Bronchogenic carcinoma: survival after surgical treatment according to stage, histologic type and immunomorphologic changes in regional lymph nodes

Evaluation of immunomorphological patterns of cervical lymph nodes in oral squamous cell carcinoma

Background:

The Immunomorphological patterns of Lymph Nodes indirectly assess the host immune response facing a malignant tumor. These patterns also help us predict the susceptibility of the patient to Lymph Node Metastasis.

Aims and Objectives:

To evaluate the Immunomorphological patterns of Lymph Nodes in Oral Squamous Cell Carcinoma and to correlate them with the histopathological subtype of Oral Squamous Cell Carcinoma, TNM staging and the degree of tumor involvement within the Lymph Nodes.

Methodology:

A total of 40 subjects were taken for the study. Individuals who were clinically and histopathologically diagnosed as cases of Squamous Cell Carcinoma, who had undergone Radical or Elective Neck dissection were considered. The excised Lymph Nodes along with the primary tumor were collected stained with Hematoxylin and Eosin. The Lymph Nodes were assessed for Metastasis and Immunomorphological patterns. Statistical Correlation was done between the Immunomorphological pattern of Lymph Nodes and (a) Size of the tumor, (b) TNM stage of the tumor, (c) Histopathological Grade of the primary tumor, (d) Metastasis of the Lymph Node and (e) Grade of the Metastasis of Lymph Node. Statistical Correlation was done between the Metastasis of the Lymph Node and (a) Size of the tumor and (b) TNM stage of the tumor.

Results and Conclusion:

Statistically, a significant association was observed between TNM staging and Immunomorphological patterns of Lymph Node (P < 0.01). The relationship between histopathological grade of primary tumor of Squamous Cell Carcinoma and the Immunomorphological patterns was statistically significant (P < 0.01). Statistically, a significant association was observed between Sinus Histiocytosis pattern and decreased occurrence of nodal metastasis (P < 0.01).

Architectural changes in the regional lymph nodes of oral squamous cell carcinoma

Background

The lymph nodes (LNs) in oral squamous cell carcinoma (OSCC) are enlarged as a result of reactive lymphadenopathy, metastasis or both. In response to tumor-associated antigens, diverse cell populations of LNs react in different ways, giving rise to a multitude of morphological patterns (MPs). The prognostic value of MPs has been contested. Hence, the aim of the study was to evaluate morphological alterations in the LNs related to LN metastasis (LNM), tumor size, grade and stage and the prognostic value for OSCC.

Materials and Methods

LN sections of 40 OSCCs were evaluated. Six MPs were observed: germinal center predominance (GCP), lymphocyte predominance (LP), sinus histiocytosis (SH), vascular transformation of sinuses (VTS), lymphocyte depleted (LD) and granulomatous reaction (GR). The data were subjected to Chi-square test.

Results

Four-hundred and eighteen nodes were evaluated, of which 24 were metastatic and 394 nonmetastatic. The predominant MP of LN reactivity was of VTS (116 nodes) followed by GCP (105); LP (90), LD (52), SH (43) and GR (12). A significant association was noted between LN status and the MPs. Risk of LNM with LP was less (13%) when compared with GCP (79%). A statistically significant relation was noted between the predominant MP and metastatic and nonmetastatic cases and with the tumor stage.

Conclusion

GCP pattern prevails in metastatic and advanced-stage tumors. LP or VTS/SH is prominent in early-stage tumors and nonmetastatic cases. MPs indicate the immune status and aid in foreseeing susceptibility to LNM, thus serving as a surrogate marker.

A New Multiparametric Classification in Lung Cancer Patients - S.M.I.G

The classification of bronchogenic carcinoma as a function of the prognosis is still an open field. The evaluation of stage, by use of the TNM system, and histologic cell type is not sufficient to guarantee a correct prognosis. The growth rate of the neoplasm is another important parameter. We propose a classification that takes into account the stage (S), histologic cell type (M), immune status (I) and the growth rate of the primary tumor (G): S.M.I.G. We studied 90 lung cancer patients according to the S.M.I.G. classification and we observed that their prognoses were directly correlated with their S.M.I.G. scores (the higher the score, the higher the 10-month mortality rate). The mortality rates within the first 10 months of follow-up were respectively 0%, 0%, 36.36%, 68%, 90.9% for the 5 groups obtained by S.M.I.G. The difference is statistically significant (P < 0.0075) and there is a linear correlation between the mortality rate and the score assigned to each group (R = 0.943; P < 0.05). The S.M.I.G. classification can predict the prognosis more efficiently than the usual classification (TNM) and histological cell type.

