Prognostic relevance of TTF-1 and MMP-9 expression in advanced lung adenocarcinoma

Use of thyroid transcription factor 1 and napsin A to predict local failure and survival after Gamma Knife radiosurgery in patients with brain metastases from lung adenocarcinoma

OBJECTIVE

Stereotactic radiosurgery (SRS), combined with contemporary targeted therapies and immunotherapies, has improved the overall survival of patients with lung adenocarcinoma (ADC). Given that histological subtypes reflect prognosis in patients with primary ADC, it is important to integrate pathological biomarkers to predict clinical outcomes after SRS in patients with brain metastases from lung ADC. Therefore, the authors investigated the prognostic relevance of various biomarkers of primary lung ADC for clinical outcomes after SRS.

METHODS

A total of 95 patients with 136 brain metastases (1-4 oligometastases) who were treated with Gamma Knife radiosurgery between January 2017 and December 2020 were included. The Kaplan-Meier method and univariate and multivariate analyses using Cox proportional hazard regression models were used to identify prognostic factors for local control, survival, and distant brain control.

RESULTS

Multivariate analysis revealed thyroid transcription factor 1 as an independent prognostic factor for local control (HR 0.098, 95% CI 0.014-0.698, p = 0.0203) and napsin A as a significant predictor of overall survival after SRS (HR 0.080, 95% CI 0.017-0.386, p < 0.01). In a subset analysis of epidermal growth factor receptor (EGFR) mutation, patients with EGFR exon 19 mutations showed better distant brain control than those with EGFR exon 21 mutations (p < 0.01).

CONCLUSIONS

Pathological biomarkers of primary cancer should be considered to predict clinical outcomes after SRS in patients with lung ADC. Use of such biomarkers may help to provide personalized treatment to each patient, improving clinical outcomes after SRS.

Relationship between brain metastasis and thyroid transcription factor 1

Brain metastases (BMs) are common in lung adenocarcinomas (ACs). Thyroid transcription factor 1 (TTF-1) is important in the diagnosis of AC. This study aimed to examine the relationship between TTF-1 and BM for the first time in literature. The data of 137 patients with AC that developed BM between 2009 and 2020 were retrospectively analyzed. A total of 137 patients, 120 (87.6%) male, and 17 (12.4%) female were examined. Their mean age was 59.78 ± 0.82 years. The Eastern Cooperative Oncology Group (ECOG) performance score was 0-1 (< 2) for 39 (28.5%) patients and 2-4 (≤ 2) for 98 (71.5%). TTF-1 was positive in 100 (73%) patients and negative in 37 (27%). More than five BMs were present in 102 (74.4%) patients and less than five in 35 (25.6%). All the patients received whole-brain radiotherapy. None of the patients was suitable for surgery or radiosurgery. The median survival time was 6.4 [95% confidence interval (CI), 5.67-7.1] months. The survival time was 7 (95% CI, 5.91-8.09) months for the TTF-1 (+) patients and 5.8 (95% CI, 4.1-7.5) months for the TTF-1 (-) patients. In the univariate analysis, there was a significant relationship between survival time and age (p = 0.047), TTF-1 (p = 0.024), and ECOG performance score (p = 0.002). The multivariance analysis revealed a significant relationship between survival and TTF-1 (p = 0.034) and ECOG score (p = 0.007). We found a correlation between survival time and ECOG performance score and TTF-1. TTF-1 can be used as a biomarker to monitor prognosis in the follow-up and treatment of patients with AC that develop BM.

The prognostic effect of TTF-1 expression in the Chinese population of patients with advanced lung adenocarcinomas

Background

Thyroid transcription factor 1 (TTF-1), which is usually expressed by lung adenocarcinomas and small cell carcinomas, is usually used to distinguish adenocarcinoma and small cell carcinoma from cells of another type of lung cancer. We examined the association between TTF-1 expression and overall survival between patients with stage IV pulmonary adenocarcinoma to investigate the role of TTF-1 as a predictive and/or prognostic tumor marker in patients with advanced lung adenocarcinomas.

Methods

Analysis of the clinicopathologic features, treatment regimens, and overall survival of 209 lung adenocarcinoma patients who had been detected for TTF-1 expression and received consecutive treatments in the Affiliated Hospital of Qingdao University.

Results

TTF-1 expression was positive in 166 (79%) and negative in 43 (21%) patients who were reviewed. Moreover, there was no significant difference between the clinicopathologic features of TTF-1 positive and TTF-1 negative tumors. In the multivariable review, the overall survival of TTF-1 positive tumor patients was significantly longer than that of TTF-1 negative tumor patients [22.7 vs. 11.8 months (P<0.0001)], increasing the prognostic effect of Karnofsky performance status and receiving first-line chemotherapy or targeted therapy. Positive TTF-1 and negative TTF-1 patients receiving pemetrexed-based chemotherapy improved the duration of treatment compared to those receiving non-pemetrexed chemotherapy.

Conclusions

TTF-1 expression was associated with an improved survival in patients with advanced lung adenocarcinomas. Both patients, either TTF-1 positive or negative, could benefit from the first-line chemotherapy or pemetrexed treatment option. However, as discovered by our investigation, TTF-1 cannot forecast a portion of the lung adenocarcinomas that had a selective sensitivity to pemetrexed.

Enzyme responsive drug delivery systems in cancer treatment

Recent technological approaches in drug delivery have attracted scientist interest for improving therapeutic index of medicines and drug compliance. One of the powerful strategies to control the transportation of drugs is implementation of intelligent stimuli-responsive drug delivery system (DDS). In this regard, tumor tissues with unique characteristics including leaky vasculature and diverse enzyme expression profiles facilitate the development of efficient enzyme-responsive nanoscale delivery systems. Based on the stimuli nature (physical, chemical and biological), these systems can be categorized into three groups according to the nature of trigger initiating the drug release. Enzymes are substantial constituents of the biotechnology toolbox offering promising capabilities and ideal characteristics to accelerate chemical reactions. Nanoparticles which have the ability to trigger their cargo release in the presence of specific enzymes are fabricated implementing fascinating physico-chemical properties of different materials in a nanoscale dimension. In order to reduce the adverse effects of the therapeutic agents, nanocarriers can be utilized and modified with enzyme-labile linkages to provide on-demand enzyme-responsive drug release. In the current review, we give an overview of drug delivery systems which can deliver drugs to the tumor microenvironment and initiate the drug release in response to specific enzymes highly expressed in particular tumor tissues. This strategy offers a versatile platform for intelligent drug release at the site of action.

