Prognostic significance of platelet and microvessel counts in operable non-small cell lung cancer

CD3, CD8, IFN-γ, tumor and stroma inflammatory cells as prognostic indicators for surgically resected SCLC: evidences from a 10-year retrospective study and immunohistochemical analysis

Current clinical guidelines limit surgical intervention to patients with cT1-2N0M0 small cell lung cancer (SCLC). Our objective was to reassess the role of surgery in SCLC management, and explore novel prognostic indicators for surgically resected SCLC. We reviewed all patients diagnosed with SCLC from January 2011 to April 2021 in our institution. Survival analysis was conducted using the Kaplan-Meier method, and independent prognostic factors were assessed through the Cox proportional hazard model. In addition, immunohistochemistry (IHC) staining was performed to evaluate the predictive value of selected indicators in the prognosis of surgically resected SCLC patients. In the study, 177 SCLC patients undergoing surgical resection were ultimately included. Both univariate and multivariate Cox analysis revealed that incomplete postoperative adjuvant therapy emerged as an independent risk factor for adverse prognosis (p < 0.001, HR 2.96). Survival analysis revealed significantly superior survival among pN0-1 patients compared to pN2 patients (p < 0.0001). No significant difference in postoperative survival was observed between pN1 and pN0 patients (p = 0.062). Patients with postoperative stable disease (SD) exhibited lower levels of tumor inflammatory cells (TIC) (p = 0.0047) and IFN-γ expression in both area and intensity (p < 0.0001 and 0.0091, respectively) compared to those with postoperative progressive disease (PD). Conversely, patients with postoperative SD showed elevated levels of stromal inflammatory cells (SIC) (p = 0.0453) and increased counts of CD3+ and CD8+ cells (p = 0.0262 and 0.0330, respectively). Survival analysis indicated that high levels of SIC, along with low levels of IFN-γ+ cell area within tumor tissue, may correlate positively with improved prognosis in surgically resected SCLC (p = 0.017 and 0.012, respectively). In conclusion, the present study revealed that the patients with pT1-2N1M0 staging were a potential subgroup of SCLC patients who may benefit from surgery. Complete postoperative adjuvant therapy remains an independent factor promoting a better prognosis for SCLC patients undergoing surgical resection. Moreover, CD3, CD8, IFN-γ, TIC, and SIC may serve as potential indicators for predicting the prognosis of surgically resected SCLC.

Pretreatment Platelet Count is a Prognostic Marker in Lung Cancer: A Danish Registry-based Cohort Study

BACKGROUND

Thrombocytosis has been associated with a poor prognosis in a wide range of malignancies. However, the results have been conflicting for lung cancer. Therefore, we evaluated the prognostic value of platelet count in a large cohort of lung cancer patients.

PATIENTS AND METHODS

All lung cancer patients diagnosed in The Central Denmark Region from 2009 to 2018 were included in the study. Data from the Danish Lung Cancer Registry were combined with data from the clinical laboratory information system on pretreatment platelet count. Platelet count was defined as low, normal, or high based on being below, within, or above the reference intervals. The prognostic value of platelet count was assessed by the Cox proportional hazard model. C-statistics were conducted to investigate if the platelet count added additional prognostic value to existing prognostic markers.

RESULTS

Totally, 6,758 patients with non-small-cell lung cancer (NSCLC) and 1150 patients with small-cell lung cancer (SCLC) were included. Low and high platelet count were significantly associated with decreased overall survival (OS) in NSCLC patients (low: adjusted hazard ratio (HR)=1.75 (95% confidence interval [CI]: 1.49-2.06); high: adjusted HR=1.24 (95% CI: 1.16-1.33)). In SCLC patients, only low platelet count was significantly associated with decreased OS (adjusted HR = 2.71 [95% CI: 2.02-3.65]). C-statistics showed that the prognostic models were significantly improved by the addition of platelet count for both NSCLC and SCLC patients (P < .0001).

CONCLUSION

Low and high platelet count were adverse prognostic factors in NSCLC patients, while only low platelet count was a prognostic marker in SCLC patients.

Prognostic significance of the combination of preoperative red cell distribution width and platelet distribution width in patients with gastric cancer

BACKGROUND

Platelet distribution width (PDW) and red cell distribution width (RDW) are readily obtainable data, and are reportedly useful as prognostic indicators in some cancers. However, their prognostic significance is unclear in gastric cancer (GC).

METHODS

We enrolled 445 patients with histopathological diagnoses of gastric adenocarcinoma who had undergone curative surgeries.

RESULTS

According to the optimal cut-off value of PDW and RDW by receiver operating characteristic (ROC) analysis, we divided patients into PDW^High (≥ 16.75%), PDW^Low (< 16.75%), RDW^High (≥ 14.25%), and RDW^Low (< 14.25%) subgroups. Overall survival (OS) was significantly worse in patients with PDW^High than in those with PDW^Low (P = 0.0015), as was disease specific survival (P = 0.043). OS was also significantly worse in patients with RDW^High than in those with RDW^Low (P <  0.0001), as was disease specific survival (P = 0.0002). Multivariate analysis for OS revealed that both PDW and RDW were independent prognostic indicators. Patients were then given PDW-RDW score by adding points for their different subgroups (1 point each for PDW^High and RDW^High; 0 points for PDW^Low and RDW^Low). OS significantly differed by PDW-RDW score (P <  0.0001), as did disease specific survival (P = 0.0005). In multivariate analysis for OS, PDW-RDW score was found to be an independent prognostic indicator.

CONCLUSIONS

The prognosis of GC patients can be precisely predictable by using both PDW and RDW.

Prognostic significance of thrombocytosis in lung cancer: a systematic review and meta-analysis

A potential relationship between poor prognosis and thrombocytosis has been suggested by previous studies in lung cancer, but the conclusions continued to be controversial. Here, we performed a meta-analysis to explore the prognostic impact of thrombocytosis in lung cancer. The Cochrane Library, EMBASE and PubMed databases were comprehensively and systematically retrieved from establishment to May 5, 2020. Pooled hazard ratios (HRs) with 95% confidence intervals (CIs) were applied to evaluate overall effects. Heterogeneity was assessed using I² statistics and Cochran's Q test. Sensitivity and subgroup analyses were performed to analyze the sources of heterogeneity. Publication bias was examined using the Egger's test and pooled HR was regulated using the trim-and-fill approach when publication bias was observed. A total of 37 studies including 14,833 patients were enrolled in the meta-analysis. Thrombocytosis was significantly correlated to poor overall survival (HR 1.033; 95% CI 1.017-1.050), disease-free survival (HR 1.568; 95% CI 1.276-1.928), and progression-free survival (HR 1.653; 95% CI 1.069-2.556). Although publication bias was identified, rectification for this bias using the trim-and-fill approach did not change the combined HR substantially. In conclusion, this meta-analysis result suggested that thrombocytosis is a predictor of poor prognosis in lung cancer.