Sarcoidal reactions in regional lymph nodes of patients with early stage non-small cell lung cancer predict improved disease-free survival: a pilot case-control study

Sarcoidal reactions occurring in regional lymph nodes of patients with non-small cell lung carcinoma appear to be limited to patients with stage I disease. The prognostic significance of this remains unknown. Such reactions are thought to represent a cell-mediated antitumor response and have been associated with improved outcomes in other solid organ malignancies. We performed a retrospective chart review of all patients undergoing lobectomy with curative intent for non-small cell lung carcinoma. Eligible cases were selected based on pathologic reports, with matched controls then drawn from the same surgical cohort. One hundred fifty-seven patients underwent lobectomy and lymph node dissection. Eight patients with sarcoidal granulomas present in regional lymph nodes were identified as cases and matched to 16 control subjects. All subjects were staged pN0. Disease recurrence was noted in no case subjects but in 7 (44%) of control subjects (P = .044, χ(2) = 4.051). The presence of sarcoidal reactions within regional lymph nodes of patients with non-small cell lung carcinoma predicts a lower rate of disease recurrence after definitive surgical resection. The exact mechanism by which antitumor immunity is achieved remains to be elucidated.

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.

Host defense and survival in patients with lung carcinoma

BACKGROUND

Numerous studies have investigated locoregional immune responses and long term survival in patients with various types of cancer; few have focused on patients with lung carcinoma. The current study was designed to assess the prognostic value of immunomorphologic changes in locoregional lymph nodes and lymphocytic infiltration of primary tumor (LI) in patients who undergo resection for bronchogenic carcinoma.

METHODS

In a retrospective analysis, immune responses in locoregional lymph nodes and at primary tumor sites were studied histologically in 172 selected patients. Lymph node morphology was studied according to the system of Cottier et al. Sinus histiocytosis and paracortical lymphoid cell hyperplasia were considered to be cellular immune responses, and follicular hyperplasia of the cortical area was considered to be a humoral reaction. LI was classified with Black's method. The survival rate was estimated by using the Kaplan-Meier product-limit method. The log rank test and the Cox proportional-hazards model were used to determine statistical significance in univariate and multivariate survival analyses.

RESULTS

Among the 172 patients, 35.5% had no evident response in regional lymph nodes, 19.8% had a marked cellular response, 11% had a marked humoral response, and 33.7% had a mixed cellular and humoral response. LI was intense in 36.6% of patients and was absent or scarcely evident in 63.4%. A lymph node cellular response and marked LI improved long term survival rates even in patients with regional lymph node metastases. Multivariate analysis identified two independent variables that had high prognostic value: lymph node immunoreactivity and LI.

CONCLUSIONS

Lymph node immunoreactivity and LI significantly influence long term survival after curative surgery for patients with carcinoma of the lung and may be useful in stratifying patients for prospective trials of adjuvant treatment, including immunotherapy.

Nuclear p53 overexpression is an independent prognostic parameter in node-negative non-small cell lung carcinoma

The prognosis of operated patients with non-small cell lung cancer (NSCLC) is poor despite thorough pre-operative staging. An improved preselection is needed of patients likely to profit from surgery. This study was undertaken to evaluate the prognostic significance of nuclear p53 overexpression in a cohort of 247 surgically treated patients with NSCLC. It showed that the prevalence of immunohistochemically detectable p53 overexpression varied between different tumour types. p53 overexpression was equally frequent in large cell carcinoma (53 per cent) and in squamous cell carcinoma (54 per cent), but significantly less frequent in adenocarcinoma (34 per cent; P = 0.009). p53 overexpression was particularly rare in bronchioloalveolar carcinoma (positivity in 1 of 17 cases). These variations may reflect aetiological differences between the histological subtypes. p53 overexpression was also associated with high tumour grade (P = 0.0157) and the presence of lymph node metastasis (P = 0.0259), but not with advanced tumour stage. Survival analysis showed no difference in clinical outcome between p53-positive and p53-negative tumours within 101 node-positive tumours. In contrast, survival time was significantly better in p53-negative tumours than in p53-positive tumours within the group of 113 node-negative tumours (P = 0.032). Stepwise regression analysis showed that p53 overexpression is an independent prognostic factor in node-negative NSCLC.