Prognostic Impact of TTF-1 Expression in Non-Squamous Non-Small-Cell Lung Cancer: A Meta-Analysis

Thyroid transcription factor-1 (TTF-1) is overexpressed in up to 95% of primary lung adenocarcinoma while negative for almost all squamous cell carcinomas. TTF-1 expression has been investigated as a prognostic factor in non-small-cell lung cancer (NSCLC) with conflicting results. We conducted this meta-analysis to gain a better insight into the prognostic role of TTF-1 in patients only with non-squamous (non-SQ) NSCLC. A systematic computerized search of the electronic databases including PubMed, PMC, EMBASE, Web of Science, and Cochrane Library was performed. From 21 studies, 6,451 patients were included in the combined analysis of hazard ratios (HRs) with 95% confidence intervals (CIs) for overall survival. Compared with patients with non-SQ NSCLC showing negative TTF-1 expression, those with tumors harboring TTF-1 overexpression had significantly better survival (HR = 0.49, 95% CI: 0.42-0.57, p < 0.00001). Subgroup analyses revealed that TTF-1 expression significantly correlated with a better prognosis in stage I (HR = 0.65, 95% CI: 0.50-0.84, p = 0.0008) as well as stage III-IV non-SQ NSCLC (HR = 0.38, 95% CI: 0.29-0.49, p < 0.00001). In conclusion, this meta-analysis demonstrates that TTF-1 overexpression is a favorable prognostic factor in patients with non-SQ NSCLC. The subgroup analyses indicate that TTF-1 is a good prognostic marker for survival not only in early-stage but also in advanced non-SQ NSCLC.

Absence of thyroid transcription factor-1 expression is associated with poor survival in patients with advanced pulmonary adenocarcinoma treated with pemetrexed-based chemotherapy

INTRODUCTION

Adenocarcinoma is the commonest histologic subtype of lung cancer and is often identified by immunohistochemical staining for thyroid transcription factor-1 (TTF-1). However, up to 20% of lung adenocarcinomas do not express TTF-1, and there is uncertainty regarding the significance of this. We aimed to evaluate the prognostic effect of TTF-1 expression status on survival in patients treated with pemetrexed-based chemotherapy for advanced adenocarcinoma of the lung.

METHODS

This retrospective study included patients treated with pemetrexed-based chemotherapy for stage IIIB/IV lung adenocarcinoma, who had known TTF-1 expression status. Clinical and demographic data were obtained from medical records. Overall survival (OS) was estimated using the Kaplan-Meier method, and differences in survival between groups assessed using the Cox proportional hazards model.

RESULTS

Forty-four patients were identified with documented TTF-1 expression: 35 with TTF-1-positive and 9 with TTF-1-negative disease. Patients in the TTF-1-negative group had poorer performance scores than those in the TTF-1-positive group (ECOG 2: 67 vs 20%, p = 0.008), and received less chemotherapy (median cycles 2 vs 4, p = 0.009), and were fewer in treatment with doublet regimens (22 vs 69%, p = 0.013). OS was significantly shorter in the TTF-1-negative group than in the TTF-1-positive group (2.4 vs 11.5 months, HR 8.38, p < 0.0001).

CONCLUSIONS

In this group of patients treated with pemetrexed-based chemotherapy for advanced pulmonary adenocarcinoma, absence of TTF-1 expression was associated with an aggressive tumor phenotype, poorer performance status, and poor survival. This subgroup of patients should be recognized as having a distinct clinical course, with limited benefit from standard chemotherapy.

Matrix metalloproteinase-9 decreased after chemotherapy in patients with non-small cell lung cancer

Aims and background

The aim of the study was to investigate the alteration in serum matrix metalloproteinase-9 (MMP-9) levels after chemotherapy and the association between the changes in serum levels of MMP-9 and response to chemotherapy in patients with advanced stage non-small cell lung cancer.

Methods and study design

Twenty-eight consecutive patients with advanced non-small cell lung cancer and 24 healthy controls were enrolled in the study. The patients were treated with cisplatin-based combination chemotherapy. After two cycles, the response was evaluated. Before and after two cycles of chemotherapy, serum samples were collected from the patients.

Results

Prechemotherapy MMP-9 (ng/ml) levels were significantly higher in patients with advanced stage non-small cell lung cancer than in controls (7.2 ± 2.8 vs 4.5 ± 2.1, P<0.001). Prechemotherapy MMP-9 levels were elevated compared to postchemotherapy levels as well (7.2 ± 2.8 vs 5.2 ± 3.3, P = 0.005). Prechemotherapy MMP-9 levels were significantly higher than postchemotherapy MMP-9 levels in patients with partial response (7 patients) (8.2 ± 1.8 and 3.2 ± 2.3, respectively; P = 0.018), but the pre- and postchemotherapy MMP-9 levels were no different in patients with stable disease or progressive disease (21 patients) (7 ± 3.1 and 5.9 ± 3.3, respectively; P = 0.08).

Conclusions

The difference between pre- and postchemotherapy MMP-9 levels in responders was more prominent than that in nonresponders. Whether the decline in serum MMP-9 levels might be used as a marker of response to chemotherapy should be investigated in larger studies.

