prepare CBs. In today's era of personalized medicine with an increasing array of molecular tests being applied to cytological specimens, there is a need for a standardized protocol for CB optimization to enhance cellularity.

Performance validation in anatomic pathology: successful integration of a new classification system into the practice setting using the updated lung non-small cell carcinoma recommendations

CONTEXT

The new, international, multidisciplinary classification of lung adenocarcinoma, from the International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society, presents a paradigm shift for diagnostic pathologists.

OBJECTIVE

To validate our ability to apply the recommendations in reporting on non-small cell lung cancer cases.

DESIGN

A test based on the new non-small cell lung cancer classification was administered to 16 pathology faculty members, senior residents, and fellows before and after major educational interventions, which included circulation of articles, electronic presentations, and live presentations by a well-known lung pathologist. Surgical and cytologic (including cell-block material) reports of lung malignancies for representative periods before and after the educational interventions were reviewed for compliance with the new guidelines. Cases were scored on a 3-point scale, with 1 indicating incorrect terminology and/or highly inappropriate stain use, 2 indicating correct diagnostic terminology with suboptimal stain use, and 3 indicating appropriate diagnosis and stain use. The actual error type was also evaluated.

RESULTS

The average score on initial testing was 55%, increasing to 88% following the educational interventions (60% improvement). Of the 54 reports evaluated before intervention, participants scored 3 out of 3 points on 15 cases (28%), 2 of 3 on 31 cases (57%), and 1 of 3 on 8 cases (15%). Incorrect use of stains was noted in 23 of 54 cases (43%), incorrect terminology in 15 of 54 cases (28%), and inappropriate use of tissue, precluding possible molecular testing, in 4 out of 54 cases (7%). Of the 55 cases after intervention, participants scored 3 out of 3 points on 46 cases (84%), 2 of 3 on 8 cases (15%), and 1 of 3 on 1 case (2%). Incorrect use of stains was identified in 9 of 55 cases (16% of total reports), and inappropriate use of tissue, precluding possible molecular testing, was found in 1 of the 55 cases (2%).

CONCLUSIONS

The study results demonstrated marked improvement in the pathologists' understanding and application of the new non-small cell lung cancer classification recommendations, which was sufficient to validate our use of the system in routine practice. The results also affirm the value of intensive education on, and validation of, pathologists' use of a classification or diagnostic algorithm.

Toward an evidence-based proposal for the best minimal immunohistochemical panel to infer lung carcinoma in metastatic supraclavicular lymph node

Carcinomas from either pulmonary or extrapulmonary sites can metastatise to supraclavicular lymph nodes. Immunohistochemistry (IHC) is invaluable to comment on the possible primary site. However, the optimal number of antibodies to be tested is debatable. Seven antibodies were tested on 135 metastatic supraclavicular lymph node biopsies to propose a "best minimal" IHC panel to infer lung carcinoma, incorporating the principles of "evidence-based medicine." The 135 cases were divided into the following: category I (110 cases), wherein the primary was in the lung based on histologic analysis (Ia, n = 14 [12.7%]), cytologic analysis (Ib, n = 43 [39.1%]), or strong clinicoradiologic evidence (Ic, n = 53 [48.2%]), and category II (25 cases) with a histologically proven extrapulmonary primary site. Categories Ia and Ib were together designated as the "control group," and category Ic was designated as the "test group." The antibodies tested were cytokeratin (CK 7, CK20), epithelial membrane antigen, carcinoembryonic antigen, thyroid transcription factor-1 (TTF-1), surfactant protein B (SPB), and vimentin. Results of both individual and panels of antibodies were statistically evaluated. The sensitivity and specificity of single antibodies for inferring a lung primary was as follows: CK7 (90%/56%), CK20 (98%/40%), epithelial membrane antigen (90.9%/4%), carcinoembryonic antigen (80.9%/36%), TTF-1 (62.7%/100%), SPB (65.6%/100%), and vimentin (60.9%/60%). The highest sensitivity (85%) and specificity (100%) were seen with a 4-antibody panel: CK7, CK20, TTF-1, and SPB. This panel revealed the highest binomial probability (.8), for diagnosing lung cancer. The results were validated using a "split sample method," and a high concordance was noted between the control and test groups. To conclude, such evidence-based validated studies analyzing IHC results would be invaluable to guide the practice of surgical pathology in the future.