Prognostic value of pretreatment platelet counts in lung cancer: a systematic review and meta-analysis

Background

The prognostic value of elevated pretreatment platelet counts remains controversial in lung cancer patients. We performed the present meta-analysis to determine its precise role in these patients.

Methods

We employed a multiple search strategy in the PubMed, EMBASE and Cochrane Library databases to identify eligible studies. Disease-free survival (DFS)/progression-free survival (PFS)/time to progression (TTP) and overall survival (OS) were used as outcomes with hazard ratios (HRs) and 95% confidence intervals (CIs). Heterogeneity among the studies and publication bias were also evaluated.

Results

A total of 40 studies including 16,696 lung cancer patients were eligible for the analysis. Overall, the pooled analysis showed that compared with normal platelet counts, elevated pretreatment platelet counts were associated with poorer OS (HR = 1.54, 95% CI: 1.37–1.72, P < 0.001) and poorer DFS/PFS/TTP (HR = 1.62, 95% CI: 1.33–1.98, P < 0.001) in patients with lung cancer. In subgroup analyses, elevated pretreatment platelet counts were also associated with poorer OS and DFS/PFS/TTP in most subgroups. There was no evidence of publication bias.

Conclusions

This meta-analysis revealed that elevated pretreatment platelet counts were an independent predictor of OS and DFS/PFS/TTP in lung cancer patients. Large-scale prospective studies and a validation study are warranted.

Presence of intra-tumoral CD61+ megakaryocytes predicts poor prognosis in non-small cell lung cancer

Background

Lung is a reservoir for megakaryocytes (MKs). The relationship between intra-tumoral MKs and non-small cell lung cancer (NSCLC) is unknown. We investigate relationship between high intra-tumoral MKs with the recurrence of NSCLC.

Methods

The tissue sections of 629 patients with resected NSCLC were stained with hematoxylin, anti-CD61, anti-CD34 and stromal cell-derived factor-1 (SDF-1). CD61+ giant cells localized in CD34+ capillaries were identified as MKs. The impact of MKs and preoperative platelet count on disease-free survival (DFS) was investigated.

Results

Overall, 18.9% of patients were positive for the presence of MKs. In univariate analysis, the median DFS of the MK+ group was shorter than the median DFS of the MK- group (69.1 vs. 80.5 months; P=0.021). Multivariate analysis indicated that MKs in tumor tissue was an unfavorable prognostic factor for DFS (HR 1.351, P=0.065), the impact of which was more significant in non-squamous cell carcinoma (NSCC) (HR 1.710, P=0.008) and in patients with N0 (HR 1.883, P=0.009). Although systemic platelet count of the MK+ group was significantly higher than the MK- group (270.6×10⁹ vs. 243.6×10⁹/L, P=0.007), the stratified subgroup DFS curves (P=0.003) showed that the effect of MKs on prognosis was independent of the blood platelet count.

Conclusions

Our results demonstrate that CD61+ MKs in tumor tissue predict unfavorable prognosis in NSCLC.

Clinical significance of cancer-associated fibroblasts and their correlation with microvessel and lymphatic vessel density in lung adenocarcinoma

Background

To determine whether cancer‐associated fibroblasts (CAFs) are associated with microvessel density (MVD) and lymphatic vessel density (LVD) in lung adenocarcinoma (ADC) or are not prognostic.

Methods

Ninety‐three lung adenocarcinoma patients without adjuvant therapy between January 2010 and June 2011 were enrolled. CAFs, MVD, and LVD were identified by α‐smooth muscle actin (α‐SMA), CD34 and D2‐40 staining via immunohistochemistry. Staining intensities were assessed and quantified. For statistics, Pearson's chi‐square test, logistic regression, Kaplan‐Meier, and log‐rank tests were applied. In addition, the Cox proportional hazards model was used for multifactor analysis to predict survival.

Results

CAFs abundance in lung adenocarcinoma is associated with higher MVD and LVD. In addition, a correlation was demonstrated between MVD and LVD (P < 0.05). CAFs, MVD, and LVD are significantly correlating with age, tumor size, differentiation grade, clinical stage, and lymph node metastasis (P < 0.05), but not influenced by gender, tumor location, and smoking history. Three‐year overall survival in the CAFs‐poor group is 64.5%, which is significant higher than that in the CAFs‐rich cohort (41.9%). Further, we found that age, clinical stage, α‐SMA, CD34, D2‐40 positivity, tumor size, differentiation grade, and lymph node metastasis significantly correlate with overall survival of patients with lung adenocarcinoma. However, sex, smoking history, and tumor location have no association with 3‐year survival. The clinical stage is an independent prognostic factor in overall survival (P < 0.05).

Conclusions

The density of CAFs identified by α‐SMA staining is associated with progression and metastasis of lung adenocarcinoma and affects the patient's disease outcome.

Integrative nomogram of CT imaging, clinical, and hematological features for survival prediction of patients with locally advanced non-small cell lung cancer

OBJECTIVES

To determine the integrative value of clinical, hematological, and computed tomography (CT) radiomic features in survival prediction for locally advanced non-small cell lung cancer (LA-NSCLC) patients.

METHODS

Radiomic features and clinical and hematological features of 118 LA-NSCLC cases were firstly extracted and analyzed in this study. Then, stable and prognostic radiomic features were automatically selected using the consensus clustering method with either Cox proportional hazard (CPH) model or random survival forest (RSF) analysis. Predictive radiomic, clinical, and hematological parameters were subsequently fitted into a final prognostic model using both the CPH model and the RSF model. A multimodality nomogram was then established from the fitting model and was cross-validated. Finally, calibration curves were generated with the predicted versus actual survival status.

RESULTS

Radiomic features selected by clustering combined with CPH were found to be more predictive, with a C-index of 0.699 in comparison to 0.648 by clustering combined with RSF. Based on multivariate CPH model, our integrative nomogram achieved a C-index of 0.792 and retained 0.743 in the cross-validation analysis, outperforming radiomic, clinical, or hematological model alone. The calibration curve showed agreement between predicted and actual values for the 1-year and 2-year survival prediction. Interestingly, the selected important radiomic features were significantly correlated with levels of platelet, platelet/lymphocyte ratio (PLR), and lymphocyte/monocyte ratio (LMR) (p values all < 0.05).

CONCLUSIONS

The integrative nomogram incorporated CT radiomic, clinical, and hematological features improved survival prediction in LA-NSCLC patients, which would offer a feasible and practical reference for individualized management of these patients.

KEY POINTS

• An integrative nomogram incorporated CT radiomic, clinical, and hematological features was constructed and cross-validated to predict prognosis of LA-NSCLC patients. • The integrative nomogram outperformed radiomic, clinical, or hematological model alone. • This nomogram has value to permit non-invasive, comprehensive, and dynamical evaluation of the phenotypes of LA-NSCLC and can provide a feasible and practical reference for individualized management of LA-NSCLC patients.

