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

Implications of Preoperative Transbronchial Lung Biopsy for Non-small Cell Lung Cancer Less than 3-cm

BACKGROUND/AIM

Transbronchial lung biopsy (TBLB) has been recommended for patients with suspected lung cancer. However, its diagnostic value is limited to small lesions, and some studies have indicated that biopsy might be related to metastasis and/or dissemination. This study aimed to evaluate the outcomes after preoperative TBLB for non-small cell lung cancer (NSCLC) patients.

PATIENTS AND METHODS

Data were reviewed from 371 patients with resected pN0 NSCLC less than 3-cm. Patients were divided into two groups: TBLB and Non-TBLB. Recurrence-free survival (RFS) curves were plotted using the Kaplan-Meier method. Cox regression analyses were used to evaluate the hazard ratio (HR) with the endpoint RFS.

RESULTS

The 5-year RFS rates were 75.5% in the TBLB group and 91.4% in the Non-TBLB group (p<0.001). Poor RFS was independently associated with TBLB (HR=2.491, 95%CI=1.337-4.640; p=0.004).

CONCLUSION

Preoperative TBLB may adversely affect RFS among NSCLC patients with small size tumours.

Wedge Resection of Tumor Before Lobectomy for Lung Cancer Could Be a No-touch Isolation Technique

BACKGROUND/AIM

Circulating tumor cells (CTCs) can be a surrogate biomarker of prospective prognosis. Surgical manipulation can promote the dissemination of CTCs. Prognosis improvement is expected with the no-touch isolation technique (NTIT), preventing surgical manipulation. The Wedge resection of the tumor site before lobectomy could prevent surgical manipulation during lobectomy for non-small cell lung cancer (NSCLC) and reduce the shedding of tumor cells, similar to a NTIT. This study aimed to evaluate the effect of wedge resection technique.

PATIENTS AND METHODS

A total of 624 resected NSCLC patients were retrospectively analyzed. Patients were divided in two groups: Wedge and Non-Wedge. Overall survival (OS) curves were plotted using the Kaplan-Meier method.

RESULTS

The 5-year OS rates were 89.9% and 84.0% in the Wedge and Non-Wedge groups, respectively (p=0.033).

CONCLUSION

The OS in the Wedge group was significantly better than that in the Non-Wedge group. Wedge resection technique for NSCLC may be a NTIT.

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.

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.

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.

Factors influencing recurrence following anatomic lung resection for clinical stage I non-small cell lung cancer

OBJECTIVES

Anatomic lung resection provides the best opportunity for long-term survival in the setting of early-stage non-small cell lung cancer (NSCLC). However, 20-30% of patients develop recurrent disease following complete (R0) resection for Stage I disease. In the current study, we analyze the impact of patient, surgical and pathologic variables upon recurrence patterns following anatomic lung resection for clinical stage I NSCLC.

PATIENTS AND METHODS

A total of 1132 patients (384 segmentectomies, 748 lobectomies) with clinical stage I NSCLC were evaluated. Predictors of recurrence were identified by proportional hazards regression. Differences in recurrence patterns between groups are illustrated by log rank tests applied to Kaplan-Maier estimates.

RESULTS

A total of 227 recurrences (20.0%) were recorded at a median follow-up of 36.8 months (65 locoregional, 155 distant). There was no significant difference in recurrence patterns when comparing segmentectomy and lobectomy. Multivariate analysis demonstrated that angiolymphatic invasion, tumor size, tumor grade and the presence of only mild-moderate tumor inflammation were independent predictors of recurrence risk.

CONCLUSIONS

Recurrence following anatomic lung resection is influenced predominantly by pathological variables (tumor size, tumor grade, angiolymphatic invasion, tumor inflammation). Optimization of surgical margin in relation to tumor size may improve outcomes. Extent of resection (segmentectomy vs. lobectomy) does not appear to have an impact on recurrence-free survival when adequate margins are obtained.