Analysis of prognostic factors in patients with resected peripheral T1 adenocarcinoma of the lung

Prognostic factors in patients with surgically-treated peripheral T1 (< or = 3 cm in greatest diameter) adenocarcinoma of the lung were analyzed in 45 cases. Statistical difference in survival was observed between stages I + II and III + IV (p < 0.05). However, neither sex, age, location of tumor, histological subtype, histological grade, tumor ploidy, nor presence of central fibrosis was of prognostic determinance. Our results suggest that only clinical stage is of prognostic importance in surgically-treated peripheral T1 adenocarcinoma of the lung.

Age and prognosis of non-small cell lung cancer. Usefulness of a relative survival model

The aim of our study was the comparative evaluation of a relative survival model and a Cox model to determine the prognostic factors of survival for patients with surgically cured non-small cell lung cancer (NSCLC). We focused particularly on the exact role of age in this survival. 156 patients treated between 1975 and 1988 were studied. Both univariate and multivariate analyses were performed, using the actuarial method and the Cox model for crude survival and the Hakulinen model for relative survival. This study confirmed the poor prognosis of NSCLC, even if a curative surgical procedure has been possible, with a 5-year survival of 48% for stage I tumours but only 6% for stage III tumours. The most significant prognostic factor was the postsurgical TNM staging. The relative survival method of Hakulinen dismissed age as a significant prognostic factor. Our study underlines the usefulness of relative survival methods which should be more frequently employed to allow comparisons between series of different origin and to set up multicentre therapeutic trials.

Relationship between tumor DNA ploidy and regional lymph node changes in lung cancer

Seventy-four patients with lung cancer, resected consecutively from April 1989 to August 1990, were divided into (1) 21 with diploid tumors having a single G0/G1 peak and a coefficient of variation (CV) of 4.9 or less, (2) 18 with peridiploid tumors having a single G0/G1 peak and a CV at 5.0 or more, and (3) 35 with aneuploid tumors having multiple G0/G1 peaks. Aneuploid tumors had higher frequencies of lymphatic invasion and metastasis to the mediastinal lymph nodes. To evaluate the relationship between ploidy tumor status and immunologic competence of the regional lymph nodes, histologic findings and the proportion of killer T-lymphocytes were examined in the dissected lymph nodes. Aneuploid tumors had significantly lower proportions of paracortical hyperplasia and killer T-lymphocytes than did diploid and peridiploid ones in the nonmetastatic lymph nodes of N0 and N1 disease. These findings suggest the possibility that a decline in the antitumor competence of these lymph nodes could cause metastasis to the nodes. The recurrence rates were 19% in diploid, 33% in peridiploid, and 54% in aneuploid tumors, and the 2-year survival rates were 87%, 78%, and 44%, respectively. Peridiploid tumors showed intermediate values between diploid and aneuploid in terms of immunologic competence, recurrence rate, and survival. They were assumed to have a different proportion of aneuploid cells than the other two.

Ki-67 immunostaining and survival in operable lung cancer

One hundred and eighty-seven operable lung tumours were immunostained with the monoclonal antibody Ki-67 and divided into groups of high, moderate or low proliferation. Patients have been followed clinically for up to 7 years to ascertain whether this immunocytochemical measurement reflected tumour behaviour in terms of survival. The majority of the tumours were squamous cell carcinomas (104 cases) and adenocarcinomas (60 cases). These were divided into three groups of low, intermediate and high growth fraction, in which survival was better for tumours of lower proliferative rate up to approximately 2 years after operation. By 5 years these differences had largely disappeared and all tumours of a particular type showed a similar survival curve. Small cell carcinomas (13 cases) had high Ki-67 labelling indices, with more than 60% of patients deal in the first year, whereas carcinoid tumours (10 cases) had low labelling rates and all but one are still alive. We conclude that measurement of lung tumour growth rate with the monoclonal antibody Ki-67 shows promise as a possible indicator of short-term survival and perhaps as a means of choosing a group of patients with adenocarcinomas and squamous cell carcinomas for post-operative chemotherapy.

Prognostic implications of DNA histogram, DNA content, and histologic changes of regional lymph nodes in patients with lung cancer

Forty-six cases of resected lung cancer, including 20 cases at Stages I and II and 26 cases at Stage III (N2), were subdivided into two groups: a good prognosis group with a longer survival period and a poor prognosis group in which the patients died earlier of the cancer. From paraffin-embedded lymph node tissues of these patients, the authors examined DNA histogram pattern and DNA content, using flow cytometry, and histologic hyperplasia of germinal center and paracortical area; they also evaluated their correlation with the prognosis. In the good prognosis group at Stages I and II, paracortical hyperplasia (PH) of the lymph nodes was observed significantly more frequently. In the good prognosis group at Stage III, the incidence of PH, G2M phase in the DNA histograms, and DNA content were all significantly higher. DNA content was positively correlated with the grade of PH.