[Prognostic and Predictive Value of Thyroid Transcription Factor-1, CD56, P40 and Other Clinical Characteristics in Small Cell Lung Cancer Patients]

背景与目的

本研究旨在分析甲状腺转录因子-1（thyroid transcription factor-1, TTF-1）、神经细胞粘附分子CD56和P40蛋白在小细胞肺癌患者中的阳性表达情况，探讨上述免疫表型标志物及其他临床特征与小细胞肺癌预后的相关性。

方法

用免疫组织化学方法检测198例初次诊治的小细胞肺癌患者石蜡包埋活检组织标本中TTF-1、CD56、P40的阳性表达情况，观察随访患者临床特征及治疗、生存情况，通过Cox风险比例模型分析上述标志物、临床病理特征与预后的相关性。

结果

198例小细胞肺癌患者TTF-1、CD56、P40的阳性率分别为73.2%（145/198）、88.4%（175/198）、7.1%（14/198）。TTF-1是否阳性为小细胞肺癌患者独立预后因素OR=0.665，95%CI：0.472-0.937。其他与预后的相关因素包括：与不吸烟者相比，吸烟指数≤400组OR=1.72，95%CI：1.061-2.789；美国东部肿瘤协作组（Eastern Cooperative Oncology Group, ECOG）得分为2分与0分者相比的OR=3.551，95%CI：2.133-5.914；广泛期与局限期患者相比OR=2.487，95%CI：1.793-3.451；合并上腔静脉压迫综合征（superior vena cava syndrome, SVCS）者OR=2.394，95%CI：1.49-3.846。

结论

小细胞肺癌中的预后与TTF-1表达及吸烟、ECOG得分、肿瘤分期、合并SVCS等多个因素相关，TTF-1、CD56、P40表达在小细胞肺癌的诊断和鉴别诊断中有辅助作用。

Negative Thyroid Transcription Factor 1 Expression Defines an Unfavorable Subgroup of Lung Adenocarcinomas

INTRODUCTION

Thyroid transcription factor 1 (TTF1) is a master regulator of pulmonary differentiation that is downregulated in a subset of lung adenocarcinoma, of which the clinicopathologic characteristics were not fully clarified.

METHODS

One thousand forty-two lung adenocarcinoma patients who underwent surgery were investigated for clinic characteristics, histologic subtyping, and spectrum of well-identified driver mutations. TTF1 expression was correlated with these clinicopathologic factors and survival.

RESULTS

Compared with TTF1 positive (TTF1+) patients, the 133 negative individuals (12.8%, TTF1-) were more likely to be male (p = 0.006) and heavy smokers (p = 0.002) who had larger tumor size (p < 0.001) and more advanced disease stage (p < 0.001). TTF1- presented more in solid and invasive mucinous-predominant carcinomas (both p < 0.001), whereas TTF1+ was identified in 100% patients with adenocarcinoma in situ, minimally invasive and lepidic-predominant adenocarcinomas. The TTF1- tumors harbored the known driver mutations in significantly low frequency compared with TTF1+ adenocarcinomas (57.8% versus 78.1%, p < 0.001), especially in epidermal growth factor receptor (EGFR) mutations (37.6% versus 60.7%, p < 0.001). There was no significant difference in recurrence-free survival between the TTF1- and TTF1+ patients, either for the whole cohort or stratified by pathologic stage, or among the driver mutation-defined subsets. However, recurrence of multiple metastases was more likely to occur in patients with TTF1- adenocarcinomas (88.1% versus 32.4%, p < 0.001). Multivariate analysis revealed that TTF1- independently predicted both poor postrecurrence survival (hazard ratio = 1.664; 95% confidence interval , 1.097-2.524; p = 0.017) and unfavorable overall survival (hazard ratio = 1.553; 95% confidence interval , 1.013-2.381; p = 0.043).

CONCLUSIONS

TTF1- correlated with solid and invasive mucinous subtypes of lung adenocarcinoma and lower frequency of EGFR mutations. It defines a subgroup of lung adenocarcinomas with unfavorable outcomes.

Thyroid transcription factor-1 expression in advanced non- small cell lung cancer: impact on survival outcome

BACKGROUND

The prognostic role of thyroid transcription factor-1 (TTF-1) expression in lung cancer has been assessed but with inconsistent results. The present study aimed to evaluate the prognostic value of TTF1 expression in advanced non-squamous non-small cell lung cancer (NSCLC).

MATERIALS AND METHODS

In this retrospective study, patients with stage IIIB-IV non-squamous NSCLC were enrolled. Progression free survival (PFS) and overall survival (OS) were assessed according to TTF1 expression status, age categories (≤60 vs >60 years), gender, performance status (PS) (0-2 vs 3-4), type of 1st line chemotherapy (pemetrexed containing vs others) and EGFR status.

RESULTS

A total of 120 patients were included. In univariate analysis, PFS was improved in patients with PS 0-2 (7.0 vs 2.0 months, p=0.002) and those who received pemetrexed-containing chemotherapy (9.2 vs 5.8 months, p=0.004). OS was improved in female patients (23.0 vs 8.7 months, p<0.0001), PS 0-2 (14.4 vs 2.0 months, p<0.0001), those with pemetrexed-containing chemotherapy (17.0 vs 11.0 months, p=0.019), TTF1-positive (12.8 vs 5.8 months, p=0.011) and EGFR- mutant patients (23.0 vs 11.7 months, p=0.006). In multivariate analysis, male gender (HR=2.34, p=0.025) and non-pemetrexed containing therapy (HR=2.24, p=0.022) were independent predictors of worse PFS. Wild EGFR status (HR=2.49, p=0.015) and male gender (HR=2.78, p=0.008) were predictors of worse OS.

CONCLUSIONS

Pemetrexed-containing therapy significantly improved PFS while OS was improved in EGFR mutant patients. Female patients had better PFS and OS. TTF1 expression was not a prognostic marker in advanced non-squamous NSCLC.