Prognostic factors including lymphovascular invasion on survival for resected non-small cell lung cancer

OBJECTIVES

The aim of this study was to report on the influence of tumor lymphovascular invasion on overall survival and in patients with resected non-small cell lung cancer and identify prognostic factors for survival.

METHODS

This is a retrospective observational study of a consecutive series of patients who had surgical resection of non-small cell lung cancer in a single institution. The study covers a 3-year period. Overall survival was estimated by Kaplan-Meier method and multivariate Cox regression analysis was used to evaluate the relationship of lymphovascular invasion and other clinicopathologic variables. A multivariate regression was used to assess the relationship between tumor lymphovascular invasion and other clinical and pathologic characteristics.

RESULTS

A total of 524 patients were identified and included in the study. Two hundred twenty-five patients (43%) had tumors with lymphovascular invasion. Patients with tumor lymphovascular invasion had a lower overall survival (P < .0001). Tumor lymphovascular invasion was independently associated with visceral pleural involvement (P < .0001). In a multivariable model, lymphovascular invasion (hazard ratio [HR], 2.58; 95% confidence interval [CI], 1.63-4.09; P < .0001), parietal pleural invasion (HR, 45.4; 95% CI, 2.08-990; P = .015), advanced age (HR, 1.028; 95% CI, 1.009-1.048; P = .004), and N2 lymph node involvement (HR, 1.837; 95% CI, 1.257-2.690; P = .002) were independent prognostic factors for lower overall survival.

CONCLUSIONS

Lymphovascular invasion is associated with a worse overall survival in patients with resected non-small cell lung cancer regardless of tumor stage. Parietal pleural involvement, N2 nodal disease, and advanced age independently predict poor overall survival.

Radiomic signature as a diagnostic factor for histologic subtype classification of non-small cell lung cancer

OBJECTIVES

To distinguish squamous cell carcinoma (SCC) from lung adenocarcinoma (ADC) based on a radiomic signature METHODS: This study involved 129 patients with non-small cell lung cancer (NSCLC) (81 in the training cohort and 48 in the independent validation cohort). Approximately 485 features were extracted from a manually outlined tumor region. The LASSO logistic regression model selected the key features of a radiomic signature. Receiver operating characteristic curve and area under the curve (AUC) were used to evaluate the performance of the radiomic signature in the training and validation cohorts.

RESULTS

Five features were selected to construct the radiomic signature for histologic subtype classification. The performance of the radiomic signature to distinguish between lung ADC and SCC in both training and validation cohorts was good, with an AUC of 0.905 (95% confidence interval [CI]: 0.838 to 0.971), sensitivity of 0.830, and specificity of 0.929. In the validation cohort, the radiomic signature showed an AUC of 0.893 (95% CI: 0.789 to 0.996), sensitivity of 0.828, and specificity of 0.900.

CONCLUSIONS

A unique radiomic signature was constructed for use as a diagnostic factor for discriminating lung ADC from SCC. Patients with NSCLC will benefit from the proposed radiomic signature.

KEY POINTS

• Machine learning can be used for auxiliary distinguish in lung cancer. • Radiomic signature can discriminate lung ADC from SCC. • Radiomics can help to achieve precision medical treatment.

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.

Interstitial growth as an aggressive growth pattern in primary lung cancer

PURPOSE

Interstitial growth (IG), which is defined as tumor cells continuously growing into the alveolar septa at the tumor periphery, was originally reported as a growth pattern of metastatic sarcoma of the lung. On the other hand, IG in the primary lung cancers has not been well described. This study aimed to examine clinicopathological features of primary lung cancer that harbors IG.

METHODS

A total of 2558 primary lung cancers which were resected from 2003 to 2012 in our hospital were examined for IG. We compared clinicopathological data and prognoses between patients with IG(+) and IG(-) specimens.

