Clinicopathological and biological assessment of lung cancers with pleural dissemination

Long-Term Treatment-Free Survival After Multimodal Therapy in a Patient with Stage IV Lung Adenocarcinoma

We report the first case of a patient with non-small cell lung cancer (NSCLC) with malignant pleural effusion (MPE) who achieved disease- and treatment-free survival for nearly 10 years. A 50-year-old man was diagnosed with NSCLC with MPE and underwent chemotherapy and salvage thoracic surgery. The patient received chemotherapy with cisplatin, pemetrexed, and bevacizumab, and a partial response was achieved. After informed consent was obtained from the patient, right middle lobectomy was performed to achieve local tumor control. Postoperative adjuvant chemotherapy with pemetrexed and bevacizumab was discontinued after almost 1 year of chemotherapy due to side effects such as diarrhea and muscle weakness. The patient has survived without recurrence of lung cancer for more than 11 years after being diagnosed and nearly 10 years after discontinuing chemotherapy.

Survival Benefits for Pulmonary Adenocarcinoma With Malignant Pleural Effusion After Thoracoscopic Surgical Treatment: A Real-World Study

Objectives

Malignant cells in the pleural fluid or pleural metastasis are classified as stage IV non-small cell lung cancer. Radical surgery is generally considered not suitable for such patients. The aim of our study was to discuss the effectiveness of video-assisted thoracoscopic surgery (VATS) in such patients.

Methods

A retrospective analysis of the clinical records of 195 patients was performed. These patients were all diagnosed with locally advanced pulmonary adenocarcinomas with malignant pleural effusion (MPE, M1a) but no distant organ metastasis. The 195 patients included 96 patients who underwent VATS plus chemotherapy and 99 patients who received thoracic drainage plus chemotherapy. The baseline characteristics of the patients included age, gender, smoking history, Eastern Cooperative Oncology Group (ECOG) score, and number of chemotherapy cycles (2–4 cycles or >4 cycles); we also analyzed clinical characteristics including the specific surgical options of the VATS group.

Results

In multivariate analysis, when compared to the thoracic drainage group, the VATS group remained significantly associated with the overall survival [HR=0.480 (95%CI 0.301-0.765)]; when compared to the lobectomy, the sub-lobectomy and the palliative surgery, remained significantly associated with the overall survival [HR=0.637 (95%CI 0.409-0.993) and HR=0.548 (95%CI 0.435-0.832), respectively]. The median survival time (MST) of patients who underwent VATS (n = 96, 49.2%) was 25 months (95% CI 22.373–27.627) whereas the patients who received thoracic drainage (n = 99, 50.8%) was 11 months (95% CI 9.978–12.022). For patients who underwent VATS, the MST of patients who received a lobectomy (n = 50, 52.1%) was 27 months (95% CI 22.432–31.568), the MST of patients who received a sub-lobectomy plus pleurodesis (n = 26, 27.1%) was 27 months (95% CI 19.157–34.843), and the MST of patients who received only pleurodesis (n = 20, 20.8%) was 12 months (95% CI 7.617–16.383).

Conclusion

For pulmonary adenocarcinomas with MPE, receiving a lobectomy or sub-lobectomy plus pleurodesis with VATS was associated with improved survival compared with patients who only received thoracic drainage and chemotherapy. Our results and previously published data may justify the use of VATS for treating pulmonary adenocarcinomas with MPE.

Prediction of overall survival of non-small cell lung cancer with bone metastasis: an analysis of the Surveillance, Epidemiology and End Results (SEER) database

Background

The prognosis of non-small cell lung cancer (NSCLC) patients with bone metastasis is extremely repulsive. The aim of this study was to potentially characterize the prevalence, associated factors and to establish a prognostic nomogram to predict the overall survival (OS) of NSCLC patients with bone metastasis.

Methods

The Surveillance, Epidemiology and End Results (SEER) database was used to collected NSCLC cases during 2010–2015. The cases with incomplete clinicopathological information were excluded. Finally, 484 NSCLC patients with bone metastasis were included in the present study and randomly divided into the training (n=340) and validation (n=144) cohorts in a ratio of 7:3 based on R software. NSCLC patients with bone metastasis were selected to investigate predictive factors for OS and cancer-specific survival (CSS) using the multivariable Cox proportional hazards regression. A nomogram incorporating these prognostic factors was developed and evaluated by a concordance index (C-index), calibration plots, and risk group stratifications.