Does Immunohistochemistry Affect Response to Therapy and Survival of Inoperable Non–Small Cell Lung Carcinoma Patients? A Survey of 145 Stage III-IV Consecutive Cases

Whether non–small cell lung carcinoma (NSCLC) unveiled by immunohistochemistry (IHC) has the same clinical outcome as those typed by morphology is still matter of debate. A total of 145 stage III-IV, consecutive inoperable NSCLC patients treated by chemotherapy (133 cases) or EGFR tyrosine kinase inhibitor (12 cases) and including 100 biopsies, 11 surgical specimens, and 34 cytological samples had originally accounted for 120 adenocarcinomas (ADs), 19 squamous cell carcinomas (SQCs), and 6 adenosquamous carcinomas (ADSQCs) by integrating morphology and thyroid transcription factor-1 (TTF1)/p40 IHC. Thirty-two NSCLC–not otherwise specified (NSCLC-NOS) cases were identified by morphology revision of the original diagnoses, which showed solid growth pattern ( P < .001), 22 ADs, 5 SQCs, and 5 ADSQCs by IHC profiling ( P < .001), and 10 gene-altered tumors (3 EGFR, 5 KRAS, and 2 ALK). While no significant relationships were observed between response to therapy and original, morphology or IHC diagnoses, driver mutations and tumor differentiation by TTF1 expression, AD run better progression-free survival (PFS) or overall survival (OS) than other tumor types by morphology ( P = .010 and P = .047) and IHC ( P = .033 and P = .046), respectively. Furthermore, patients with NSCLC-NOS confirmed as AD by IHC tended to have poorer OS ( P = .179) and PFS ( P = .193) similar to that of ADSQC and SQC ( P = .702 and P = .540, respectively). A category of less differentiated AD with poorer prognosis on therapy could be identified by IHC, while there were no differences for SQC or ADSQC. The terminology of “NSCLC-NOS, favor by IHC” is appropriate to alert clinicians toward more aggressive tumors.

Integrated molecular portrait of non-small cell lung cancers

Background

Non-small cell lung cancer (NSCLC), a leading cause of cancer deaths, represents a heterogeneous group of neoplasms, mostly comprising squamous cell carcinoma (SCC), adenocarcinoma (AC) and large-cell carcinoma (LCC). The objectives of this study were to utilize integrated genomic data including copy-number alteration, mRNA, microRNA expression and candidate-gene full sequencing data to characterize the molecular distinctions between AC and SCC.

Methods

Comparative genomic hybridization followed by mutational analysis, gene expression and miRNA microarray profiling were performed on 123 paired tumor and non-tumor tissue samples from patients with NSCLC.

Results

At DNA, mRNA and miRNA levels we could identify molecular markers that discriminated significantly between the various histopathological entities of NSCLC. We identified 34 genomic clusters using aCGH data; several genes exhibited a different profile of aberrations between AC and SCC, including PIK3CA, SOX2, THPO, TP63, PDGFB genes. Gene expression profiling analysis identified SPP1, CTHRC1and GREM1 as potential biomarkers for early diagnosis of the cancer, and SPINK1 and BMP7 to distinguish between AC and SCC in small biopsies or in blood samples. Using integrated genomics approach we found in recurrently altered regions a list of three potential driver genes, MRPS22, NDRG1 and RNF7, which were consistently over-expressed in amplified regions, had wide-spread correlation with an average of ~800 genes throughout the genome and highly associated with histological types. Using a network enrichment analysis, the targets of these potential drivers were seen to be involved in DNA replication, cell cycle, mismatch repair, p53 signalling pathway and other lung cancer related signalling pathways, and many immunological pathways. Furthermore, we also identified one potential driver miRNA hsa-miR-944.

Conclusions

Integrated molecular characterization of AC and SCC helped identify clinically relevant markers and potential drivers, which are recurrent and stable changes at DNA level that have functional implications at RNA level and have strong association with histological subtypes.