The Position of Neutrophils-To-Lymphocytes and Lymphocytes-To-Platelets Ratio as Predictive Markers of Progression and Prognosis in Patients with Non-Small Cell Lung Cancer

BACKGROUND

Non-small cell lung cancer (NSCLC) is an insidious metastasis condition of the lungs often presenting no symptoms at the onset. Defining markers for quick determination of prognosis is essential for building up a treatment strategy.

AIM

The aim of this study is to define the role of the Neutrophils-to-Lymphocytes ratio (NLR) and Platelets-to- Lymphocytes ratio (PLR) as biomarkers in patients with NSCLC, according to the stage and prognosis of the disease.

METHODS

We investigated 20 patients with NSCLC. NLR and PLR are calculated and are evaluated according to the presence or absence of metastasis, stage of the disease, histological type and survival rate.

RESULTS

We found that thirteen of the patients had low NLR, while the rest 7 had high NLR (mean 3.15). By analysing PLR we found that 11 patients have low and 9 have high level of PLR (mean 1.42). After the correlations have been made we discovered that in 90.1% of the patients with low PLR no lymph metastasises were detected, while in 50% of the patients with high PLR lymph metastasises were observed (χ2 = 3.99; P = 0.046). We also discovered that in 84.6% of the patients with low NLR lymph metastases were absent, while in 42.9% with high NLR lymph metastasises were present (χ 2 = 1.83; P = 0.176).

CONCLUSION

In conclusion, NLR and PLR were discovered as prominent biomarkers which provide relatively fast determination for prognosis in patients with NSCLC.

Flattened microvessel independently predicts poor prognosis of patients with non-small cell lung cancer

Angiogenesis plays an essential role in improving tumor progression, whereas, its value in prognosis predicting remains controversial, especially in non-small cell lung cancer (NSCLC). Most recently, microvessel pattern has been raised as a novel prognosis factor. In this study, flattened microvessel, evaluated by tumor microvessel aspect ratio (TMAR), was conducted as a prognostic factor in NSCLC patients. A total of 100 patients with NSCLC were retrospectively reviewed. Microvessel in tumor was visualized by immunochemistry staining and then TMAR was determined. The prognostic role of TMAR was evaluated by univariate and multivariate analysis. Most of intratumor microvessels were flattened with a median TMAR of 3.65 (range, 2.43 - 6.28). Patients were stratified into high TMAR group (TMAR ≥ 3.6) and low TMAR group (TMAR < 3.6). Compared with subpopulation with low TMAR, high TMAR had significantly high risk of cancer-related death (univariate analysis: HR = 5.06, 95% CI: 2.44-10.47, p<0.001; multivariate analysis: HR = 4.53, 95% CI: 1.70-12.06, p=0.002).

In conclusion, the results of our study demonstrate that flattened microvessel in tumor tissue is a promising prognosis predictor of NSCLC patients.

Vascular Endothelial Growth Factor Levels in Serum and Plasma following Esophageal Cancer Resection - Relationship to Platelet Count

In patients with cancer circulating vascular endothelial growth factor (VEGF) may be tumor-derived and have prognostic significance. Activated platelets may also be a source of VEGF, releasing it in serum formation. Debate exists as to whether serum or plasma VEGF (S-VEGF, P-VEGF) is the most appropriate surrogate marker of tumor angiogenesis. As healing wounds produce VEGF that can spill over into the circulation, we aimed to investigate the potential confounding effects of cancer surgery on both perioperative S-VEGF and P-VEGF levels and to evaluate their relationship with platelet count. S-VEGF, P-VEGF and platelet counts were measured in 23 patients undergoing esophageal cancer resection. Samples were taken preoperatively and six weeks following surgery. Seven patients were also sampled on postoperative days 1, 5 and 10. VEGF was assayed using a commercial enzyme linked immunosorbent assay. S-VEGF and P-VEGF both rose after surgery (S-VEGF; day 5: 1017 [446–1224] pg/mL and day 10: 1231 [626–2046] pg/mL versus pre-op: 329 [189–599] pg/mL. P-VEGF; day 1: 55 [46–104] pg/mL and day 10: 58 [20–154] pg/mL versus pre-op: 23 [13–46] pg/mL), falling towards pre-operative levels by six weeks. Platelet count correlated with S-VEGF (rho=0.281; p<0.05, Spearman's rank) and P-VEGF (rho=0.330; p<0.01, Spearman's rank). Platelets may contribute to VEGF levels in plasma as well as in serum. The effects of surgery on S-VEGF or P-VEGF levels are mainly transient. Care must be exercised when interpreting circulating VEGF levels in the early postoperative period.

Elevated pretreatment neutrophil/white blood cell ratio and monocyte/lymphocyte ratio predict poor survival in patients with curatively resected non-small cell lung cancer: Results from a large cohort

Background

The prognostic values of preoperative neutrophil/lymphocyte ratio (NLR), monocyte/lymphocyte ratio (MLR), and platelet/lymphocyte ratio (PLR) in non‐small cell lung cancer (NSCLC) have been previously described. This study assessed the prognostic values of other pretreatment complete blood cell parameters in Chinese patients with curatively resected NSCLC.

Methods

A total of 1466 consecutive NSCLC patients who received curative surgery from January 1, 2005 to December 31, 2009 with complete data from pretreatment blood tests were enrolled in this retrospective study. Correlations between each blood test parameter and overall survival were examined by Kaplan–Meier method or Cox proportional hazards regression, followed by a stratification analysis of significant variables.

Results

Optimal cut‐off values of 0.55 for neutrophil/white blood cell ratio (NWR), 0.28 for lymphocyte/white blood cell ratio (LWR), 0.09 for monocyte/white blood cell ratio (MWR), 2.06 for NLR, 0.35 for MLR, 204.00 for PLR, and 38.25 for platelet/white blood cell ratio (PWR) were identified using X‐tile software. Univariate analysis suggested that NWR ≥ 0.55, LWR < 0.28, MWR ≥ 0.09, NLR ≥ 2.06, MLR ≥ 0.35, and PLR ≥ 204.00 predicted a poor prognosis in NSCLC patients. However, only NWR and MLR were identified as independent significant prognostic factors in multivariable analysis, especially in tumor node metastasis stage I and I/II/III NSCLCs.

Conclusion

Pretreatment NWR, MWR, LWR, NLR, MLR, and PLR values are associated with poor overall survival for patients with curatively resected NSCLC. NWR and MLR are independent prognostic factors in curatively resected NSCLC.