Results

In the Cox proportional hazards model, sex, race, American Joint Committee on Cancer (AJCC) N, T stage, liver metastasis, and chemotherapy were regarded as prognostic factors of OS. The nomogram based on sex, race, AJCC N, T stage, liver metastasis and chemotherapy was developed for cancer-specific death to predict 1-, 3-, and 5-year survival rate with good performance. The C-index of established nomogram was 0.695 for cancer-specific death in the study population with an acceptable calibration.

Conclusions

The female gender, the patients with chemotherapy and not liver metastasis may indicate improved survival. However, the global prospective data with the latest tumor, node, metastasis (TNM) classification is needed to further improve this model.

Surgical Resection of Primary Tumors Provides Survival Benefits for Lung Cancer Patients With Unexpected Pleural Dissemination

Background: Surgery is not generally recommended for non-small cell lung cancer (NSCLC) patients with malignant pleural dissemination (PD). However, in some cases, PD is found unexpectedly during surgery. There is no consensus on whether surgical intervention can provide survival benefit for them. We investigated the role of surgery in NSCLC patients with unexpected PD by a cohort study.

Methods: Clinical data of consecutive patients who intended to undergo radical surgery for NSCLC between January 2010 and December 2015 at Shanghai Chest Hospital and Huadong Hospital were collected from a lung cancer database. Patients diagnosed with unexpected malignant pleural nodules intraoperatively were enrolled in this retrospective study.

Results: A total of 181 NSCLC patients were diagnosed with unexpected malignant PD intraoperatively and confirmed with postoperatively histological examinations. Out of these, 80 (44.2%) patients received pleural nodule biopsies alone, and 101 (55.8%) received primary tumor resection (47 with sublobar resection and 54 with lobectomy). The median progression-free survival and overall survival for all patients were 13 and 41 months respectively. Patients in the resection group had significantly better progression-free survival (19.0 vs. 10.0 months, P < 0.0001) and overall survival (48.0 vs. 33.0 months, P < 0.0001) than patients in the biopsy group. In the resection group, there was no statistical difference between patients with sublobar resection and lobectomy (P = 0.34). Univariate and multivariate analyses identified primary tumor resection, targeted adjuvant therapy, and tumor size (≤ 3 cm) as independent prognostic factors.

Conclusions: NSCLC patients with unexpected intraoperative PD potentially benefited from surgical resection of the primary tumor and multidisciplinary targeted therapy, particularly when tumor size did not exceed 3 cm. Our data demonstrated that the resection type was not associated with survival differences, which remains to be defined with a larger sample size.

Predictive factors related to pleural dissemination in non-small cell lung cancer

Background

The prognosis of non-small-cell lung cancer (NSCLC) patients with pleural dissemination is poor, and pleural dissemination is generally considered a contraindication for radical surgery. However, if pleural dissemination is missed intraoperatively, patients with false-negative stage IV NSCLC cannot receive appropriate chemotherapy, and their prognosis might worsen.

Methods

In the present study, we enrolled 144 patients who received surgery for NSCLC between January 2008 and December 2019 with available data on the maximum standardized uptake value (SUV_max) on positron emission tomography (PET) with lesions adjacent to the visceral pleura and without lesions invading the chest wall.

Results

Seven patients who had pleural dissemination were compared with 137 patients who had not pleural dissemination. The relationships between pleural dissemination and the clinicopathological variables were analyzed, and significant differences in the histopathological type (P=0.03), and differentiation (P<0.01) were noted. It was suggested that squamous cell carcinoma tended not to show dissemination to the pleural cavity. The logistic regression analyses of the predictive factors related to pleural dissemination in non-squamous cell carcinoma patients were analyzed, and the age (P=0.01) and differentiation (P<0.01) were identified as significant predictive factors related to pleural dissemination.

Conclusions

Cases with non-squamous cell carcinoma, a young age, and poor differentiation of undifferentiated grade of histological differentiation are factors associated with early pleural cavity dissemination.