Global analysis of serum microRNAs as potential biomarkers for lung adenocarcinoma

Early diagnosis and the ability to predict the most relevant treatment option for individuals is essential to improve clinical outcomes for non-small cell lung cancer (NSCLC) patients. Adenocarcinoma (ADC), a subtype of NSCLC, is the single biggest cancer killer and therefore an urgent need to identify minimally invasive biomarkers to enable early diagnosis. Recent studies, by ourselves and others, indicate that circulating miRNAs have potential as biomarkers. Here we applied global profiling approaches in serum from patients with ADC of the lung to explore if miRNAs have potential as diagnostic biomarkers. This study involved RNA isolation from 80 sera specimens including those from ADC patients (equal numbers of stages 1, 2, 3, and 4) and age- and gender-matched controls (n = 40 each). Six hundred and sixty-seven miRNAs were co-analyzed in these specimens using TaqMan low density arrays and qPCR validation using individual miRNAs. Overall, approximately 390 and 370 miRNAs were detected in ADC and control sera, respectively. A group of 6 miRNAs, miR-30c-1* (AUC = 0.74; P<0.002), miR-616* (AUC = 0.71; P = 0.001), miR-146b-3p (AUC = 0.82; P<0.0001), miR-566 (AUC = 0.80; P<0.0001), miR-550 (AUC = 0.72; P = 0.0006), and miR-939 (AUC = 0.82; P<0.0001) was found to be present at substantially higher levels in ADC compared with control sera. Conversely, miR-339-5p and miR-656 were detected at substantially lower levels in ADC sera (co-analysis resulting in AUC = 0.6; P = 0.02). Differences in miRNA profile identified support circulating miRNAs having potential as diagnostic biomarkers for ADC. More extensive studies of ADC and control serum specimens are warranted to independently validate the potential clinical relevance of these miRNAs as minimally invasive biomarkers for ADC.

Lung Cancer Biomarkers: Present Status and Future Developments

The publication of the “Molecular Testing Guideline for Selection of Lung Cancer Patients for EGFR and ALK Tyrosine Kinase Inhibitors: Guideline From the College of American Pathologists, International Association for the Study of Lung Cancer, and Association for Molecular Pathology” has now provided a guideline for biomarker testing for first-generation lung cancer tyrosine kinase inhibitors. Biomarker testing has forever altered the role of pathologists in the management of patients with lung cancer. Current, unresolved issues in the precision medicine of lung cancer will be addressed by the development of new biomarker tests, new drugs, and new test technologies and by improvement in the cost to benefit ratio of biomarker testing.

Impact of the College of American Pathologists, the International Association for the Study of Lung Cancer, and the Association for Molecular Pathology clinical practice guidelines for EGFR and ALK testing in lung cancer in Canada

This paper summarizes the practical impact of the College of American Pathologists, the International Association for the Study of Lung Cancer, and the Association for Molecular Pathology lung cancer biomarkers guidelines on the lung cancer approach in Canada, providing possible practical solutions for other similar health care systems in which scientific reality needs to be constantly balanced against economic reality.

Prognosis in patients with symptomatic metastatic spinal cord compression: survival in different cancer diagnosis in a cohort of 2321 patients

STUDY DESIGN

A retrospective cohort study of 2321 patients consecutively admitted to one center and diagnosed with acute symptoms of metastatic spinal cord compression (MSCC).

OBJECTIVE

To assess the possible change in 1-year survival for patients with MSCC from year 2005 through 2010 with respect to the primary cancer diagnosis.

SUMMARY OF BACKGROUND DATA

An increasing number of patients are offered surgical treatment for MSCC. Among the reasons for this development are high evidence clinical studies, improved surgical techniques, and an increasing number of patients being treated for an oncological condition. Preoperative scoring systems are routinely used in the evaluation of these patients, and the primary oncological diagnosis is an important variable in all these systems. To our knowledge, no studies in a large group of patients have assessed the change in survival in these patients. This is of relevance because such changes in survival could have implications on the scoring systems used in the preoperative evaluation.

METHODS

All patients referred to the university hospital, Rigshospitalet, suspected of acute symptoms caused by spinal metastases and diagnosed with MSCC from January 1, 2005, to December 31, 2010, were included in a retrospective cohort, n = 2321. For all patients primary tumor, treatment, and 1-year survival was registered.

RESULTS

The overall 1-year survival did not change significantly from 2005 to 2010, but there was a significant increase in 1-year survival for the subgroups of patients with lung cancer hazard ratio = 0.93 (P = 0.008, 95% CI: 0.83-0.98) and renal cancer hazard ratio = 0.77 (P = 0.004, 95% CI: 0.56-0.92).

CONCLUSION

Patients with MSCC from pulmonary and renal cancers experienced improved survival in the study period. No improvement was seen for patients with other oncological diagnoses. This corresponds to reports from oncological studies and could affect preoperative scoring systems.