RESULTS

Thirty-three cases out of 2558 (1.3 %) had IG components. IG was significantly more associated with positive smoking history, advanced pathological stage, presence of vascular invasion and pleural invasion. Thirty-three IG(+) cases include nine pleomorphic carcinoma, nine squamous cell carcinoma and eight adenocarcinoma. Interestingly, nine (24 %) out of 38 pleomorphic carcinoma specimens had IG components, which was a higher rate than any other histological subtypes. The IG(+) cancers had significantly shorter overall and recurrence-free survival than did the IG(-) cancers.

CONCLUSIONS

We firstly reported on IG in various types of primary lung cancer. IG appears to be a sign of an aggressive lung cancer phenotype, mainly found in pleomorphic carcinoma.

Unique intravascular tumor microenvironment predicting recurrence of lung squamous cell carcinoma

PURPOSE

Histological vascular invasion (VI) by tumors is a risk factor for recurrence after surgical resection. However, VI features vary histologically. The aim of this study was to identify characteristic VI features that are associated with recurrence in squamous cell carcinoma (SCC) of the lung.

METHODS

We enrolled 149 patients with pathological stage I primary lung SCC in this study and examined whether the presence, frequency, and size of VI were associated with recurrence. We also evaluated immunophenotypes of carcinoma cells and stromal cells within VI areas.

RESULTS

Of the 149 patients, 58 had tumors with VI. The presence of VI was significantly correlated with shorter recurrence-free survival (RFS) (P = 0.018). Although VI frequency was not associated with RFS, larger VI size (>425 µm) was significantly correlated with shorter RFS (P = 0.003). Carcinoma cells within larger VI areas expressed significantly higher levels of podoplanin, cancer stem cell marker (P = 0.039); higher numbers of CD34(+) microvessels (P = 0.009), CD204(+) macrophages (P = 0.026), and α-SMA(+) myofibroblasts (P = 0.056) were present within larger VI areas than within smaller VI ones.

CONCLUSIONS

Our results indicate that larger VI areas are a predictor for recurrence in lung SCC; also, within the larger blood vessel, cancer stem cells and abundant stromal cells can create a more favorable microenvironment for tumor metastasis.

Prognostic factors of tumor recurrence in completely resected non-small cell lung cancer

BACKGROUND

Patients with completely resected non-small cell lung cancer (NSCLC) have an excellent outcome; however tumor recurs in 30%-77% of patients. This study retrospectively analyzed the clinicopathologic features of patients with any operable stage of NSCLC to identify the prognostic factors that influence tumor recurrence, including intratumoral blood vessel invasion (IVI), tumor size, tumor necrosis, and intratumoral lymphatic invasion.

METHODS

From January 2002 to December 2011, 227 consecutive patients were enrolled in this study. They were divided into two groups: the "no recurrence" group and the "recurrence" group. Recurrence-free survival was analyzed by multivariable Cox regression analysis, stratified by tumor staging, chemotherapy, and nodal involvement.

RESULTS

IVI, tumor necrosis, tumor diameter more than 5 cm, and nodal involvement were identified as independent prognostic factors of tumor recurrence. The hazard ratio (HR) of patients with IVI was 2.1 times higher than that of patients without IVI (95% confident interval [CI]: 1.4-3.2) (P = 0.001).The HR of patients with tumor necrosis was 2.1 times higher than that of patients without tumor necrosis (95% CI: 1.3-3.4) (P = 0.001). Patients who had a maximum tumor diameter greater than 5 cm had significantly higher risk of recurrence than patients who had a maximum tumor diameter of less than 5 cm (HR 1.9, 95% CI: 1.0-3.5) (P = 0.033).

CONCLUSION

IVI, tumor diameter more than 5 cm, and tumor necrosis are prognostic factors of tumor recurrence in completely resected NSCLC. Therefore, NSCLC patients, with or without nodal involvement, who have one or more prognostic factors of tumor recurrence may benefit from adjuvant chemotherapy for prevention of tumor recurrence.