Management of occult malignant pleural disease firstly detected at thoracotomy for non-small cell lung cancer patients

Background

The current study was to investigate the risk factors of occult malignant pleural disease (MPD) detected at thoracotomy and the outcomes of surgical intervention for these non-small cell lung cancer (NSCLC) patients with or without MPD.

Methods

We reviewed 2,093 consecutive NSCLC patients who underwent thoracotomy from January 2006 to January 2015. We used univariate and multivariate statistics to analyze the associations between clinicopathological variables and occurrence of occult MPD. Survival probability was estimated by the Kaplan-Meier method.

Results

5.26% (110/2,093) MPD was observed for these NSCLC patients with 28% of 5-year estimated survival rate. Age ≤50 (P=0.055), high CEA level (P=0.006), advanced N stage (P=0.005), adenocarcinoma (P=0.001) and pleural invasion (P=0.041) were detected to be independent risk factors for the occult MPD. Combination of these five factors, 0.756 of area under curve (AUC) was shown by the integrated prediction model test. Based on the optimal cut-off value (risk score =2.795), low-risk patients have better prognosis than the high-risk patients (median survival time 61.4 months vs. not reached, P<0.001; 5-year survival 71.8% vs. 51.1%, P<0.001). Significantly, 49.0 months/31.7% and 29.4 months/19.5% of the median survival time/5-year survival rate were found for the occult MPD 110 patients receiving primary lesion resection and open-close surgery, respectively (P=0.037).

Conclusions

We summarized that a new prediction model including 5-risk factors of age, carcinoembryonic antigen (CEA), N stage, adenocarcinoma and pleural invasion was provided to diagnose MPD for the NSCLC patients and primary lesion resection greatly contributed for these MPD patients.

Gp78 E3 Ubiquitin Ligase: Essential Functions and Contributions in Proteostasis

As per the requirement of metabolism and fitness, normal cellular functions are controlled by several proteins, and their interactive molecular and signaling events at multiple levels. Protein quality control (PQC) mechanisms ensure the correct folding and proper utilization of these proteins to avoid their misfolding and aggregation. To maintain the optimum environment of complex proteome PQC system employs various E3 ubiquitin ligases for the selective degradation of aberrant proteins. Glycoprotein 78 (Gp78) is an E3 ubiquitin ligase that prevents multifactorial deleterious accumulation of different misfolded proteins via endoplasmic reticulum-associated degradation (ERAD). However, the precise role of Gp78 under stress conditions to avoid bulk misfolded aggregation is unclear, which can act as a crucial resource to establish the dynamic nature of the proteome. Present article systematically explains the detailed molecular characterization of Gp78 and also addresses its various cellular physiological functions, which could be crucial to achieving protein homeostasis. Here, we comprehensively represent the current findings of Gp78, which shows its PQC roles in different physiological functions and diseases; and thereby propose novel opportunities to better understand the unsolved questions for therapeutic interventions linked with different protein misfolding disorders.

Monoclonal antibodies against autocrine motility factor suppress gastric cancer

Autocrine motility factor (AMF), which is a secreted form of phosphoglucose isomerase, is mainly secreted by various tumors and has cytokine-like activity. AMF is known to stimulate proliferation, survival and metastasis of cancer cells, and angiogenesis within a tumor. The present study investigated whether inhibition of AMF using targeted-antibodies was able to suppress the growth of cancer. A migration assay using a Boyden chamber was utilized to measure the activity of AMF on the motility of cancer cells. A recombinant human AMF (rhAMF) prepared from E. coli transformed with the pET22b-AMF vector increased the motility of MDA-MB-231 and A549 cells, but it did not affect that of NCI-N87 or HepG2 cells, which exhibited the ability to secrete high amounts of their own endogenous AMF into the culture medium. The extent to which the AMF receptor was expressed on cancer cells did not correlate clearly with the cell motility stimulated by rhAMF. In A549-xenografted nude mice treated with sunitinib or cetuximab, a decrease in the plasma AMF concentration was accompanied by a reduction in tumor weight, suggesting an association between the plasma AMF concentration and anticancer activity. A monoclonal antibody (9A-4H), which revealed a high binding affinity for E. coli-derived rhAMF, significantly suppressed the growth of tumors in Balb/c nude mice transplanted with the human gastric cancer cell line NCI-N87, to the similar extent as trastuzumab, an anticancer antibody. The present study suggests, for the first time, that an antibody specific to AMF may be a therapeutic agent for gastric cancer.