Nuclear DNA content by cytofluorometry of stage I adenocarcinoma of the lung in relation to postoperative recurrence

Forty-six cases of adenocarcinoma of the lung, categorized as stage I (T1N0M0, T2N0M0) pathologically, were studied in terms of nuclear DNA content (NDC) determined by cytofluorometry. They comprised 23 cases each with and without tumor recurrence within five years postoperatively, and the NDC was compared in 23 pairs in which the tumor size and the degree of histologic differentiation were completely matched. The NDC was larger in the recurrent group than in the nonrecurrent group in terms of mean nuclear DNA content (MNDC), DNA histogram pattern, and occurrence of the aneuploid stem cell line, of which the difference in MNDC was statistically significant (p less than 0.05). When the comparison of NDC was made between the nonrecurrent and recurrent groups in the well differentiated (W/D), moderately to poorly differentiated (M.P/D), T1, and T2 subgroups, the NDC of the recurrent group was significantly larger than that of the nonrecurrent group in the W/D (MNDC, p less than 0.01 and DNA histogram pattern, p less than 0.005) and T1 subgroups (MNDC, p less than 0.05), but not in the M.P/D and T2 subgroups. The results indicate that the NDC is a good predictor of prognosis in stage I adenocarcinoma of the lung and its prognostic importance increases in more differentiated and smaller tumors, compared to less differentiated and larger tumors.

Morphometric and morphologic evaluations in stage III non-small cell lung cancers. Prognostic significance of quantitative assessment of infiltrating lymphoid cells

This study evaluated data from 30 non-small cell lung cancer (NSCLC) patients to determine whether demographic, clinical, and morphologic and morphometric data that were obtained prior to treatment, could be used to predict survival. All patients had Stage III disease, and all subsequently were treated identically with concurrent radiotherapy, cisplatin, and 5-fluorouracil. The series consisted of 18 squamous carcinomas, eight adenocarcinomas, and four large cell carcinomas. Morphometric measurements of randomized selected cancer cells per case included diameter of cytoplasm, nuclei, and nucleoli. Morphologic parameters evaluated were mitotic index, histologic differentiation, and pattern of nuclear chromatin of cancer cells, and the degree of necrosis and fibrosis of tumor tissue. The lymphoid and neutrophil index defined as the ratio of lymphoid cells and neutrophils to cancer cells from randomized microscopic fields (median = 25) at 400 x magnification were also determined. Our study indicated that the peritumor lymphoid index was the only factor significantly associated with the length of survival. The correlation coefficient (Pearson r) of these two factors was 0.5 (P less than 0.005). The median survival time of patients with peritumor lymphoid index less than 3 and greater than or equal to 3 was 95 days and 376 days, respectively (Kaplan-Meier estimation). The peritumor lymphoid index was an independent prognosticator of clinical outcome of Stage III NSCLC patients, and did not correlate with any of the other parameters analyzed.

Histopathologic prognostic factors in adenocarcinomas of the peripheral lung less than 2 cm in diameter

The histologic prognostic factors of pulmonary adenocarcinomas of the lung less than 2 cm in diameter were analyzed in 75 patients who had undergone surgical resection. The pathologic stage, lymph node involvement, and pleural involvement were found to be the major determinants of prognosis (P less than 0.01). In addition, other single factors, such as tumor differentiation (P less than 0.01), vascular invasion (P less than 0.01), the degree of collagenization in the fibrotic focus (P less than 0.01), the standard deviation (SD) of nuclear areas (P less than 0.05), and mitotic index (P less than 0.05) correlated significantly with prognosis by the log-rank test on the Kaplan-Meier survival curves of these factors. Patients with dense infiltration of "T-zone histiocytes" survived significantly longer than those with less infiltration (P less than 0.05). Cox's proportional hazard general linear model analysis showed the importance of factors, such as lymph node or pleural involvement and the SD of nuclear area, when the pathologic stage was excluded, and of the mitotic index when all four factors were excluded to emphasize the cellular characteristics. It is possible to predict the postoperative prognosis of patients with small pulmonary adenocarcinoma more precisely by combination of the above histopathologic factors.