Protease-mediated release of chemotherapeutics from mesoporous silica nanoparticles to ex vivo human and mouse lung tumors

Nanoparticles allow for controlled and targeted drug delivery to diseased tissues and therefore bypass systemic side effects. Spatiotemporal control of drug release can be achieved by nanocarriers that respond to elevated levels of disease-specific enzymes. For example, matrix metalloproteinase 9 (MMP9) is overexpressed in tumors, is known to enhance the metastatic potency of malignant cells, and has been associated with poor prognosis of lung cancer. Here, we report the synthesis of mesoporous silica nanoparticles (MSNs) tightly capped by avidin molecules via MMP9 sequence-specific linkers to allow for site-selective drug delivery in high-expressing MMP9 tumor areas. We provide proof-of-concept evidence for successful MMP9-triggered drug release from MSNs in human tumor cells and in mouse and human lung tumors using the novel technology of ex vivo 3D lung tissue cultures. This technique allows for translational testing of drug delivery strategies in diseased mouse and human tissue. Using this method we show MMP9-mediated release of cisplatin, which induced apoptotic cell death only in lung tumor regions of Kras mutant mice, without causing toxicity in tumor-free areas or in healthy mice. The MMP9-responsive nanoparticles also allowed for effective combinatorial drug delivery of cisplatin and proteasome inhibitor bortezomib, which had a synergistic effect on the (therapeutic) efficiency. Importantly, we demonstrate the feasibility of MMP9-controlled drug release in human lung tumors.

Diagnostic and prognostic significances of MUC5B and TTF-1 expressions in resected non-small cell lung cancer

To investigate the relationships between the expression of MUC5B and clinicopathological parameters, the expression of MUC5B was immunohistochemically studied. MUC5B expression was observed in 129 of 198 (65.2%) adenocarcinomas and in 4 of 49 (8.2%) squamous cell carcinomas (P < 0.00001). MUC5B expression was significantly associated with poorer differentiation (P = 0.0303), higher pathological TNM stage (p = 0.0153) and poorer prognosis of adenocarcinoma patients (P = 0.0017). Multivariable analysis with Cox proportional hazards models confirmed that MUC5B expression increased the hazard of death after adjusting for other clinicopathological factors (HR = 2.66; 95%CI, 1.26–5.61). We also immunohistochemically evaluated TTF-1 expression and found that the combination of MUC5B with TTF-1 is a useful marker for adenocarcinomas. The diagnostic accuracies of TTF-1 and MUC5B for adenocarcinoma were 83.8% and 70.4%, respectively. The accuracy increased to 94.3% when the two factors were combined. In survival analysis, the MUC5B(High)/TTF-1(−) group was significantly associated with a poorer outcome compared with the MUC5B(Low)/TTF-1(+) group (p < 0.0001). The present study suggested that the combination of MUC5B and TTF-1 expression is useful for discriminating adenocarcinomas from squamous cell carcinomas, yielding prognostic significance in patients with lung adenocarcinoma.

Prognostic value of TTF-1 expression in patients with non-small cell lung cancer: A meta-analysis

BACKGROUND

Observational studies on the prognostic role of thyroid transcription factor 1 (TTF-1) in non-small-cell lung cancer (NSCLC) are controversial.

METHODS

To clarify the impact of TTF-1 in NSCLC survival, we performed this meta-analysis that included eligible studies. The combined hazard ratios and their corresponding 95% confidence intervals were calculated in terms of overall survival.

RESULTS

A total of 17 studies with 2235 patients were evaluable for this meta-analysis. The studies were categorized by histology, disease stage and patient race. Our results suggested that TTF-1 overexpression had a favorable impact on survival of patients with NSCLC, the HR (95% CI) was 0.49 (0.42 to 0.55) overall, 0.46 (0.38-0.54) in Asian patients, 0.52 (0.42-0.63) in non-Asian patients, 0.45 (0.38-0.52) in adenocarcinoma, 0.63 (0.39-0.86) in stage I NSCLC, and 0.43 (0.33-0.53) in stage IIIb-IV NSCLC. The data collected were not sufficient to determine the prognostic value of VEGF in patients with squamous cell lung carcinomas. But there was a high heterogeneity between the studies.

CONCLUSION

TTF-1 overexpression indicates a favorable prognosis for patients with NSCLC, this effect appears also significant when the analysis is restricted in lung AC patients, stage I and stage IIIb-IV NSCLC.

Promotion of lung tumor growth by interleukin-17

Recent findings demonstrate that inhaled cigarette smoke, the predominant lung carcinogen, elicits a T helper 17 (Th17) inflammatory phenotype. Interleukin-17A (IL-17), the hallmark cytokine of Th17 inflammation, displays pro- and antitumorigenic properties in a manner that varies according to tumor type and assay system. To investigate the role of IL-17 in lung tumor growth, we used an autochthonous tumor model (K-Ras(LA1) mice) with lung delivery of a recombinant adenovirus that expresses IL-17A. Virus-mediated expression of IL-17A in K-Ras(LA1) mice at 8-10 wk of age doubled lung tumor growth in 3 wk relative to littermates that received a green fluorescent protein-expressing control adenovirus. IL-17 induced matrix metalloproteinase-9 (MMP-9) expression in vivo and in vitro. In accord with this finding, selective and specific inhibitors of MMP-9 repressed the increased motility and invasiveness of IL-17-treated lung tumor cells in culture. Knockdown or mutation of p53 promoted the motility of murine lung tumor cells and abrogated the promigratory role of IL-17. Coexpression of siRNA-resistant wild-type, but not mutant, human p53 rescued both IL-17-mediated migration and MMP-9 mRNA induction in p53 knockdown lung tumor cells. IL-17 increased MMP-9 mRNA stability by reducing interaction with the mRNA destabilizing serine/arginine-rich splicing factor 1 (SRSF1). Taken together, our results indicate that IL-17 stimulates lung tumor growth and regulates MMP-9 mRNA levels in a p53- and SRSF1-dependent manner.