Surgical Intervention for Non-Small-Cell Lung Cancer Patients with Pleural Carcinomatosis: Results From the Japanese Lung Cancer Registry in 2004

INTRODUCTION

A subset of non-small-cell lung cancer (NSCLC) patients with malignant pleural effusion and/or malignant pleural nodules is now classified as stage IV and is generally considered a contraindication to surgery. However, several reports have demonstrated that the prognosis of patients with pleural carcinomatosis first detected at thoracotomy is relatively favorable. The aim of this study was to describe the results of surgical intervention in NSCLC patients with pleural carcinomatosis in Japan.

METHODS

In 2010, the Japanese Joint Committee of Lung Cancer Registry conducted a nationwide registration of lung cancer patients who underwent surgery in 2004. Using this database, we performed a retrospective study focused on pleural carcinomatosis. We examined the clinicopathological features, the current status of therapy, and surgical outcomes in patients with pleural carcinomatosis.

RESULTS

Among the 11,420 registered NSCLC patients, 329 (2.9%) patients had pleural carcinomatosis. The median survival time and 5-year survival rate of 313 patients without other metastatic disease were 34.0 months and 29.3%, respectively. Primary tumor resection was performed in 256 (81.8%) patients, and macroscopic complete resection was achieved in 152 (48.6%) patients, with 5-year survival rates of 33.1% and 37.1%, respectively. Multivariate analysis revealed that Eastern Cooperative Oncology Group performance status (p < 0.001), best stage nodal status (p = 0.002), and the presence or absence of gross residual tumor (p = 0.013) were independent predictors of survival.

CONCLUSION

In our surgical registry for NSCLC, patients with pleural carcinomatosis accounted for 2.9%, and macroscopic complete resection for them was associated with better survival.

Accidental invisible intrathoracic disseminated pT4-M1a: a distinct lung cancer with favorable prognosis

OBJECTIVE

In the 7(th) edition of the TNM classification of malignant tumors, the prognosis for pT4-M1a stage IV lung cancer is better than for stage pIIIB. Subgroups of lung cancer patients who underwent incomplete resection (R1/R2) have a favorable prognosis. This study compares the prognosis between cases of invisible local residual disease and intrathoracic disseminated pT4-M1aIV.

METHODS

Patient characteristics and histological and molecular profiles were retrospectively collected for lung cancer patients who underwent resection intended to be curative but were accidentally incomplete. All patients were divided into either a local residual group or an intrathoracic disseminated pT4M1a group. Progression-free survival (PFS) and overall survival (OS) were evaluated by Kaplan-Meier and Cox regression models.

RESULTS

In total, 1,483 consecutive lung cancer patients receiving thoracotomies at Guangdong Lung Cancer Institute were retrospectively analyzed. Fifty-eight patients receiving incomplete resections (R1/R2) were enrolled, including 38 patients with local residual cancer (2.6% of all patients) and 20 patients with disseminated pM1a (1.3%). Patient characteristics, and histological and molecular profiles of the two groups were different. Compared to the local residual group, the disseminated pT4-M1a group contained more females (P=0.002), more patients younger than 60 years of age (P=0.028), more non-smokers (P=0.037), more adenocarcinomas (20/20 vs. 20/38, P<0.001), more adenocarcinomas with lepidic pattern (11/20 vs. 4/38, P<0.001), higher carcinoembryonic antigen (CEA) levels (P=0.06), higher epidermal growth factor receptor (EGFR) mutation rates (16/20 vs. 7/38, P<0.001), a higher R2/R1 resection ratio (P=0.013), a higher advanced stage IV/IIIB ratio (P<0.001), but fewer lymph node metastases (P=0.013). Median PFS for the local residual and disseminated pT4-M1a groups was 9.0 and 18.0 months, respectively [95% confidence interval (CI), 5.285-16.715; P =0.099]. Median OS was 15.0 and 45.0 months, respectively (95% CI, 18.972-39.028; P=0.001). Cox regression analysis revealed that group (local residual vs. disseminated pT4-M1a) was the only independent prognostic factor (P=0.044) for OS.