Immune response against P815X2 mastocytoma growing in syngeneic DBA/2 mice. I. Morphometric assessment of lymph node immunoreactivity and analysis of circulating antibodies

To assess the significance of humoral immune mechanisms in host reactivity against the P815X2 mastocytoma grown in syngeneic DBA/2 mice, an approach was made to correlate immunomorphology of the lymph nodes with the functional assays measuring cytotoxic and tumor cell membrane-bound antibodies in mouse sera. Regional and non-regional (RLN, NRLN) lymph nodes, were subjected to stereological analysis to determine the volume fractions (Vv) of the cortex (C), the paracortex (PCA), the germinal centers (GC), and the medulla (M), using a computerized analysis system (IBAS I, Kontron). In both RLN:s and NRLN:s, lymphocyte subsets were identified and their ratios determined using the ABC (avidin-biotin peroxidase complex) technique and following monoclonal antibodies; Anti-Thy 1.2, Anti-Lyt 1, Anti-Lyt 2, and Anti-I-Ad. The 51Cr release assay was used to test the mouse sera for cytotoxic antibodies, and an indirect immunofluorescence (IF) technique to assess the sera for tumor cell membrane-bound antibodies. There was a marked enlargement of the RLN:s reaching the peak on day 12, due to increase of the Vv of the B-zone as well as of the T-zone. Evidence of distinct B-cell stimulation by the growing of P815X2 was provided by an early decrease of Thy1.2+/I-Ad+ cell ratio both in the RLN:s and in NRLN:s. This activation of B-cells seems to be parallel to the elevation of Lyt1+/Lyt2+ ratio in T-cell region on day 6. The IF-tests for or the presence of tumor cell membrane-bound antibodies were almost invariably negative. With exception of two sera, the 51Cr-release assay for cytotoxic antibodies against P815X2 targets was negative. The present study confirms the previous observations on failure to find circulating cytotoxic or cell membrane-bound antibodies in DBA/2 mice bearing P815X2 mastocytoma, despite the morphologically well definable activation in RLN:s and in NRLN:s of the B-cell areas. This is in alignment with the findings in the majority of human tumors, where B-cell predominance in RLN:s does not represent a favourable prognostic sign.

Immune response against P815X2 mastocytoma growing in syngeneic DBA/2 mice. II. Morphometric assessment of immunoreactivity in the thymus and spleen related to lymphocyte subsets in peripheral blood

To assess the significance of humoral immune mechanisms in host reactivity against the P815X2 mastocytoma grown in syngeneic DBA/2 mice, an approach was made to correlate immunomorphology of the thymus and spleen with the functional assays measuring cytotoxic (51Cr-release assay) and tumor cell membrane-bound antibodies (IF test) as well as phenotyping (with monoclonal antibodies Anti-Thy1.2, Anti-Lyt1, Anti-Lyt2, and Anti-I-Ad) the lymphocyte subsets in peripheral blood. The volume fractions (Vv) of the cortex (C), and medulla (M) of the thymus, as well as central (C-PALS) and peripheral periarteriolar lymphoid sheath (P-PALS) in the spleen were determined morphometrically. There was a steady increase of the C/M ratio from the control levels until day 8, not accompanied by any major fluctuations in the percentages of Thy1.2+ or I-Ad+ cells in C and M. In M, two significant peaks were found in Lyt1+/Lyt2+ cell ratio. In the spleen P-PALS, Thy1.2+/I-Ad+ cell ratio was subject to major early elevation, followed by a rapid and permanent decline to levels below the controls. Two high peaks of Lyt1+/Lyt2+ ratio were found in P-PALS, on day 10 and 16. In the C-PALS, a marked decline in Thy1.2+/I-Ad+ ratio was observed throughout the experiment. As determined by Vv, there was a marked early enlargement of P-PALS reaching the peak on day 4, and followed by a steady reduction reaching the control values on day 10. In peripheral blood, there was an initial increase of T-cells, leading to elevated Thy1.2+/I-Ad+ ratio and a subsequent elevation of Lyt1+/Lyt2+ ratio on day 8.(ABSTRACT TRUNCATED AT 250 WORDS)

Morphometry of lymphoid organs in health and disease

Structural modification of lymph nodes in bronchogenic carcinoma, thymus cortex as a function of age, area and form factors of lymphoid cell nuclei in lymphomas and of epithelioid cell nuclei in tuberculosis and sarcoidosis have been measured by means of test point and/or image semiautomated analyzer.