NEUTROPHIL/LYMPHOCYTE RATIO AND PLATELET/LYMPHOCYTE RATIO IN PATIENTS WITH NSCLC

OBJECTIVE

to compare neutrophil/lymphocyte ratio (NLR) and platelet/lymphocyte ratio (PLR) in patients with NSCLC (Non- Small- Cell Lung Cancer): with and without metastases at the time of diagnosis to find out if there is the importance of these cell ratios in the assessment of severity NSCLC.

MATERIAL AND METHODS

this is the retrospective analysis of NRL and PRL in patients with NSCLC at the time of the diagnosis of disease before any anti tumor treatment (chemotherapy, radiotherapy, surgery). 57 of patients with NSCLC treated in the first three months of 2016. year were chosen at random regardless of sex and age. We examined full blood count cells (FBC), calculated NLR and PLR in every patient and compared obtained values in patients with and patients without metastases.

RESULTS

In 57 patients with NSCLC there were 15 males with metastases, 28 without metastases, and 8 females with metastases, 6 without metastases. Since there was no regularity in the distribution of obtained values of NLR and PLR we made the Mann-Whitney U test. Mean values are presented with a median and interquartile percentiles. There was no significant difference in NLR between patients without and with metastases (p = 0.614; p = NS) as well as in PLR (p=0,068; p=NS).

CONCLUSION

There must be a link between the immune status of the organism and lung cancer development. Immune cells have become of interest in recent years and much work has been done to study their role in the genesis of cancer but it did not give satisfactory results. Further clinical studies on large number of patients and further laboratory examination of the role of immune cells in cancer development and suppression are required.

X-ray phase contrast with injected gas for tumor microangiography

We show that the microvasculature of mouse tumors can be visualized using propagation-based phase-contrast x-ray imaging with gas as the contrast agent. The large density difference over the gas-tissue interface provides high contrast, allowing the imaging of small-diameter blood vessels with relatively short exposure times and low dose using a compact liquid-metal-jet x-ray source. The method investigated is applied to tumors (E1A/Ras-transformed mouse embryonic fibroblasts) grown in mouse ears, demonstrating sub-15-µm-diameter imaging of their blood vessels. The exposure time for a 2D projection image is a few seconds and a full tomographic 3D map takes some minutes. The method relies on the strength of the vasculature to withstand the gas pressure. Given that tumor vessels are known to be more fragile than normal vessels, we investigate the tolerance of the vasculature of 12 tumors to gas injection and find that a majority withstand 200 mbar pressures, enough to fill 12-µm-diameter vessels with gas. A comparison of the elasticity of tumorous and non-tumorous vessels supports the assumption of tumor vessels being more fragile. Finally, we conclude that the method has the potential to be extended to the imaging of 15 µm vessels in thick tissue, including mouse imaging, making it of interest for, e.g., angiogenesis research.

Platelet count predicts prognosis in operable non-small cell lung cancer

Platelets play a significant role in cancer cell growth, progression and metastasis. However, in non-small cell lung cancer (NSCLC), the association between a patient's platelet count and prognosis has not previously been fully elucidated. The aim of the present study was to investigate the correlation between platelet count, patients' characteristics and prognosis in patients with NSCLC. A total of 510 NSCLC patients were enrolled in the present study. The median platelet count in the NSCLC patients was 203×10⁹/l (95% CI, 115-358×10⁹/l). The median platelet count in T3 and T4 patients was significantly higher than that of T1 and T2 patients (median, 263×10⁹/l and 253.5×10⁹/l vs. 199.5×10⁹/l and 196.5×10⁹/l, respectively; P<0.001). The 3-year cumulative overall survival (OS) probability was 75.3% for patients with normal platelet counts and 59.2% for patients with elevated platelet counts. When compared with the patients with normal platelet counts, the patients with elevated platelet counts had an increased risk of disease progression (HR, 1.568; 95% CI, 1.015-2.453). Pre-operative platelet counts are a novel independent prognostic biomarker in operable NSCLC.

Phosphodiesterase-4 promotes proliferation and angiogenesis of lung cancer by crosstalk with HIF

Lung cancer is the leading cause of cancer death worldwide. Recent data suggest that cyclic nucleotide phosphodiesterases (PDEs) are relevant in various cancer pathologies. Pathophysiological role of phosphodiesterase 4 (PDE4) with possible therapeutic prospects in lung cancer was investigated. We exposed 10 different lung cancer cell lines (adenocarcinoma, squamous and large cell carcinoma) to hypoxia and assessed expression and activity of PDE4 by real-time PCR, immunocytochemistry, western blotting and PDE activity assays. Expression and activity of distinct PDE4 isoforms (PDE4A and PDE4D) increased in response to hypoxia in eight of the studied cell lines. Furthermore, we analyzed various in silico predicted hypoxia-responsive elements (p-HREs) found in in PDE4A and PDE4D genes. Performing mutation analysis of the p-HRE in luciferase reporter constructs, we identified four functional HRE sites in the PDE4A gene and two functional HRE sites in the PDE4D gene that mediated hypoxic induction of the reporter. Silencing of hypoxia-inducible factor subunits (HIF1α and HIF2α) by small interfering RNA reduced hypoxic induction of PDE4A and PDE4D. Vice versa, using a PDE4 inhibitor (PDE4i) as a cyclic adenosine monophosphate (cAMP) -elevating agent, cAMP analogs or protein kinase A (PKA)-modulating drugs and an exchange protein directly activated by cAMP (EPAC) activator, we demonstrated that PDE4-cAMP-PKA/EPAC axis enhanced HIF signaling as measured by HRE reporter gene assay, HIF and HIF target genes expression ((lactate dehydrogenase A), LDHA, (pyruvate dehydrogenase kinase 1) PDK1 and (vascular endothelial growth factor A) VEGFA). Notably, inhibition of PDE4 by PDE4i or silencing of PDE4A and PDE4D reduced human lung tumor cell proliferation and colony formation. On the other hand, overexpression of PDE4A or PDE4D increased human lung cancer proliferation. Moreover, PDE4i treatment reduced hypoxia-induced VEGF secretion in human cells. In vivo, PDE4i inhibited tumor xenograft growth in nude mice by attenuating proliferation and angiogenesis. Our findings suggest that PDE4 is expressed in lung cancer, crosstalks with HIF signaling and promotes lung cancer progression. Thus, PDE4 may represent a therapeutic target for lung cancer therapy.

Tumor-platelet interaction in solid tumors

Elevated platelet counts in patients diagnosed with malignant tumors were first described more than 100 years ago. Today it is well known that in many types of solid tumors, thrombocytosis at the time of diagnosis is associated with shorter survival. From this well-documented clinical correlation between platelet count and prognosis of solid tumors, the following questions arise: (i) Are the increased platelet counts the reason for shortened survival as platelet-secreted cytokines might boost tumor growth and angiogenesis? (ii) Do platelets affect tumor metastasis thereby shortening survival time? or (iii) Are increased platelet counts simply an epiphenomenon of tumor growth with larger tumors resulting in higher platelet counts and shorter survival times? We address these three questions within our review of the current literature to provide a comprehensive overview of the current concepts in tumor-platelet interaction.