Relationship between lung adenocarcinoma histological subtype and patient prognosis

PURPOSE

Lung adenocarcinoma (AC) demonstrates various histological subtypes within the tumour tissue. A panel established jointly by the IASLC, ATS and ERS classified invasive lung ACs based on the predominant histological subtype. We examined the distribution of tumours in lung AC patients according to histological subtype and analysed the effects of this classification on survival.

METHODS

The records of patients who had pulmonary resection for lung cancer between January 2000 and December 2009 were reviewed and 226 lung AC patients who fulfilled the inclusion criteria were identified. Histological subtypes of the ACs and their ratios in the tumour tissue were determined. Tumours were classified according to the predominant histological subtype and subsequently graded. The relationship between the predominant histological subtype, grade and survival were analysed.

RESULTS

Tumours were predominantly acinar in 99 cases (43.8%), solid in 89 (39.3%), lepidic in 20 (8.8%), and papillary in 11 (4.8%), whereas 7 tumours (3%) were variants of AC. Stage significantly affected survival (p = 0.001); however, the predominant histological subtype had no significant effect. The 5-year survival rate for patients with histologically grade II tumours was 48.6%, whereas that in patients with grade III tumours was 56%. (p = 0.69).

CONCLUSION

Invasive lung ACs may be defined by their predominant histological subtype. However, it is not yet possible to conclude that this classification is related to survival.

Lung cancer genotype-based therapy and predictive biomarkers: present and future

CONTEXT

The advent of genotype-based therapy and predictive biomarkers for lung cancer has thrust the pathologist into the front lines of precision medicine for this deadly disease.

OBJECTIVE

To provide the clinical background, current status, and future perspectives of molecular targeted therapy for lung cancer patients, including the pivotal participation of the pathologist.

DATA SOURCES

Data were obtained from review of the pertinent peer-reviewed literature.

CONCLUSIONS

First-generation tyrosine kinase inhibitors have produced clinical response in a limited number of non-small cell lung cancers demonstrated to have activating mutations of epidermal growth factor receptor or anaplastic lymphoma kinase rearrangements with fusion partners. Patients treated with first-generation tyrosine kinase inhibitors develop acquired resistance to their therapy. Ongoing investigations of second-generation tyrosine kinase inhibitors and new druggable targets as well as the development of next-generation genotyping and new antibodies for immunohistochemistry promise to significantly expand the pathologist's already crucial role in precision medicine of lung cancer.

Root cause analysis of problems in the frozen section diagnosis of in situ, minimally invasive, and invasive adenocarcinoma of the lung

CONTEXT

Frozen sections can help determine the extent of surgery by distinguishing in situ, minimally invasive, and invasive adenocarcinoma of the lung.

OBJECTIVE

To evaluate our experience with the frozen section diagnosis of these lesions using root-cause analysis.

DESIGN

Frozen sections from 224 consecutive primary pulmonary adenocarcinomas (in situ, 27 [12.1%]; minimally invasive, 46 [20.5%]; invasive, 151 [67.4%]) were reviewed. Features that could have contributed to frozen section errors and deferrals were evaluated.

RESULTS

There were no false-positive diagnoses of malignancy. Frozen section errors and deferrals were identified in 12.1% (27 of 224) and 6.3% (14 of 224) of the cases, respectively. Significantly more errors occurred in the diagnosis of in situ and minimally invasive adenocarcinoma than in the diagnosis of invasive adenocarcinoma (P < .001). Frozen section errors and deferrals were twice as frequent in lesions smaller than 1.0 cm (P = .09). Features significantly associated with errors and deferrals included intraoperative consultation by more than one pathologist (P = .003) and more than one sample of frozen lung section (P = .001). Inflammation with reactive atypia, fibrosis/scar, sampling problems, and suboptimal quality sections were identified in 51.2% (21 of 41), 36.6% (15 of 41), 26.8% (11 of 41), and 9.8% (4 of 41) of the errors and deferrals, respectively (more than one of these factors was identified in some cases). Frozen section errors and deferrals had significant clinical impact in only 4 patients (1.8%); each had to undergo completion video-assisted thoracoscopic lobectomy less than 90 days after the initial surgery.

CONCLUSIONS

The distinction of in situ from minimally invasive adenocarcinoma is difficult in both frozen and permanent sections. We identified several technical and interpretive features that likely contributed to frozen section errors and deferrals and suggest practice modifications that are likely to improve diagnostic accuracy.