CONCLUSIONS

Accidental invisible intrathoracic disseminated pT4-M1a may be a distinct lung cancer subtype with a favorable prognosis. The prolonged PFS and OS might reflect the natural history of this distinct subtype, together with a favorable response to EGFR tyrosine kinase inhibitors (EGFR-TKI). For asymptomatic and slow-growing accidental pT4-M1a disease, the role of a wait-and-see strategy and the appropriate timing of systemic treatment require further investigation.

Preoperative concurrent chemoradiotherapy followed by extrapleural pneumonectomy for patients with non-small cell lung cancer with malignant pleural effusion and/or pleural nodules: Ten-year results of a prematurely terminated single institute phase II trial

BACKGROUND

Malignant pleural effusion and/or pleural nodules are a final stage of disease extension of non-small cell lung cancer (NSCLC), which is currently classified as M1a-Stage IV disease. The role of surgery, especially extrapleural pneumonectomy (EPP) for local disease control and its impact on the survival of patients remains uncertain.

PATIENTS AND METHODS

This single institute phase II trial was performed from March 1997 to March July 2004 to assess the effects of induction concurrent chemoradiotherapy (CRT) using a pro-drug of 5-FU, uracil-tegafur (UFT(®), Taiho Pharmaceutical Co., Ltd, Tokyo, Japan), plus cisplatin concurrently with 40 Gy hemithorax radiation followed by EPP. Intraoperative hypotonic cisplatin treatment in the pleural cavity before resection of the pericardium and diaphragm was performed. The primary endpoint of this study was the overall survival (OS), and the secondary endpoint was the disease-free survival (DFS), safety, response to the induction CRT, local disease control period in the affected thorax and the type of disease recurrence.

RESULTS

This trial was prematurely terminated because of the slow registration pace. During the study period, 11 patients were enrolled. There were five males and six females, with a median age of 55 (36-64) years. All patients had adenocarcinoma. All patients received the planned induction CRT. Five patients achieved a partial response and five achieved stable disease, and one patient could not be evaluated. One patient underwent exploratory thoracotomy due to unresectable chest wall invasion, and nine patients (81.8%) underwent EPP. No perioperative deaths were encountered. The median follow-up time was matured at 32.1 (range 15.0-100) months. The one-, three- and five-year DFS rates were 77.8% (95%CI: 50.6-100%), 11.1% and 11.1% (95%CI: 95%CI: 0-31.7%), respectively. The one-, three- and five-year OS rates were 100.0%, 33.3% (95%CI: 2.5-64.1%) and 22.2% (95%CI: 0.0-49.4%), respectively. Recurrence developed in eight of nine patients who underwent EPP (88.9%). All first recurrent sites were distant regions, and no ipsilateral local recurrence was identified.

CONCLUSION

The trimodality treatment used in this trial appears to be a choice of treatment for highly selected patients. However, the impact on the survival of NSCLC patients with malignant pleural effusion and/or pleural nodules still remains uncertain given the small number of patients enrolled in the study.

Evaluation of the 7th edition of the TNM classification for lung cancer at a single institution

PURPOSE

To assess the utilities and drawbacks of the 7th edition of the TNM classification for lung cancer.

METHODS

Subjects included 1,469 patients who underwent pulmonary resection for primary non-small cell lung cancer. Survival characteristics were compared using the 6th and 7th editions of the staging system.

RESULTS

According to the 6th and 7th editions, respectively, the 5-year survival rates based on stages were as follows: pStage IA (81.0, 81.0 %), pStage IB (70.6, 72.0 %), pStage IIA (61.3, 59.7 %), pStage IIB (56.6, 47.2 %), pStage IIIA (43.4, 37.6 %), pStage IIIB (8.9, 14.9 %), and pStage IV (14.0, 8.0 %). According to the 6th edition, there was no significant difference between pStages IB and IIA (P = 0.268), or between pStages IIA and IIB (P = 0.622), or between pStages IIIB and IV (P = 0.737). According to the 7th edition, there were significant differences between each adjacent stage group, except between pStages IIIB and IV (P = 0.424). According to the 7th edition staging system, 5-year survival rates by T classification were as follows: pT1a, 81.6 %; pT1b, 75.9 %; pT2a, 60.1 %; pT2b, 44.7 %; pT3, 24.4 %; and pT4, 13.2 %; with significant differences between each adjacent pT classification. The 5-year survival rates by M classification were as follows: M0, 57.2 %, M1a, 9.1 %, M1b, 0 %, with a significant difference between M0 and M1a, but there was no significant difference between M1a and M1b.