Prospective evaluation of angiogenic, hypoxic and EGFR-related biomarkers in recurrent glioblastoma multiforme treated with cetuximab, bevacizumab and irinotecan

Several recent studies have demonstrated a beneficial effect of anti-angiogenic treatment with the vascular endothelial growth factor-neutralizing antibody bevacizumab in recurrent high-grade glioma. In the current study, immunohistochemical evaluation of biomarkers involved in angiogenesis, hypoxia and mediators of the epidermal growth factor receptor (EGFR) pathway were investigated. Tumor tissue was obtained from a previous phase II study, treating recurrent primary glioblastoma multiforme (GBM) patients with the EGFR inhibitor cetuximab in combination with bevacizumab and irinotecan. Of the 37 patients with available tumor tissue, 29 were evaluable for response. We concurrently performed immunohistochemical stainings on tumor tissue from 21 GBM patients treated with bevacizumab and irinotecan. We found a tendency of correlation between the hypoxia-related markers, indicating that they share the same regulatory mechanisms. None of the EGFR-related biomarkers showed any significant correlations with each other. None of the biomarkers tested alone or in combination could identify a patient population likely to benefit from bevacizumab and irinotecan, with or without the addition of cetuximab. There is still an urgent need for one or more reliable and reproducible biomarkers able to predict the efficacy of anti-angiogenic therapy.

Platelet indices in patients with colorectal cancer

The interaction between cancer cells and platelets has been known for a long time. Although platelet indices have been also investigated in several clinical settings, it has not been exactly demonstrated in cancer patients. We investigated platelet indices in colorectal cancer patients and compared with healthy subjects. Two hundred and twenty-one colorectal cancer patients and 110 healthy subjects were enrolled into the retrospective study. Data were obtained from computerized medical records of our hospital. Medical record review was performed for all patients regarding thrombocyte indices. Platelet count (325.000/mm3 ± 265.000/mm3 vs 267.000/mm3 ± 67.000/mm3; p=0.025; respectively) and plateletcrit (Pct) (0.25% ± 0.10 vs 0.21 ± 0.05; p<0.001; respectively) were increased in patients compared with healthy subjects while mean platelet volume (MPV) and platelet distribution width (PDW) were similar. The platelet indices were not related to existence of metastasis or acute abdomen. Platelet count and Pct, but not MPV and PDW, are elevated in colorectal cancer patients. Future studies that investigate platelet morphology, function, and putative role of platelets in tumorigenesis and metatasis should be established.

Pentastatin-1, a collagen IV derived 20-mer peptide, suppresses tumor growth in a small cell lung cancer xenograft model

Background

Angiogenesis is the formation of neovasculature from a pre-existing vascular network. Progression of solid tumors including lung cancer is angiogenesis-dependent. We previously introduced a bioinformatics-based methodology to identify endogenous anti-angiogenic peptide sequences, and validated these predictions in vitro in human umbilical vein endothelial cell (HUVEC) proliferation and migration assays.

Methods

One family of peptides with high activity is derived from the α-fibrils of type IV collagen. Based on the results from the in vitro screening, we have evaluated the ability of a 20 amino acid peptide derived from the α5 fibril of type IV collagen, pentastatin-1, to suppress vessel growth in an angioreactor-based directed in vivo angiogenesis assay (DIVAA). In addition, pentastatin-1 suppressed tumor growth with intraperitoneal peptide administration in a small cell lung cancer (SCLC) xenograft model in nude mice using the NCI-H82 human cancer cell line.

Results

Pentastatin-1 decreased the invasion of vessels into angioreactors in vivo in a dose dependent manner. The peptide also decreased the rate of tumor growth and microvascular density in vivo in a small cell lung cancer xenograft model.

Conclusions

The peptide treatment significantly decreased the invasion of microvessels in angioreactors and the rate of tumor growth in the xenograft model, indicating potential treatment for angiogenesis-dependent disease, and for translational development as a therapeutic agent for lung cancer.

Evaluation of angiogenesis using micro-computed tomography in a xenograft mouse model of lung cancer

Quantitative evaluation of lung tumor angiogenesis using immunohistochemical techniques has been limited by difficulties in generating reproducible data. To analyze intrapulmonary tumor angiogenesis, we used high-resolution micro-computed tomography (micro-CT) of lung tumors of mice inoculated with mouse Lewis lung carcinoma (LLC1) or human adenocarcinoma (A549) cell lines. The lung vasculature was filled with the radiopaque silicone rubber, Microfil, through the jugular vein (in vivo application) or pulmonary artery (ex vivo application). In addition, human adenocarcinoma lung tumor-bearing mice treated site-specifically with humanized monoclonal antibody (bevacizumab) against vascular endothelial growth factor. Quantitative analysis of lung tumor microvessels imaged with micro-CT showed that more vessels (mainly small, <0.02 mm(2)) were filled using the in vivo (5.4%) compared with the ex vivo (2.1%) method. Furthermore, bevacizumab-treated lung tumor-bearing mice showed significantly reduced lung tumor volume and lung tumor angiogenesis compared with untreated mice as assessed by micro-CT. Interestingly, microvascularization of mainly the smaller vessels (<0.02 mm(2)) was reduced after bevacizumab treatment. This observation with micro-CT was nicely correlated with immunohistochemical measurement of microvessels. Therefore, micro-CT is a novel method for investigating lung tumor angiogenesis, and this might be considered as an additional complementary tool for precise quantification of angiogenesis.

Thrombospondin 1 expression and angiogenesis in breast carcinoma and their relation with platelet activity

This study investigates angiogenesis and the expression of thrombospondin 1 in invasive ductal carcinoma of the breast and their possible relation to platelet counts and platelet activity. The study included 20 cases of invasive ductal carcinoma. Platelet activity was evaluated by determining thromboxane B2 and cyclic guanosine monophosphate (cGMP) levels by enzyme immunoassay (EIA).Thrombospondin (TSP) 1 and CD34 expression was studied immunohistochemically. Mean platelet count of the patient group was significantly greater than the mean platelet count of the control group (P < 0.05). The platelet counts were positively correlated with tumour size (r=0.609; P < 0.01). Platelet counts were higher in the patients who had grade 3 microvessel density (P < 0.05). The mean basal platelet cGMP level in the patient group was significantly lower than it was in the control group (P < 0.05). Focal TSP immunoreactivity was detectable in 5 (20%) cases in the tumour cells, and in 9 (45%) cases in the stroma. We did not find any correlation between TSP-1 staining and angiogenesis, platelet counts, platelet activity, and the histological prognostic parameters. Our study confirms the essential role of platelets in tumour growth and angiogenesis. Decreased levels of cGMP in the patient group may cause platelet hyperreactivity. Although thrombospondin 1 may be upregulated in malignant breast tissue, this is not sufficient for tumour growth and dissemination according to our results.