Enteric adenocarcinoma lung: a rare presentation in an Omani woman

Pulmonary adenocarcinoma is a common neoplasm, yet the one with enteric or intestinal differentiation poses a diagnostic challenge to pathologists as it shares a common immunohistochemical profile with metastatic colorectal carcinoma. We report a case of a 61-year-old woman. She was on surveillance when incidentally she was discovered to have multiple bilateral lung nodules on imaging; the largest was surgically removed for histological examination. Morphology was consistent with a moderately differentiated adenocarcinoma .The tumour cells were positive for cytokeratin (CK) 7, CDX2, CK20 and were negative for thyroid transcription factor 1. The morphology and immune histochemical profile raised the differential diagnosis of a metastatic colorectal carcinoma and a primary lung adenocarcinoma with enteric differentiation. On the basis of morphology and CK7 positivity we established the diagnosis of enteric-type adenocarcinoma of primary lung origin. She has completed planned courses of palliative chemotherapy and remains on surveillance.

The evolving role of the pathologist in the management of lung cancer

Major advances in pathology, molecular biology, patient diagnosis and care, as well as the advent of personalized therapy, have resulted in a greatly increased role for the pathologist, who has emerged as a key member of the lung cancer management team. A new multidisciplinary, clinically relevant classification of pulmonary adenocarcinoma has resulted in a paradigm shift in how we view and practice lung cancer pathology. In the future, the role of the pathologist will continue to grow and become fully integrated with clinical care.

The impact on the multidisciplinary team of molecular profiling for personalized therapy in non-small cell lung cancer

The composition of the multidisciplinary team (MDT) that treats lung cancer varies by region and practice setting but generally includes a thoracic medical oncologist, a thoracic surgeon, a thoracic radiation oncologist, and an interventional radiologist, as well as a pathologist, pulmonologist, and specialist nurses. Growing clinical evidence supports a personalized approach to non-small cell lung cancer (NSCLC) treatment, and clinical trials in advanced disease have shown the value of testing for epidermal growth factor receptor gene (EGFR) mutations prior to first-line therapy with erlotinib or gefitinib and testing for anaplastic lymphoma kinase gene (ALK) rearrangements prior to therapy with crizotinib. The most recent National Comprehensive Cancer Network (NCCN) guidelines also recommend sequential EGFR and ALK testing for patients with a diagnosis of recurrent or metastatic adenocarcinoma, large cell carcinoma, or not otherwise specified histology, and simultaneous molecular screening has also been proposed. Here, we explore potential challenges for the MDT implied by the move toward personalized therapy in NSCLC and the increasing need for molecular diagnoses, and anticipate how the working roles and responsibilities of team members may develop to accommodate them.

Classification of lung cancer: proposals for change?

Clinical need and developments in pathology and molecular biology require our cancer classifications to be constantly updated to keep them relevant and useful. A review of lung cancer classification is due and has been initiated with new proposals on classification of lung adenocarcinoma. Other major lung cancer types also deserve a similar consideration. As well as addressing the categories of tumor, as signed out in surgical resection specimens, recent proposals on small diagnostic-sample reporting would be an important addition to any new classification. The huge increase in data on the molecular biology of lung cancer has improved our understanding of these diseases, has driven improved therapy for some patients, and must be reflected in the way lung cancer is classified.

Precision Medicine for Lung Cancer: Role of the Surgical Pathologist

Precision medicine is altering the traditional role of the surgical pathologist in caring for patients with lung cancer. Diagnosing specific cell type is now a foundation for selecting lung cancers for predictive-biomarker testing by molecular techniques. Using conventional techniques and familiar equipment, the surgical pathologist's role goes beyond this important step and will include screening for, and possibly diagnosis of, predictive biomarkers as we illustrate for one predictive biomarker. Pathologists should embrace the innovations described at the Houston Lung Symposium but must recognize that their traditional expertise will be an important component of precision medicine for the foreseeable future.

Percutaneous cryoablation of metastatic lesions from non-small-cell lung carcinoma: initial survival, local control, and cost observations

PURPOSE

To assess feasibility, complications, local tumor recurrences, overall survival (OS), and estimates of cost effectiveness for multisite cryoablation (MCA) of oligometastatic non-small-cell lung cancer (NSCLC).