Expression of the potential cancer stem cell markers, CD133, CD44, ALDH1, and β-catenin, in primary lung adenocarcinoma--their prognostic significance

The present study investigated expression profiles of the potential CSC markers including CD133, CD44, ALDH1, and β-catenin, and evaluated their prognostic value in lung adenocarcinomas. One-hundred-and-seventy-seven tumors (stage I) were immunohistochemically examined for the expression of these markers, and thresholds to subdivide expression levels were determined using receiver operating characteristics curves. Tumors with high levels of CD133 (adjusted hazard ratio (HR) 4.55 (95% confidence interval (CI) 1.26-16.40, P = 0.021), CD44 (HR 3.73, 95% CI 1.20-11.58, P = 0.023) or ALDH1 (HR 3.61, 95% CI 1.09-12.3, P = 0.036), but not β-catenin (HR 2.43, 95% CI 0.59-10.8, P = 0.220), showed a significantly higher risk of recurrence than the corresponding low expressers. In conclusion, levels of CD133, CD44, and ALDH1 had independent prognostic value to predict the recurrence of lung adenocarcinoma.

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.

Prognostic impact of intratumoural microvascular invasion and microlymphatic permeation on node-negative non-small-cell lung cancer: which indicator is the stronger prognostic factor?

OBJECTIVES

Microvascular invasion and microlymphatic permeation are indicators of microscopic tumour invasion into small vessels and have been considered to be powerful prognostic indicators for non-small-cell lung cancer (NSCLC). Several studies have suggested that these should be included in the TNM classification, but, there have been conflicting results regarding the prognostic impact of microvascular invasion and microlymphatic permeation. The aim of the current study was to clarify the prognostic impact of microvascular invasion and microlymphatic permeation on resected node-negative NSCLC by comparative analyses.

METHODS

We reviewed the data of 1039 consecutive patients with pathological size-based stage T1a-3N0M0 NSCLC who underwent lobectomy or greater resection between 1993 and 2005. The median follow-up period was 108 months. Microvascular invasion and microlymphatic permeation were identified by the Victoria blue-van Gieson staining. The overall survival was then analysed.

RESULTS

Microvascular invasion and microlymphatic permeation were observed in 358 (34.5%) and 205 (19.7%) of patients, respectively. Both microvascular invasion and microlymphatic permeation were more prevalent in non-adenocarcinoma and larger-sized tumours. The 5-year overall survival rate of the microvascular invasion-positive group and microlymphatic permeation-positive group were 69.2 and 84.6%, respectively, and the difference was statistically significant (P = 0.002). On multivariate analyses, microvascular invasion, but not microlymphatic permeation, was an independent prognostic factor (microvascular invasion, hazard ratio [HR] 1.648, P = 0.001; microlymphatic permeation, HR 1.138, P = 0.588). The 5-year overall survival rate of either the microvascular invasion- or microlymphatic permeation-positive T1a-b group was significantly lower than that of the corresponding double-negative (dn) T1a-b group (dnT1a-b, 93.7%; microvascular invasion-positive T1a-b, 85.2%, P < 0.001; microlymphatic permeation-positive T1a-b, 85.4%, P = 0.014), and overlapped to that of the dnT2a group (84.8%). However, in the T2a-b group, only microvascular invasion-positive T2a-b patients showed significantly lower overall survival than dnT2a-b patients, and their overall survival overlapped that of dnT3 patients (dn T2a-b, 83.5%; microvascular invasion-positive T2a-b, 60.6%, P < 0.001; dnT3, 53.8%; P = 0.316). The 5-year overall survival of microlymphatic permeation-positive T2a-b patients (86.2%) did not statistically differ from that of dnT2a-b patients (P = 0.856).

CONCLUSIONS

Microvascular invasion and microlymphatic permeation have different impact on survival, and microvascular invasion rather than microlymphatic permeation is a strong prognostic factor in resected node-negative NSCLC. Microvascular invasion and microlymphatic permeation should be examined separately by elastic staining.