Microvessel density as a prognostic factor in non-small-cell lung carcinoma: a meta-analysis of individual patient data

BACKGROUND

Angiogenesis is a potential prognostic factor that has been investigated in patients with non-small-cell lung carcinoma. However, published studies of the role of angiogenesis as a prognostic factor are inconclusive. We aimed to collect individual patient data to assess microvessel-density counts (ie, a measure of angiogenesis) as a prognostic factor in non-small-cell lung carcinoma.

METHODS

We obtained published and unpublished datasets and extracted appropriate data, taking particular care to ensure data quality. Detailed information was obtained for the laboratory methods used by every research centre that generated the data. The outcome of interest was overall survival. We did a meta-analysis to estimate the prognostic role of microvessel density by combining separately estimated hazard ratios (HR) from every study, which were adjusted for tumour stage and age. Analyses were done separately for studies that used the Chalkley method or for those that counted all microvessels.

FINDINGS

17 centres provided data for 3200 patients, 2719 of which were included in the analysis. All but three centres (datasets 9, 10, and 13-367 cases) had already published their findings, and six had updated follow-up information (datasets 1, 2, 3, 6, 7, and 8-1273 cases). For all but three centres (datasets 4, 11, and 13) some data corrections were necessary. For microvessel density counts obtained by the Chalkley method, the HR for death per extra microvessel was 1.05 (95% CI 1.01-1.09, p=0.03) when analysed as a continuous variable. For microvessel density counts obtained by the all vessels method, the HR for death per ten extra microvessels was 1.03 (0.97-1.09, p=0.3) when analysed as a continuous variable.

INTERPRETATION

Microvessel density does not seem to be a prognostic factor in patients with non-metastatic surgically treated non-small-cell lung carcinoma. This conclusion contradicts the results of a meta-analysis of published data only. Therefore, the methodology used to assess prognostic factors should be assessed carefully.

Molecular markers (PECAM-1, ICAM-3, HLA-DR) determine prognosis in primary non-Hodgkin's gastric lymphoma patients

AIM

To investigate the prognostic significance of PECAM-1, ICAM-3 and HLA-DR antigens in patients with primary non-Hodgkin's gastric lymphoma.

METHODS

We immunohistochemically studied PECAM-1, ICAM-3 and HLA-DR antigen expression in 36 B-cell MALT-type primary gastric lymphoma patients. Ten non-malignant and ten healthy gastric tissue specimens were used as controls. Clinicopathological and survival data were correlated with the staining results.

RESULTS

HLA-DR antigen expression was detected in 33 gastric lymphoma patients (91.7%) and 6 non-malignant patients (54.5%). PECAM-1 stained tumor cells of 10 patients (27.8%), endothelial cells of 9 patients (25%) and inflammatory infiltrate of 4 patients (40%) with benign gastric disease. ICAM-3 expression was observed on the tumor cells of 17 patients (47.2%), while 5 non-malignant patients (50%) were stained positive as well. None of the healthy controls was stained for any of the genes studied. In the multivariate analysis, HLA-DR antigen and PECAM-1 were proved to be statistically significant independent prognostic factors associated with a favourable and an unfavourable prognosis respectively (P=0.009 and P=0.003). In the univariate analysis, PECAM-1(+)/ICAM-3(-) and HLA-DR(-)/ICAM-3(-) patients exhibited a significantly decreased overall survival compared to those with the exactly opposite gene expression patterns (P=0.0041 and P=0.0091, respectively). Those patients who were HLA-DR(+)/ICAM-3(+)/PECAM-1(-) (n=8) had a significantly higher survival rate compared to the rest of the group (n=24) (P=0.0289).

CONCLUSION

PECAM-1, ICAM-3 and HLA-DR are representative markers of tumor expansion potential and host immune surveillance respectively. Their combined use may help us to identify high-risk patients who could benefit from more aggressive therapeutic protocols.

Targeting Angiogenesis in Lung Cancer

The prognosis for the majority of patients with lung cancer remains poor, and treatment strategies including newer generation chemotherapeutics have not improved survival. New approaches are required to further improve patient outcome and survival. Recently, key molecules involved in signal transduction pathways that contribute to tumor growth have been identified as therapeutic targets, particularly molecules involved in cellular proliferation and angiogenesis. Novel therapeutics that specifically target angiogenesis have shown promise as single agents and in combination with standard chemotherapy. The results of recent studies validate the use of this class of targeted therapeutics as an important new treatment modality in cancer therapy. This review will focus on a discussion of antiangiogenic therapeutic monoclonal antibodies in development for the treatment of non-small cell lung cancer.

Angiogenesis and lung cancer: prognostic and therapeutic implications

Lung cancer is the most common cause of cancer death worldwide, with most patients dying with metastatic disease. The prognosis for the majority of patients remains poor. It is evident that advances in the treatment of this and other tumor types will require new approaches, and recent research has focused on molecular-targeted therapies. A key therapeutic strategy is inhibition of specific processes essential for tumor vascular development (a concept known to be beneficial in colorectal cancer) and a range of such antiangiogenic agents are currently in development. The most promising of these target the proangiogenic vascular endothelial growth factor (VEGF), either by preventing VEGF-receptor binding or inhibiting downstream receptor signaling. However, other more direct approaches against tumor vasculature are also in development. Since antiangiogenic agents often exert an indirect, cytostatic effect, many are being evaluated in combination with conventional chemotherapies in order to optimize the anticancer effects of both strategies. Additionally, the combination of several antiangiogenic agents is also being explored. This has become possible given the large number of agents currently available. As part of this evaluation process, the assessment of surrogate markers of target inhibition and treatment effect is ongoing in the hope of identifying reliable surrogate markers to aid the development of this new generation of anticancer agents.

Increased preoperative platelet count is associated with decreased survival after resection for adenocarcinoma of the pancreas

BACKGROUND

Platelets are thought to participate in tumor metastasis. However, the relationship between platelet count and prognosis in pancreatic cancer remains unresolved.

METHODS

A chart review of patients undergoing resection for pancreatic adenocarcinoma was undertaken. Demographic, perioperative, and outcome data were collected. Kaplan-Meier survival and Cox regression analyses were used to determine the impact of preoperative platelet count on survival.

RESULTS

Between June 1995 and March 2003, 109 patients (63% male) with a median age of 68 years (range 42 to 85 years) underwent resection for pancreatic cancer. Univariate analysis demonstrated that platelet count, lymph node or margin status, and histology were associated with survival. In multivariate analysis, the association between increased platelet count and poor survival maintained significance.