MATERIALS AND METHODS

A total of 49 computed tomography- and/or ultrasound-guided percutaneous MCA procedures were performed on 60 tumors in 31 patients (19 women and 12 men) with oligometastatic NSCLC. Average patient age was 65 years. Tumor location was grouped according to common metastatic sites. Median OS was determined by Kaplan-Meier method and defined life-years gained (LYGs). Estimates of MCA costs per LYG were compared with established values for systemic therapies.

RESULTS

Total numbers of tumors and cryoablation procedures for each anatomic site were as follows: lung, 20 and 18; liver, nine and seven; superficial, 12 and 11; adrenal, seven and seven; paraaortic/isolated, two and two; and bone, 10 and seven. A mean of 1.6 procedures per patient were performed, with a median clinical follow-up of 11 months. Major complication and local recurrence rates were 8% (four of 49) and 8% (five of 60), respectively. Median OS for MCA was 1.33 years, with an estimated 1-year survival rate of approximately 53%. MCA appeared cost-effective even when added to the cost of best supportive care or systemic regimens, with an adjunctive cost-effectiveness ratio of $49,008-$87,074.

CONCLUSIONS

MCA was associated with very low morbidity and local tumor recurrence rates for all anatomic sites, and possibly increased OS. Even as an adjunct to systemic therapies, MCA appeared cost-effective for palliation of oligometastatic NSCLC.

Folate receptor in adenocarcinoma and squamous cell carcinoma of the lung: potential target for folate-linked therapeutic agents

CONTEXT

Lung cancer is the number one cause of cancer deaths in the United States and globally. The advent of targeted therapies has offered a new treatment paradigm for lung cancer, but currently validated and emerging drugs are effective in only a small minority of lung cancers, predominantly adenocarcinomas. Folate receptors can serve as targets for drugs attached to folate and are overexpressed in many cancers.

OBJECTIVE

To determine the frequency of folate receptor overexpression in lung cancers of different cell types as potential targets for folate-linked therapy.

DESIGN

High-density tissue microarrays were constructed from archival formalin-fixed, paraffin-embedded resection specimens from 188 primary stage I or stage II adenocarcinomas or squamous cell carcinomas of the lung with three 0.1-cm cores from each tumor. Tissue microarrays were immunostained for folate receptor α with mAb343 and the results scored (0 to 1+ = weak expression, 2+ to 3+ = strong expression).

RESULTS

Eighty-four of 117 (72%) of the adenocarcinomas were strongly positive for the folate receptor, and 36 of 71 (51%) of the squamous cell carcinomas were strongly positive for the folate receptor.

CONCLUSIONS

Our data indicate that a large percentage of lung cancers, including squamous cell carcinomas in addition to adenocarcinomas, strongly express folate receptor. This suggests that folate-linked targeted therapy can potentially be used to treat the majority of lung cancers, both adenocarcinomas and, particularly, squamous cell carcinomas, that do not respond to current targeted therapies.

A personalized approach to treatment: use of EGFR tyrosine kinase inhibitors for the treatment of non-small-cell lung cancer in Canada

Lung cancer is one of the most commonly diagnosed malignancies and the leading cause of cancer-related mortality in Canada. The heterogeneity of nsclc and the importance of linking new targeted agents to the appropriate disease subtype require an individualized approach to treatment. In patients with EGFR (epidermal growth factor receptor gene) mutations, EGFR tyrosine kinase inhibitors (TKIs) provide a highly effective treatment option, with improved toxicity compared with standard chemotherapy. However, the identification of mutation-positive patients is limited by a lack of funding for testing. The length of time required to receive test results and insufficient tissue from biopsies are additional limitations. In Canada, the use of EGFR-TKIs varies based on differences in provincial funding for both testing and treatment. With improvements in testing and access to funding for treatment, targeted use of EGFR-TKIs may greatly improve outcomes in NSCLC.

High expression of FoxP1 is associated with improved survival in patients with non-small cell lung cancer

FoxP1 has been reported to be expressed in several types of human malignant tumors, and has been associated with metastasis and patient prognosis. Quantitative real-time polymerase chain reaction (PCR) and immunohistochemical analysis with tissue microarray were used to characterize the expression of FoxP1 in non-small cell lung cancer (NSCLC). It was revealed that the expression of FoxP1 messenger RNA (mRNA) and protein was significantly higher in NSCLC tissue than in corresponding peritumoral tissue (P = .013 and P < .001, respectively). The expression of FoxP1 protein in NSCLC was related to gender, histologic type, and 5-year survival rate (all P < .05). Finally, we evaluated the prognostic significance of the expression of FoxP1 in a group of patients. Kaplan-Meier survival and Cox regression analyses showed that low expression of FoxP1 (P < .001) and later stage grouping by TNM (P = .022) were independent factors predicting poor prognosis for NSCLC.