Detection of circulating vascular endothelial growth factor and matrix metalloproteinase-9 in non-small cell lung cancer using Luminex multiplex technology

It has been previously reported that vascular endothelial growth factor (VEGF) and matrix metalloproteinase (MMP)-9 are important for the occurrence and development of non-small cell lung cancer (NSCLC). The present study was designed to detect the serum levels of VEGF and MMP-9 in NSCLC, and to explore their diagnostic and prognostic values. A total of 543 cases were involved, of which 332 were NSCLC (272 cases in the pretreatment group and 60 cases in the postoperative group), 91 were patients with benign lung diseases and 120 were healthy controls. The serum levels of VEGF and MMP-9 were determined by Luminex multiplex technology. The serum levels of VEGF and MMP-9 were found to be significantly higher in the pretreatment group than those in the patients with benign lung diseases and healthy controls (VEGF, P<0.0001; MMP-9, P<0.0001). Compared with the pretreatment group, the serum levels of VEGF and MMP-9 in the postoperative group were significantly decreased (VEGF, P=0.005; MMP-9, P=0.002), and the levels of VEGF and MMP-9 in the pretreatment group of patients with stages III and IV were higher than those with stages I and II (VEGF, P<0.0001; MMP-9, P=0.021). In addition, the levels of VEGF and MMP-9 were found to closely correlate with lymph node metastasis (VEGF, P<0.0001; MMP-9, P<0.0001) in the pretreatment group, while being independent of other clinicopathological parameters (P>0.05). Furthermore, a positive correlation was observed between the serum levels of VEGF and MMP-9 (r=0.159; P=0.009). A receiver operating characteristic curve analysis showed that the diagnostic value of MMP-9 was higher than that of VEGF in the pretreatment group. The log-rank test indicated that the inoperable NSCLC patients with low levels of VEGF exhibited a significantly longer overall survival time than those with high VEGF levels (P<0.0001). Additionally, the serum levels of VEGF and lymph node metastasis were identified as independent prognostic factors of the inoperable NSCLC patients in a multivariate Cox regression analysis (P<0.05). These results indicated that VEGF and MMP-9 may be potential biomarkers for the diagnosis and prognosis of NSCLC.

Rewiring of human lung cell lineage and mitotic networks in lung adenocarcinomas

Analysis of gene expression patterns in normal tissues and their perturbations in tumors can help to identify the functional roles of oncogenes or tumor suppressors and identify potential new therapeutic targets. Here, gene expression correlation networks were derived from 92 normal human lung samples and patient-matched adenocarcinomas. The networks from normal lung show that NKX2-1 is linked to the alveolar type 2 lineage, and identify PEBP4 as a novel marker expressed in alveolar type 2 cells. Differential correlation analysis shows that the NKX2-1 network in tumors includes pathways associated with glutamate metabolism, and identifies Vaccinia-related kinase (VRK1) as a potential drug target in a tumor-specific mitotic network. We show that VRK1 inhibition cooperates with inhibition of PARP signaling to inhibit growth of lung tumor cells. Targeting of genes that are recruited into tumor mitotic networks may provide a wider therapeutic window than that seen by inhibition of known mitotic genes.

Exhaled matrix metalloproteinase-9 in lung cancer

BACKGROUND

Matrix metalloproteinase-9 (MMP-9) has been recognized in several types of tumor development and progression, including lung cancer, for its role in the degradation and remodeling of lung tissue. Furthermore, increased MMP-9 has been commonly described in the serum and airways of non-small cell lung cancer (NSCLC) patients.

OBJECTIVE

The aim of this study was to investigate, for the first time, MMP-9 in the exhaled breath condensate (EBC) of NSCLC patients.

PARTICIPANTS

We enrolled 40 NSCLC patients and 40 controls affected by transudative pleural effusion.

MEASUREMENTS

MMP-9 concentrations were measured in the EBC, whole blood (WB), and pleural effusion (PE) of all the subjects under study using enzyme immunoassay (EIA) kits.

RESULTS

MMP-9 levels were found to be significantly higher in EBC, WB, and PE of NSCLC patients compared with controls. A positive correlation was observed between MMP-9 in EBC, cigarettes smoked, and stage of cancer.

CONCLUSION

Exhaled MMP-9 was elevated in NSCLC patients, especially during tumor progression, and could represent a suitable noninvasive marker in the diagnosis and monitoring of lung cancer.

Matrix metalloproteinases in cancer: their value as diagnostic and prognostic markers and therapeutic targets

Biomarkers are used as tools in cancer diagnostics and in treatment stratification. In most cancers, there are increased levels of one or several members of the matrix metalloproteinases (MMPs). This is a family of proteolytic enzymes that are involved in many phases of cancer progression, including angiogenesis, invasiveness, and metastasis. It has therefore been expected that MMPs could serve as both diagnostic and prognostic markers in cancer patients, but despite a huge number of studies, it has been difficult to establish MMPs as cancer biomarkers. In the present paper, we assess some of the challenges associated with MMP research as well as putative reasons for the conflicting data on the value of these enzymes as diagnostic and prognostic markers in cancer patients. We also review the prognostic value of a number of MMPs in patients with lung, colorectal, breast, and prostate cancers. The review also discusses MMPs as potential target molecules for therapeutic agents and new strategies for development of such drugs.

Toward Personalized Medicine of Lung Cancer

We evaluated clinical parameters, histomorphology, and thyroid transcription factor 1 (TTF-1) immunoreactivity in 40 epidermal growth factor receptor (EGFR) mutation– and anaplastic lymphoma kinase (ALK) rearrangement–negative invasive pulmonary adenocarcinomas. Tumors were histomorphologically quantitated by a pulmonary pathologist and TTF-1 immunohistochemistry applied. EGFR mutation and ALK rearrangement status was determined with polymerase chain reaction/DNA sequencing and fluorescence in situ hybridization, respectively. Treatment response was related to type of treatment ( P < .005) and clinical stage ( P = .001). EGFR mutation– and ALK rearrangement–negative pulmonary adenocarcinomas containing papillary/micropapillary histology showed greater morphologic heterogeneity ( P < .001), greater TTF-1 immunoreactivity ( P = .004), and were more common in treatment responders ( P < .05). These findings support that patients with pulmonary adenocarcinomas that are subject to nontargeted therapies may respond to treatment as a function of tumor cell differentiation with TTF-1 as a potential biomarker of this response.