CONCLUSION

The UICC 7th edition staging system is considered valid for non-small cell lung cancer patients and appears to be superior in defining different prognostic groups than the 6th edition.

Pulmonary resection for lung cancer with malignant pleural disease first detected at thoracotomy

OBJECTIVES

The prognosis of non-small-cell lung cancer (NSCLC) patients with malignant pleural disease (MPD), characterized by malignant pleural effusion and/or malignant pleural nodules, is reported to be poor, and patients with MPD are generally not subjected to surgery. However, whether or not the primary tumor should be resected, when MPD is first detected at thoracotomy, is controversial.

METHODS

The clinical records of 1623 consecutive NSCLC patients, who underwent surgery between 1990 and 2007, were retrospectively reviewed. A hundred patients (6.2%) were classified with pathological stage IV disease according to the seventh edition of the Union for International Cancer Control (UICC) staging system. There were 73 patients with MPD, which included 32 with effusion without nodules (MPE) and 41 with nodules with or without effusion (MPN). Intra- or postoperative pleural chemotherapy was administered to 37 MPD patients.

RESULTS

The median survival time, the 3-year survival rate and the 5-year survival rate for MPD patients were 25.9 months, 41.4%, and 23.7%, respectively, which are better outcomes than those for M1b patients (8.7 months, 18% and 18%, respectively) (log-lank test: p=0.014). Among MPD patients, N0-1 disease was determined to be a favorable prognostic factor (p=0.01). MPD status (MPE or MPN) was not prognostically significant (p=0.40). MPE patients with N0-1 disease had a significantly better prognosis with a 5-year survival rate of 63.6% compared to MPE patients with N2-3 disease (p=0.003). Twenty-seven percent of MPN patients with N0-1 disease achieved 5-year survival, whereas none of the MPD patients with N2-3 disease survived longer than 5 years after surgery.

CONCLUSIONS

The prognosis of patients with surgically detected MPD, who underwent resection, was better than that of M1b patients. MPE patients with N0-1 disease may be candidates for resection.

Surgery for metastatic pleural extension of non-small-cell lung cancer

OBJECTIVE

Malignant cells in the pleural fluid or pleural metastases are now classified stage IV in lung cancer and alter the treatment. Our purpose was to question the role of surgery in such patients.

METHODS

The clinical records of 4668 patients, who underwent lung cancer surgery, were reviewed. In some, an undiagnosed pleural malignant disease (M1a) was discovered during thoracotomy. When feasible, selected patients underwent complete surgical resection of the primary tumor and pleural nodules. We analyzed the epidemiology, pathology, and prognosis characteristics of that group (study group), as compared with the population undergoing pulmonary resection in a curative attempt (overall population) or exploratory thoracotomy in case of unexpected disseminated carcinomatous pleuritis (control group).

RESULTS

The study group included 32 patients (25 males), mean age 59 ± 8.8 years, who underwent pneumonectomy (n = 9) or lobectomy (n = 23), associated with mediastinal lymph nodes dissection and surgical resection of associated pleural nodules. There were 21 adenocarcinomas, seven squamous cell carcinomas, two undifferentiated large cell carcinomas, and two miscellaneous tumors. Pathological node (pN) was: N0 in 10 patients (31.3%), N1 in four (12.5%), and N2 in 18 (56.3%). Five-year survival rate was 16% after resection, and 21% if the resection was a lobectomy.

CONCLUSION

Complete surgical resection of non-small-cell lung cancer (NSCLC) associated with limited metastatic pleural involvement is associated with long-term survival in 16% of the cases. A review of the published data, together with the results of this series, may justify the inclusion of surgery in multimodality treatment of NSCLC patients with metastatic pleural extension.