Napsin A, a new marker for lung adenocarcinoma, is complementary and more sensitive and specific than thyroid transcription factor 1 in the differential diagnosis of primary pulmonary carcinoma: evaluation of 1674 cases by tissue microarray

CONTEXT

Differentiation of non-small cell carcinoma into histologic types is important because of new, successful therapies that target lung adenocarcinoma (ACA). TTF-1 is a favored marker for lung ACA but has limited sensitivity and specificity. Napsin A (Nap-A) is a functional aspartic proteinase that may be an alternative marker for primary lung ACA.

OBJECTIVES

To compare Nap-A versus TTF-1 in the typing of primary lung carcinoma and the differentiation of primary lung ACA from carcinomas of other sites.

DESIGN

Immunohistochemistry for Nap-A and TTF-1 was performed on tissue microarrays of 1674 cases of carcinoma: 303 primary lung ACAs (18.1%), 200 primary squamous cell lung carcinomas (11.9%), 52 primary small cell carcinomas of the lung (3.1%), and carcinomas of the kidney (n  =  320; 19.1%), thyroid (n  =  96; 5.7%), biliary (n  =  89; 5.3%), bladder (n  =  47; 2.8%), breast (n  =  93; 5.6%), colon (n  =  95; 5.7%), liver (n  =  96; 5.7%), ovaries (n  =  45; 2.7%), pancreas (n  =  48; 2.9%), prostate (n  =  49; 2.9%), stomach (n  =  93; 5.6%), and uterus (n  =  48; 2.9%). Cases were evaluated against a negative control as negative, weak positive, and strong positive.

RESULTS

Nap-A was more sensitive than TTF-1 for primary lung ACA (87% versus 64%; P < .001). Nap-A was more specific than TTF-1 for primary lung ACA versus all tumors, excluding kidney, independent of tumor type (P < .001).

CONCLUSIONS

Nap-A is superior to TTF-1 in distinguishing primary lung ACA from other carcinomas (except kidney), particularly primary lung small cell carcinoma, and primary thyroid carcinoma. A combination of Nap-A and TTF-1 is useful in the distinction of primary lung ACA (Nap-A(+), TTF-1(+)) from primary lung squamous cell carcinoma (Nap-A(-), TTF-1(-)) and primary lung small cell carcinoma (Nap-A(-), TTF-1(+)).

FoxQ1 overexpression influences poor prognosis in non-small cell lung cancer, associates with the phenomenon of EMT

Background

We determined the expression of forkhead box Q1 (FoxQ1), E-cadherin (E-cad), Mucin 1 (MUC1), vimentin (VIM) and S100 calcium binding protein A4 (S100A4), all epithelial-mesenchymal transition (EMT) indicator proteins in non-small cell lung cancer (NSCLC) tissue samples. We also investigated the relationship between these five proteins expression and other clinicopathologic factors in NSCLC. Finally, we assessed the potential value of these markers as prognostic indicators of survival in NSCLC's patients.

Methods

Quantitative real-time PCR and immunohistochemistry were used to characterize the expression of the FoxQ1 mRNA and protein in NSCLC. Expression of transcripts and translated products for the other four EMT indicator proteins was assessed by immunohistochemistry in the same clinical NSCLC samples.

Results

FoxQ1 mRNA and protein were up-regulated in NSCLC compared with normal tissues (P = 0.015 and P<0.001, respectively). Expression of FoxQ1 in adenocarcinoma was higher than in squamous cell carcinoma (P = 0.005), and high expression of FoxQ1 correlated with loss of E-cad expression (P = 0.012), and anomalous positivity of VIM (P = 0.024) and S100A4 (P = 0.004). Additional survival analysis showed that high expression of FoxQ1 (P = 0.047) and E-cad (P = 0.021) were independent prognostic factors.

Conclusion

FoxQ1 maybe plays a specific role in the EMT of NSCLC, and could be used as a prognostic factor for NSCLC.