Angiolymphatic invasion exerts a strong impact on surgical outcomes for stage I lung adenocarcinoma, but not non-adenocarcinoma

Angiolymphatic invasion (ALI), representing lymphatic invasion (Ly) and intratumoral vascular invasion (V), is considered to be a useful prognostic factor for pathological stage I non-small cell lung carcinoma (NSCLC). However, the types of tumor for which prognoses are most influenced by ALI positivity have not previously been discussed, nor has the question of whether these findings should influence postoperative therapeutic decision-making after complete resection. The present study investigated 195 cases of stage I NSCLC treated by potentially curative surgical resection of the primary tumor and systematic lymphadenectomy. ALI-positive (ALI(+)) results were found in 31.8% of tumors, and 5.1% exhibited both Ly(+) and V(+). Five-year recurrence-free survival was significantly lower in ALI(+) cases (50.6%) than in ALI(-) cases (85.9%; p<0.0001, log-rank test). In particular, 5-year recurrence-free survival rate was only 10.0% for Ly(+)V(+) cases. ALI(+) correlated with high age, male sex, tumor size (>2.0 cm), elevated preoperative serum carcinoembryonic antigen level (≥5.0 ng/mL), high maximum standard uptake value (SUVmax) on (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) (≥5.0), pleural invasion, and histological classification of non-adenocarcinoma (ADC). According to histopathological subset analyses, ALI(+) was associated with shorter recurrence-free survival than ALI(-) only among ADC patients (p<0.0001, log-rank test), and not among non-ADC patients (p=0.7710). High preoperative serum CEA level, high SUVmax on FDG-PET, pleural invasion, Ly(+), and V(+) were significant risk factors for recurrence in univariate Cox survival analysis among stage I ADC patients. Importantly, Ly(+) and V(+) were identified as independent risk factors for recurrence by multivariate analysis. Histopathological detection of ALI as a risk factor for recurrence should be considered for inclusion in the staging criteria and as additional information for determining postoperative adjuvant treatment of stage I NSCLC, particularly among ADC patients, but not among non-ADC patients.

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.

Prognostic significance of lymphovascular invasion for patients with stage I non-small cell lung cancer

AIMS

This study retrospectively investigated the clinical significance of lymphovascular invasion (LVI) following a complete resection for stage I non-small cell lung cancer (NSCLC).

METHODS

A total of 226 patients who underwent a complete resection for pathological stage I NSCLC were examined.

RESULTS

Lymphatic invasion was pathologically diagnosed as ly0 in 156 patients, ly1 in 65, and ly2 in 5 patients. The pathological vascular invasion was diagnosed as v0 in 178 patients, v1 in 35, v2 in 10, and v3 in 3 patients. The 5-year survival rate after surgery of the patients with and without lymphatic invasion was 76.8 and 90.6%, respectively. There was a significantly more unfavorable prognosis in patients with lymphatic invasion (p = 0.042). The 5-year survival rate of the patients with vascular invasion was also significantly more unfavorable (67.8%) than that of patients without vascular invasion (90.4%; p = 0.004). LVI was found to significantly correlate with tumor size and the presence of pleural invasion.

CONCLUSION

The LVI of NSCLC is a significant prognostic factor in patients with stage I tumors. In future clinical trials, it is necessary to evaluate the efficacy of adjuvant therapy for the selection of patients according to this criterion.

Prognostic impact of MMP-2 and MMP-9 expression in pathologic stage IA non-small cell lung cancer

BACKGROUND

The purpose of the present study was to assess the value of matrix metalloproteinase (MMP)-2 and MMP-9 expression and other potential prognostic factors in predicting the clinical outcome of patients after definitive surgery for pathologic stage IA non-small cell lung cancer (NSCLC).

METHODS

One hundred and forty-six consecutive and non-selected patients who underwent definitive surgery for stage IA NSCLC were included in this study. Formalin-fixed paraffin-embedded specimens were stained for MMP-2 and MMP-9, which were statistically evaluated for their prognostic value and other clinicopathological parameters.