Retrospective review of lung cancer patients with pleural dissemination after limited operations combined with parietal pleurectomy

BACKGROUND AND OBJECTIVES

The long-term control of malignant effusion is necessary to achieve long-term survival in lung cancer patients with carcinomatous pleuritis. This report describes our results of limited operations including parietal pleurectomy (pl) on a hypothesis that the most effective target area for controlling malignant pleural effusion is the parietal pleura.

METHODS

Forty-two patients with pleural dissemination with/without malignant pleural effusion were analyzed retrospectively. The operative procedures used were partial resection of the primary site with pl in 20 cases, segmentectomy with pl in 2 cases, lobectomy with pl in 19 cases, and pl only in 1 case. Postoperative adjuvant treatment was performed in 31 patients.

RESULTS

Adenocarcinoma was the dominant histology, and the pathological stages were IIIB in 34 cases and IV (intrapulmonary metastasis) in 8 cases. The overall 3-, 5-, and 10-year survival rates were 30.1%, 17.2%, and 10.3%, respectively. When stratified by the TNM classification, the overall 3-, 5-, and 10-year survival rates were 56.3%, 32.1%, and 24.1%, respectively, in the T4N0M0 group and 21.1%, 7.0%, and 0%, respectively, in the T4N1-2M0 group (P = 0.0257). Among the 24 patients whose recurrent patterns could be identified, only 2 patients developed recurrent malignant effusion.

CONCLUSIONS

With appropriate patient selection, the use of limited surgery combined with pl followed by intrapleural and systemic chemotherapy appears to be effective in management of the disease.

Enhancement of pleural dissemination and lymph node metastasis of intrathoracic lung cancer cells by vascular endothelial growth factors (VEGFs)

The expression of vascular endothelial growth factors (VEGFs) in tumors including lung cancer is considered to be associated with tumor development via capillary and lymph vessel neogenesis. Dissemination of the tumor cells to the pleura or regional lymph nodes is a critical poor prognostic factor for lung cancer patients. To investigate how VEGFs expressed in the intrathoracic infiltrating lung cancer cells participate in disease progression, we established stably VEGF-A-, VEGF-C-, VEGF-D-, VEGF-A and VEGF-C-, and VEGF-A and VEGF-D-expressing large cell lung cancer clones (TKB5/VEGF-A, TKB5/VEGF-C, TKB5/VEGF-D, TKB5/VEGF-A/C, and TKB5/VEGF-A/D), orthotopically inoculated these into the right thoracic cavity (i.t.) of nude mice, and evaluated the subsequent development of lung lesion, pleural effusion, pleural dissemination, and lymph node metastasis. While there were no significant differences either in culture or in subcutaneous tumor cell growth between the empty vector-transfected group (TKB5/empty) and each transfectant, the i.t. model demonstrated significantly different biological properties between the transfectants. TKB5/empty-inoculated mice frequently developed a large tumor on the pleura without pleural effusion, dissemination, or lymph node (LN) metastasis. In contrast, VEGF-A promoted a bloody pleural effusion (6/14), and VEGF-A and VEGF-D frequently generated pleural dissemination (11/14 and 9/11, respectively). Although both VEGF-C and VEGF-D generated LN metastasis (6/10 and 8/11, respectively), the locations of the metastasized LNs were quite different. TKB5/VEGF-C metastasized on the same side of axillary LNs as i.t. (right axillary LNs), whereas TKB5/VEGF-D metastasized to the mediastinal and left axillary and/or cervical LNs. Since the TKB5/VEGF-A/C or TKB5/VEGF-A/D co-transfectants revealed overlapping tumor progression patterns of VEGF-A and VEGF-C or VEGF-D, the metastatic LNs had abundant new capillaries and were larger than those of TKB5/VEGF-C or TKB5/VEGF-D-inoculated mice. Our results clearly demonstrate that VEGF-A secreted from intrathoracic lung cancer cells plays important roles in producing pleural effusion, dissemination, and capillary neogenesis, that VEGF-C is involved in LN metastasis, and VEGF-D in pleural dissemination and LN metastasis. It is most likely, however, that the mechanisms by which VEGF-C promotes LN metastasis are different from those of VEGF-D. The regulation of the expression of VEGFs in intrathoracic lung cancer cells might be a useful therapeutic approach to inhibiting tumor development and improving patient prognosis.