CONCLUSIONS

Increased preoperative platelet count is associated with adverse survival outcome in patients undergoing resection for pancreatic cancer. Antiplatelet medications warrant further study in an attempt to improve survival in these patients.

Novel targeted agents in the treatment of lung cancer

Lung cancer is the leading cause of cancer-related mortality in the US. Although an improvement in outcome is possible with the continued advancement of cytotoxic-based treatment, clinical research is currently focused on utilising novel molecular targets with proven efficacy in preclinical models and a low toxicity profile. This is the result of advances in understanding of tumour biology and molecular pathways that have been implicated in cancer pathogenesis and progression. Novel agents targeting cell cycle regulation, angiogenesis and signal transduction pathways have reached clinical testing in lung cancer and are discussed in this review.

A Three-dimensional Analysis of Blood Vessels in Bronchioloalveolar Carcinoma

The three-dimensional architecture of blood vessels within lung adenocarcinomas has not been well studied. In 19 cases with bronchioloalveolar carcinoma with central fibrosis, we three-dimensionally examined blood vessel architecture in 150 microm thick sections stained with elastin staining and anti-CD34 antibody. We examined four regions: normal alveoli and three regions within the tumor including an area adjacent to the normal alveoli (external area), an area in which tumor cells were replacing epithelial cells (replacement area), and a central fibrotic area (fibrotic area). Elastin staining showed that elastic fibers formed the framework of the alveoli, and the alveolar structure shrank more strongly to the center of the tumor due to folding of alveolar walls invaded by adenocarcinoma cells. We also measured three vessel parameters in these four regions. The vessel diameters were 4.08+/-1.10 microm, 3.95+/-1.02 microm, 5.04+/-1.56 microm, and 6.11+/-2.23 microm, the circumferences of those vessels seen as complete circles were 43.11+/-12.78 microm, 43.71+/-12.87 microm, 95.21+/-39.32 microm, and 126.77+/-54.65 microm; the lengths between vessel bifurcations were 13.28+/-3.08 microm, 13.47+/-4.58 microm, 24.91+/-9.66 microm, and 41.82+/-28.08 microm in the normal alveoli, and the external, replacement, and fibrotic areas, respectively. Blood vessel architecture changed such that the vessels became larger and coarser towards the center of the tumor. Our three-dimensional analysis suggests continuous remodeling of alveolar capillaries rather than angiogenesis within bronchioloalveolar carcinoma.

Hypoxia-inducible factor-1 alpha in non small cell lung cancer: relation to growth factor, protease and apoptosis pathways

Hypoxia-inducible factor (HIF)-1 alpha is the regulatory subunit of HIF-1 that is stabilized under hypoxic conditions. Under different circumstances, HIF-1 alpha may promote both tumorigenesis and apoptosis. There is conflicting data on the importance of HIF-1 alpha as a prognostic factor. This study evaluated HIF-1 alpha expression in 172 consecutive patients with stage I-IIIA non small cell lung cancer (NSCLC) using standard immunohistochemical techniques. The extent of HIF-1 alpha nuclear immunostaining was determined using light microscopy and the results were analyzed using the median (5%) as a low cut-point and 60% as a high positive cut-point. Using the low cut-point, positive associations were found with epidermal growth factor receptor (EGFR; p = 0.01), matrix metalloproteinase (MMP)-9 (p = 0.003), membranous (p < 0.001) and perinuclear (p = 0.004) carbonic anhydrase (CA) IX, p53 (p = 0.008), T-stage (p = 0.042), tumor necrosis (TN; p < 0.001) and squamous histology (p < 0.001). No significant association was found with Bcl-2 or either N- or overall TMN stage or prognosis. When the high positive cut-point was used, HIF-1 alpha was associated with a poor prognosis (p = 0.034). In conclusion, the associations with EGFR, MMP-9, p53 and CA IX suggest that these factors may either regulate or be regulated by HIF-1 alpha. The association with TN and squamous-type histology, which is relatively more necrotic than other NSCLC types, reflects the role of hypoxia in the regulation of HIF-1 alpha. The prognostic data may reflect a change in the behavior of HIF-1 alpha in increasingly hypoxic environments.

Prognostic factors

The best predictive models of today can predict no more than 50% of the natural variability of the disease, despite the sophisticated mathematic analyses and the dozens of variables assessed. Clearly, a universe of still unknown prognostic factors remains to be discovered. Analogous to infinity being immeasurable, the fate of the individual patient will never be calculated mathematically. As the discovery of new prognostic factors continues, however, the prediction of the outcome of patients becomes more reliable. Although some prognostic factors (eg, tumor neoangiogenesis and quality of life) are already supported by a large body of evidence, recent research has introduced new groups of prognostic factors (eg, molecular genetic markers and the subclinical activation of coagulation fibrinolysis). Other intriguing factors (eg, a state of mental depression) might also be recognized as important in the near future. A new small portion of the universe has been explored.

Tumor Necrosis Correlates With Angiogenesis and Is a Predictor of Poor Prognosis in Malignant Mesothelioma *

OBJECTIVES

Malignant mesothelioma (MM) is a fatal tumor of increasing incidence related to asbestos exposure. Microscopic tumor necrosis (TN) is a poor prognostic factor in solid tumors, but it has not been characterized in MM. We wished to evaluate the incidence of TN in MM and its correlations with clinicopathologic factors, angiogenesis, and survival.

METHODS

TN was graded in 171 routine formalin-fixed, paraffin-embedded hematoxylin-eosin-stained tumor sections by two independent observers. Angiogenesis was assessed by the microvessel count (MVC) of CD34 immunostained sections. TN was correlated with survival by Kaplan-Meier and log-rank analysis, and stepwise, multivariate Cox models were used to compare TN with angiogenesis and established prognostic factors and prognostic scoring systems.

RESULTS

TN was identified in 39 cases (22.8%) and correlated with low hemoglobin (p = 0.01), thrombocytosis (p = 0.04), and high MVC (p = 0.02). TN was a poor prognostic factor in univariate analysis (p = 0.008). Patients with TN had a median survival of 5.3 months vs 8.3 months in negative cases. Independent indicators of poor prognosis in multivariate analysis were nonepithelioid cell type (p = 0.0001), performance status > 0 (p = 0.007), and increasing MVC (p = 0.004) but not TN. TN contributed independently to the European Organisation for Research and Treatment of Cancer (EORTC) [p = 0.03] and to the Cancer and Leukemia Group B (CALGB) [p = 0.03] prognostic groups in respective multivariate Cox analyses.

CONCLUSIONS

TN correlates with angiogenesis and is a poor prognostic factor in MM. TN contributes to the EORTC and CALGB prognostic scoring systems.