RESULTS

Of the 146 patients studied, 102 (69.9%) cases were classified as having high expression for MMP-2. A total of 89 carcinomas (61.0%) had high expression for MMP-9. MMP-9 expression correlated with Eastern Cooperative Oncology Group (ECOG) performance status, pT stage, and differentiation (P = 0.005, <0.001, and <0.001, respectively). Vessel invasion, pT stage, and MMP-9 expression maintained their independent prognostic influence on overall survival (P = 0.037, <0.001, and <0.001, respectively).

CONCLUSIONS

From results of our relatively large database, MMP-9 may be considered as a viable biomarker that can be used in conjunction with other prognostic factors such as vessel invasion and pT stage to predict the prognosis of patients with completely resected pathologic stage IA NSCLC.

Significance of the presence of microscopic vascular invasion after complete resection of Stage I-II pT1-T2N0 non-small cell lung cancer and its relation with T-Size categories: did the 2009 7th edition of the TNM staging system miss something?

INTRODUCTION

The aim of this study was to assess the significance of microscopic vascular invasion (MVI) in a population of resected patients with early-stage non-small cell lung cancer (NSCLC), along with an analysis of the effect of the combination of MVI and tumor size for the T-size categories T1a-T2b according to the 2009 7th edition of the tumor, node, metastasis (TNM) classification.

METHODS

From January 1993 to August 2008, 746 patients with pT1-T2N0 NSCLC received resection at our institution. MVI was ascertained using histopathological and immunohistochemical techniques.

RESULTS

MVI was observed in 257 patients (34%). Prevalence was higher in adenocarcinoma (ADK) than in squamous cell carcinoma (p = 0.002). A significant correlation was found between MVI and ADK (p = 0.03), increased tumor dimension (p = 0.05), and the presence of tumor-infiltrating lymphocytes (p = 0.02). The presence of MVI was associated with a reduced 5-year survival overall (p = 0.003) and in ADK (p = 0.0002). In a multivariate survival analysis, MVI was an indicator of poor survival overall (p = 0.003) and in ADK (p = 0.0005). In each T category (T1a-T2b) of the 2009 TNM staging system, survival of MVI+ patients was significantly lower than the corresponding MVI- patients; T1a and T1b MVI+ patients had a survival similar to MVI- T2 patients.

CONCLUSIONS

The finding of MVI in pT1-T2N0 NSCLC is frequent. MVI correlates with adenocarcinoma histotype, increased tumor dimensions, and tumor-infiltrating lymphocytes. The presence of MVI is an independent negative prognostic factor. In our experience, MVI was a stronger prognostic indicator than T size in T1a-T2b categories according to the 2009 TNM staging system.

Positron emission tomography/computed tomography and lymphovascular invasion predict recurrence in stage I lung cancers

BACKGROUND

Although pathologic stage I lung cancers generally have a favorable prognosis, approximately 20% of patients experience recurrence after surgery. Therefore, a method of selecting patients who need adjuvant therapy is necessary. The goal of this study was to evaluate the significance of positron emission tomography (PET)/computed tomography (CT) results after lung cancer surgery and to identify the predictive factors for recurrence in cases of pathologic stage I lung cancer.

METHODS

From January 2004 to December 2008, 356 patients with lung cancer underwent surgery at our institution. Of these, 282 patients received F-18 fluorodeoxyglucose PET/CT, and the maximum standardized uptake value (max SUV) was measured. There were 201 patients with pathologic stages IA and IB evaluated. The associations between disease-free survival (DFS) and the following clinicopathological factors were analyzed: age, gender, smoking history, carcinoembryonic antigen level, tumor size, max SUV values, histology, and lymphovascular and pleural invasion.