Nkx2-1: a novel tumor biomarker of lung cancer

Nkx2-1 (Nkx homeobox-1 gene), also known as TTF-1 (thyroid transcription factor-1), is a tissue-specific transcription factor of the thyroid, lung, and ventral forebrain. While it has been shown to play a critical role in lung development and lung cancer differentiation and morphogenesis, molecular mechanisms mediating Nkx2-1 cell- and tissue-specific expression in normal and cancerous lungs have yet to be fully elucidated. The recent identification of prognostic biomarkers in lung cancer, particularly in lung adenocarcinoma (ADC), and the different reactivity of patients to chemotherapeutic drugs have opened new avenues for evaluating patient survival and the development of novel effective therapeutic strategies. The function of Nkx2-1 as a proto-oncogene was recently characterized and the gene is implicated as a contributory factor in lung cancer development. In this review, we summarize the role of this transcription factor in the development, diagnosis, and prognosis of lung cancer in the hope of providing insights into the utility of Nkx2-1 as a novel biomarker of lung cancer.

Thyroid transcription factor-1 expression is an independent predictor of recurrence and correlates with the IASLC/ATS/ERS histologic classification in patients with stage I lung adenocarcinoma

BACKGROUND

In the current study, the authors investigated whether thyroid transcription factor-1 (TTF-1) expression is correlated with the International Association for the Study of Lung Cancer (IASLC)/American Thoracic Society (ATS)/European Respiratory Society (ERS) classification and whether it stratifies patients with stage I lung adenocarcinoma with respect to disease recurrence.

METHODS

Patients with stage I lung adenocarcinoma were classified according to the IASLC/ATS/ERS classification. Tissue microarrays were constructed and immunostaining for TTF-1 was performed. A total of 452 cases were available for analysis. Tumors were dichotomized based on the intensity of nuclear TTF-1 expression as negative (score of 0) or positive (score of 1-3). The cumulative incidence of recurrence (CIR) was used to estimate disease recurrence probabilities.

RESULTS

TTF-1 expression was identified in 92% of patients, including 100% of patients with minimally invasive or lepidic-predominant adenocarcinoma, 94% of patients with acinar-predominant adenocarcinoma, 98% of patients with papillary-predominant adenocarcinoma, 93% of patients with micropapillary-predominant adenocarcinoma, 86% of patients with solid-predominant adenocarcinoma, 67% of patients with colloid-predominant adenocarcinoma, and 47% of patients with invasive mucinous carcinoma. The CIR for patients with negative TTF-1 expression (n = 34 patients; 5-year CIR, 40%) was significantly higher than that for patients with positive TTF-1 expression (n = 418 patients; 5-year CIR, 15%) (P < .001). Among the patients with intermediate-grade tumors, the CIR for patients with negative TTF-1 expression (n = 16 patients; 5-year CIR, 45%) was significantly higher than that for patients with positive TTF-1 expression (n = 313 patients; 5-year CIR, 14%) (P < .001). On multivariate analysis, negative TTF-1 expression was found to be significantly correlated with an increased risk of disease recurrence (hazards ratio, 2.55; P = .009).

CONCLUSIONS

TTF-1 expression was found to be an independent predictor of disease recurrence, stratifying intermediate-grade tumors into 2 prognostic subsets, and it correlates with the IASLC/ATS/ERS classification.

Cathepsin D as a potential prognostic marker for lung adenocarcinoma

We previously identified cathepsin D as a possible marker for lung adenocarcinoma (AD). The purpose of the present study is to evaluate the correlation between cathepsin D expression and clinicopathological findings or prognosis. We conducted immunohistochemistry (IHC) to assess 150 AD tissues. For these 150 tumors, TTF-1 expression, EGFR and KRAS gene mutations, and ALK rearrangements had already been examined. Cathepsin D expression was detected in 44% (66 of 150, IHC score ≥1+) and 27.3% (41 of 150, IHC score ≥2+). Cathepsin D-positive (IHC score ≥2+) tumors were more poorly differentiated than cathepsin D-negative ones, while all lepidic predominant invasive adenocarcinomas showed no cathepsin D expression. Univariate analysis revealed a poor prognosis for cathepsin D-positive lung AD patients with an IHC score ≥2+ (P=0.044). Cathepsin D expression was more frequent in TTF-1-negative than in TTF-1-positive ADs (P=0.034), and more frequent in ADs with EGFR wild genotype than mutant EGFR (P<0.001). Regarding AD patients with ALK rearrangements, 4 were positive for Cathepsin D, while 2 were negative. Cathepsin D expression is indicated to be a possible prognostic marker for lung AD and to correlate with a more poorly differentiated form.