RESULTS

The 4-year DFS rate was 86.3%. Multivariate analysis revealed lymphovascular invasion (LVI; p < 0.01) and max SUV ≥4.7 (p < 0.01) to be independent predictive factors. Patients with a max SUV more than 4.7 had a significantly high risk of recurrence. DFS of patients with high max SUVs and LVI (n = 18) was significantly reduced compared with other patients (n = 183, p < 0.01).

CONCLUSIONS

The PET-CT results significantly correlated with recurrence in pathologic stage I lung cancers. Patients with high max SUVs and LVI were more likely to have recurrence and should be candidates for adjuvant chemotherapy.

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 impact of blood vessel invasion in gastrointestinal stromal tumor of the stomach

Gastrointestinal stromal tumors have a wide spectrum of biologic behavior, and occasional cases show liver metastases. The modified risk grade based on tumor size and mitotic counts has been proposed to predict the biologic behavior in gastric gastrointestinal stromal tumors. Blood vessel invasion (BVI) is important in the development of metastasis of various kinds of cancer. The aim of this study was to elucidate the potential role of blood vessel invasion in gastric gastrointestinal stromal tumors. Blood vessel invasion was found in 17 of 122 cases (13.9%) of gastrointestinal stromal tumors, and was significantly correlated with larger tumor size, higher mitotic count and higher modified risk grade. Among 83 cases of primary, localized gastric gastrointestinal stromal tumors available for follow-up information, liver metastasis was observed in 14 cases (16.9%). When blood vessel invasion was positive in the primary tumor, liver metastasis occurred in 80% of cases after the initial surgery, indicating that blood vessel invasion was a significant risk factor of liver metastasis (P < .0001). In univariate and multivariate analyses, tumor size (>5 cm), mitotic count (>5/50 high-power fields) and blood vessel invasion (positive) were significantly associated with a shorter period of disease-free survival. Our results suggest that the evaluation of blood vessel invasion may be useful for predicting the risk of liver metastasis and aggressive biologic behavior of gastrointestinal stromal tumors, and may serve as important information for determining the therapeutic strategies including adjuvant molecular target therapy.

Prognostic significance of intratumoral blood vessel invasion in pathologic stage IA non-small cell lung cancer

BACKGROUND

The 5-year survival rate of pathologic stage IA non-small cell lung cancer (NSCLC) is excellent; however, up to 10% of patients with pathologic stage IA NSCLC still relapse postoperatively and die. This study retrospectively analyzed the clinicopathologic features of patients with pathologic stage IA NSCLC to identify the prognostic factors and investigate the effect of a combination of intratumoral vessel invasion and tumor size.

METHODS

From December 1991 to December 2003, 217 consecutive patients with stage IA NSCLC were selected, and disease-free survival (DFS) was analyzed.

RESULTS

Intratumoral blood vessel invasion (BVI) was identified as an independent poor prognostic factor (p = 0.0006). The relative risk for patients with BVI was 4.599 times higher than that for patients without BVI (95% confidence interval, 1.913 to 11.056). According to the new T N M system, the difference in DFS between the patients with and without BVI was statistically significant, not only in tumors exceeding 2 cm (T1b with BVI vs T1b without BVI, p = 0.0020) but also in tumors smaller than 2 cm (T1a with BVI vs T1a without BVI, p < 0.0001). The survival curve of T1b patients without BVI was similar to that of T1a patients without BVI (p = 0.0892). Distant recurrence was frequently observed in both T1a and T1b patients with BVI.

CONCLUSIONS

BVI is an independent poor prognostic factor in patients with pathologic stage IA NSCLC. These T1a and T1b patients with BVI both might benefit from adjuvant chemotherapy.

miRNA control of tumor cell invasion and metastasis

MicroRNAs have emerged as a novel class of noncoding RNAs that regulate gene expression at the post-translational level in almost every biological event. A large body of evidence indicates that microRNAs regulate the expression of different genes that play an important role in cancer cell invasion, migration and metastasis. In this review, we briefly describe the role of various miRNAs in invasion, migration and metastasis which are essential steps during cancer progression.