DNA methylation of the homeobox genes PITX2 and SHOX2 predicts outcome in non-small-cell lung cancer patients

Biomarkers that facilitate prediction of disease progression in lung cancer patients might be clinically valuable in optimizing individualized therapy. In this study, the ability of the DNA methylation biomarkers PITX2 and SHOX2 to predict disease outcome in lung cancer patients has been evaluated. Quantitative, methylation-specific (HeavyMethyl), real-time polymerase chain reaction assays were used to measure DNA methylation of PITX2 and SHOX2 in bisulfite-converted DNA from formalin-fixed, paraffin-embedded tissues from 474 non-small-cell lung cancer patients. In univariate Cox Proportional Hazard analysis, high methylation of SHOX2 and PITX2 was a significant predictor of progression-free survival [SHOX2: n=465, hazard ratio (HR)=1.395 (1.130 to 1.721), P=0.002; PITX2: n=445, HR=1.312 (1.059 to 1.625), P=0.013]. Patients with low methylation of either PITX2 and/or SHOX2 (n=319) showed a significantly higher risk of disease progression as compared with patients with higher methylation of both genes [n=126; HR=1.555 (1.210 to 1.999), P=0.001]. This was particularly true for the subgroup of patients receiving no adjuvant radiotherapy or chemotherapy [n=258, HR=1.838 (1.252 to 2.698), P=0.002]. In multivariate analysis, both biomarkers added significant independent prognostic information to pT, pN, pM, and grade. Another interesting finding of this study was that SHOX2 and PITX2 DNA methylation was shown to be inversely correlated with TTF1 (also known as NKX2-1) expression (PITX2: P=0.018, SHOX2: P<0.001). TFF1 expression was previously found to be associated with improved survival in the same patient cohort. DNA methylation of PITX2 and SHOX2 is an independent prognostic biomarker for disease progression in non-small-cell lung cancer patients.

Prognostic value of matrix metalloproteinase 9 expression in patients with non-small cell lung cancer

BACKGROUND

The role of matrix metalloproteinase 9 (MMP-9) expression in non-small cell lung cancer (NSCLC) remains controversial. We performed a systematic review of the literature with meta-analysis.

METHODS

Electronic databases were used to identify published studies before December 1, 2011. Pooled hazard ratio (HR) with 95% confidence interval (95% CI) was used to estimate the strength of the association between MMP-9 expression survival of NSCLC patients. Heterogeneity and publication bias were also assessed.

RESULTS

The final analysis of 2029 NSCLC cases from 17 studies is presented. The combined HR of 1.84 (95% CI: 1.62-2.09) suggested that MMP-9 over-expression had a poor prognosis in patients with NSCLC. Subgroup analyses also detected significant association. Heterogeneity and publication bias was absent in current meta-analysis. Sensitivity analyses suggested that the summary statistics obtained should approximate the actual average.

CONCLUSION

High MMP-9 expression is associated with a poor prognosis in patients with NSCLC.

The effect of TTF-1 expression on ipsilateral mediastinal nodal (N2) metastases in primary adenocarcinoma of the lung

Aim of the study

To study the effect of thyroid transcription factor-1 (TTF-1) expression on ipsilateral mediastinal nodal (N2) metastases in primary adenocarcinoma of the lung.

Material and methods

The patients operated on with a diagnosis of primary adenocarcinoma of the lung were retrospectively analyzed and divided into two groups according to their TTF-1 expression. The relationship between TTF-1 expression and N2 metastases was evaluated.

Results

There were 73 patients (58 male, 15 female) with a mean age of 58.4 ±10.2 in the study group. Sixty-six lobectomies or pneumonectomies and mediastinal lymph node dissection, and seven mediastinoscopies were performed. Positivity of the TTF-1 protein expression detected by the immunohistochemical staining of the specimens was present in 33 patients (45.2%); these patients were classified as group A and the rest of the patients as group B. Eleven patients had N2 disease in group A versus five patients in group B and the difference between the two groups was statistically significant.

Conclusions

Patients with primary adenocarcinoma of the lung having TTF-1 expression are more likely to have N2 disease. They might be considered as candidates for adjuvant therapy.

Significance of thymidylate synthase and thyroid transcription factor 1 expression in patients with nonsquamous non-small cell lung cancer treated with pemetrexed-based chemotherapy

INTRODUCTION

This study is to evaluate whether thymidylate synthase (TS) or thyroid transcription factor 1 (TTF1) protein expression can predict clinical outcomes for pemetrexed-based chemotherapy in patients with nonsquamous non-small cell lung cancer (NSCLC).

METHODS

Two hundred eighty-five consecutive patients with nonsquamous NSCLC treated with pemetrexed-based chemotherapy were immunohistochemically analyzed for the expressions of TS and TTF1.

RESULTS

TS and TTF1 expression were successfully analyzed in 193 and 284 cases, respectively. Tumors with TS-negativity or TTF1-positivity were more frequent in patients who were female, younger, had adenocarcinoma, or had never smoked. Higher response rates for pemetrexed-based chemotherapy were associated with TS-negativity (33.7% versus 14.1%, p = 0.002) and TTF1-positivity (28.1% versus 9.8%, p < 0.001). In univariate analysis, progression-free survival for pemetrexed-based chemotherapy was significantly longer in groups with adenocarcinoma (2.9 versus 1.4 months, p = 0.001), TS-negativity (4.1 versus 2.0 months, p = 0.001), and TTF1-positivity (3.8 versus 1.3 months, p < 0.001). In multivariate analysis, TS-negativity (hazard ratio [HR] = 0.70; 95% confidence interval [CI], 0.51-0.97) and TTF1-positivity (HR = 0.51; 95% CI, 0.35-0.73) were associated with longer progression-free survival. Patients with TTF1-positive tumors also had significantly longer overall survival times than patients with TTF1-negative tumors (25.4 versus 14.2 months, HR = 0.55; 95% CI, 0.39-0.77).

CONCLUSIONS

Low TS or high TTF1 protein expression was significantly associated with better clinical outcomes in nonsquamous NSCLC patients who were treated with pemetrexed-based chemotherapy. The predictive role of TS or TTF1 expression should be further validated in a prospective randomized study.

The relationship between RGS5 expression and cancer differentiation and metastasis in non-small cell lung cancer

BACKGROUND

Regulator of G-protein signaling 5 (RGS5), a tissue-specific signal regulating molecular, plays important roles in the development of vasculature. Recently, we have found that the mRNA level of RGS5 was oppositely related with tumor metastasis in non-small cell lung cancer (NSCLC). However, the distribution of RGS5 in NSCLC and its significance need further study. We therefore investigated the expression of RGS5 in NSCLC, as well as its relationship with clinicopathologic parameters.

METHODS

Tumor tissues from 51 NSCLC patients were analyzed and expression of RGS5 in tumor tissues was examined by immunohistochemistry. Chi-square test (or Fisher's exact test), Breslow test and multivariate Cox regression model were performed for statistical analysis.

RESULTS

RGS5 were highly expressed in 47% (24/51) of NSCLC specimens. Expression of RGS5 was associated with tumor cell differentiation in NSCLC and low expression of RGS5 was strongly associated with cancer vasculature invasion and lymph node metastasis in NSCLC. Patients with high RGS5 expression in NSCLC had a prolonged progression free survival (15.0 months (95%CI: 6.1-23.9) vs. 6.0 months (95%CI: 1.3-10.7), P = 0.030).

CONCLUSION

RGS5 might be involved in cancer differentiation and metastasis in NSCLC. And it might be a candidate prognostic marker for PFS in NSCLC.

Both gene amplification and allelic loss occur at 14q13.3 in lung cancer

PURPOSE

Because loss of Nkx2-8 increases lung cancer in the mouse, we studied suppressive mechanisms in human lung cancer.

EXPERIMENTAL DESIGN

NKX2-8 is located within 14q13.3, adjacent to its close relative TTF1/NKX2-1. We first analyzed LOH of 14q13.3 in forty-five matched human lung cancer and control specimens. DNA from tumors with LOH was then analyzed with high-density single-nucleotide polymorphism (SNP) arrays. For correlation with this genetic analysis, we quantified expression of Nkx2-8 and TTF1 mRNA in tumors. Finally, suppressive function of Nkx2-8 was assessed via colony formation assays in five lung cancer cell lines.

RESULTS

Thirteen of forty-five (29%) tumors had LOH. In six tumors, most adenocarcinomas, LOH was caused by gene amplification. The 0.8-Mb common region of amplification included MBIP, SFTA, TTF1, NKX2-8, and PAX9. In 4 squamous or adenosquamous cancers, LOH was caused by deletion. In three other tumors, LOH resulted from whole chromosome mechanisms (14(-), 14(+), or aneuploidy). The 1.2-Mb common region of deletion included MBIP, SFTA, TTF1, NKX2-8, PAX9, SLC25A21, and MIPOL1. Most tumors had low expression of Nkx2-8. Nevertheless, sequencing did not show NKX2-8 mutations that could explain the low expression. TTF1 overexpression, in contrast, was common and usually independent of Nkx2-8 expression. Finally, stable transfection of Nkx2-8 selectively inhibited growth of H522 lung cancer cells.

CONCLUSIONS

14q13.3, which contains NKX2-8, is subject to both amplification and deletion in lung cancer. Most tumors have low expression of Nkx2-8, and its expression can inhibit growth of some lung cancer cells.

Nucleophosmin gene mutations promote NIH3T3 cell migration and invasion through CXCR4 and MMPs

Nucleophosmin (NPM1) plays key roles in ribosome biogenesis, centrosome duplication, and maintenance of genomic integrity. NPM1 mutations have been recently identified as the most frequent genetic alteration in acute myeloid leukemia and are related to leukemogenesis. NPM1 mutations are involved in the regulation of cell proliferation, cell cycle, and apoptosis. However, the oncogenic potential of NPM1 mutations is not fully understood. Here, we investigated the change of cell migration and invasion in vitro and the role of NPM1 mutations in this process. In our study, NIH3T3 cells were transfected with plasmids encoding NPM1 mutation A (NPM1 mA), and the cell chemotactic response in vitro was evaluated by cell migration and invasion assays. In addition, the expression levels of MMP-2, MMP-9 and CXCR4 were assayed by quantitative real-time PCR and western blotting. Our findings suggested that the migration and invasion of NIH3T3 cells were significantly enhanced after transfection with NPM1 mA (p<0.01). Furthermore, there was greater expression of MMP-9 and CXCR4 (p<0.01), but a lower expression of MMP-2 in the NPM1 mA group. These results demonstrate that NPM1 mutations may promote cell migration and invasion in vitro, and MMP-9 and CXCR4 may be involved in the regulation of cell invasion. Thus, this study sheds new light on the effect of NPM1 mutations on leukemogenesis.

Expression of thyroid transcription factor-1 in colorectal carcinoma

Thyroid transcription factor-1 (TTF-1) is a member of the homeodomain transcription family expressed in epithelial cells of the thyroid and lung. Although nuclear TTF-1 is generally considered a specific marker for lung and thyroid neoplasms, it has been reported to be positive in other types of tumors including colorectal carcinoma (CRC). During metastatic adenocarcinoma workup for patients who had a history of CRC, we identified 4 positive TTF-1 cases using clone 8G7G3/1. Three of the 4 corresponding primary carcinomas were also positive for TTF-1. Therefore, we sought to retrospectively investigate the expression of TTF-1 in 100 CRC cases constructed in tissue microarray blocks and whole tissue sections of the 4 primary tumors corresponding to the 4 positive metastases. In tissue microarray cases, all cases had negative nuclear staining. Our results suggest that during immunohistochemical workup for adenocarcinoma, especially when the differential diagnosis includes the lung and CRC, TTF-1 results should be interpreted with caution as a small percentage of CRC expresses this marker. Positive nuclear TTF-1 in a metastatic carcinoma does not rule out CRC primary. Clinicopathologic correlation, tumor morphology, and a panel of immunohistochemical markers are essential to render the correct diagnosis.

Role of immunohistochemistry in the diagnosis of lung cancer

The role of immunohistochemistry is to recognize antigens and, consequently, to identify and classify specific cells within a cell population whose morphology is heterogenous or apparently homogenous. The visualization of the antigen-antibody complex is made possible through the addition of either a fluorochrome conjugate or an enzyme to the antibody, which is then viewed under microscopy. Immunohistochemistry can be used in the routine diagnosis of lung cancer, in order to identify biological markers (diagnostic and prognostic). The essential immunohistochemistry panels will be discussed in this review.