Matrix metalloproteinases 2 and 9 (gelatinases A and B) expression in malignant mesothelioma and benign pleura

Matrix metalloproteinases (MMPs), in particular the gelatinases (MMP-2 and -9), play a significant role in tumour invasion and angiogenesis. The expression and activities of MMPs have not been characterised in malignant mesothelioma (MM) tumour samples. In a prospective study, gelatinase activity was evaluated in homogenised supernatants of snap frozen MM (n=35), inflamed pleura (IP, n=12) and uninflammed pleura (UP, n=14) tissue specimens by semiquantitative gelatin zymography. Matrix metalloproteinases were correlated with clinicopathological factors and with survival using Kaplan-Meier and Cox proportional hazard models. In MM, pro- and active MMP-2 levels were significantly greater than for MMP-9 (P=0.006, P<0.001). Active MMP-2 was significantly greater in MM than in UP (P=0.04). MMP-2 activity was equivalent between IP and MM, but both pro- and active MMP-9 activities were greater in IP (P=0.02, P=0.009). While there were trends towards poor survival with increasing total and pro-MMP-2 activity (P=0.08) in univariate analysis, they were both independent poor prognostic factors in multivariate analysis in conjunction with weight loss (pro-MMP-2 P=0.03, total MMP-2 P=0.04). Total and pro-MMP-2 also contributed to the Cancer and Leukemia Group B prognostic groups. MMP-9 activities were not prognostic. Matrix metalloproteinases, and in particular MMP-2, the most abundant gelatinase, may play an important role in MM tumour growth and metastasis. Agents that reduce MMP synthesis and/or activity may have a role to play in the management of MM.

Quantification of angiogenesis as a prognostic marker in human carcinomas: a critical evaluation of histopathological methods for estimation of vascular density

Chalkley counts have been suggested as the primary method for immunohistochemical evaluation of angiogenesis, however, most studies have used microvessel density (MVD). We present paired Chalkley and MVD estimates in carcinomas of the prostate, breast, bladder and lung. The clinical data has previously been reported. In prostate carcinomas, high MVD indicated poor prognosis, whereas high Chalkley counts in breast carcinoma were associated with a poor prognosis. In bladder carcinoma, high estimates using both methods showed good prognosis and were associated with a high degree of inflammation. Neither of the counts revealed prognostic value in lung carcinomas, where the vascular pattern indicated that this cancer was non-angiogenic. We highlight methodological problems with both counting methods. Since angiogenic processes in lung and bladder cancers may be different from those occuring in prostate cancer, we suggest that future analyses also focus on measuring angiogenic factors to obtain more information on the biology of angiogenesis.

Lung cancer 5: state of the art radiotherapy for lung cancer

Radiotherapy has a key role in curative and palliative treatments of patients with lung cancer. Important advances are described in the technique of treatment delivery and its integration with chemotherapy.

Platelet-endothelial interaction in tumor angiogenesis and microcirculation

Activated platelets release angiogenic growth factors and have therefore been proposed to contribute to tumor angiogenesis within a potentially prothrombotic tumor microcirculation. The aim of the study was to investigate interactions of platelets with the angiogenic microvascular endothelium of highly vascularized solid tumors during growth and in response to endothelial stimulation in comparison with normal subcutaneous tissue. Experiments were performed in the dorsal skinfold chamber preparation of C57BL/6J mice bearing the Lewis lung carcinoma (LLC-1) or methylcholanthrene-induced fibrosarcoma (BFS-1). Fluorescently labeled rolling and adherent platelets, red blood cell velocity, and vessel diameters were assessed by intravital fluorescence microscopy on days 1, 3, 8, and 14 after tumor cell implantation. Slightly elevated numbers of rolling platelets were observed in the early stages of tumor angiogenesis at day 1 (control, 1.7 +/- 0.6; LLC-1, 3.4 +/- 1.8; BFS-1, 3.0 +/- 0.7 [1/mm/s], P <.05) and day 3 (control, 1.6 +/- 0.6; LLC-1, 4.1 +/- 1.7, P <.05; BFS-1, 2.3 +/- 0.5 [1/mm/s]) after tumor cell implantation. Endothelial stimulation with calcium ionophore A23187 at day 14 after tumor cell implantation resulted in a minor increase to 2.1 +/- 0.4 (LLC-1) and 1.8 +/- 0.8 (BFS-1) rolling platelets (1/mm/s) in tumor microvessels compared with 4.9 +/- 0.9 in controls (P <.05). Platelet adherence was not observed. We therefore conclude that in the 2 experimental tumors under study, (1) slightly increased platelet rolling is a transient phenomenon after tumor cell implantation, and (2) platelet-endothelial interaction in response to endothelial stimulation is reduced in tumor microvessels.

Epidermal growth factor receptors and cyclooxygenase-2 in the pathogenesis of non-small cell lung cancer: potential targets for chemoprevention and systemic therapy

The epidermal growth factor receptor (EGFR) is part of a family of plasma membrane receptor tyrosine kinases that control many important cellular functions, from growth and proliferation to cell death. Cyclooxygenase (COX)-2 is an enzyme which catalyses the conversion of arachidonic acid to prostagladins and thromboxane. It is induced by various inflammatory stimuli, including the pro-inflammatory cytokines, Interleukin (IL)-1beta, Tumour Necrosis Factor (TNF)-alpha and IL-2. Both EGFR and COX-2 are over-expressed in non-small cell lung cancer (NSCLC) and have been implicated in the early stages of tumourigenesis. This paper considers their roles in the development and progression of lung cancer, their potential interactions, and reviews the recent progress in cancer therapies that are directed toward these targets. An increasing body of evidence suggests that selective inhibitors of both EGFR and COX-2 are potential therapeutic agents for the treatment of NSCLC, in the adjuvant, metastatic and chemopreventative settings.

Novel therapies for lung cancer

Lung cancer remains the leading cause of cancer mortality in the US. For the majority of patients with advanced non-small cell lung cancer, chemotherapy with or without radiation therapy is the mainstay of treatment. Despite the modest improvement in survival for these patients, prognosis remains dismal. However, the expanding knowledge of tumor biology in recent years has resulted in the promising development of a new class of "molecularly targeted" agents, which selectively target cancer cells at the molecular, biochemical, and genetic level, thus minimizing toxic effects on normal tissues. A wide range of molecularly targeted agents are being actively investigated in lung cancer therapy as single agents or in combination with conventional modalities. In this review, we discuss some of the agents furthest along in development: epidermal growth factor receptor inhibitors, anti-angiogenic agents, inhibitors of biologically important enzymes such as matrix metalloproteinases and farnesyltransferase, gene therapy including gene replacement and antisense therapy, and cell cycle disruptors.

The role of new agents in the treatment of non-small cell lung cancer

Lung cancer is one of the most frequent causes of cancer deaths worldwide. Non-small cell lung cancer (NSCLC) accounts for approximately 80% of cases and no curative treatment is available for the advanced stages of disease (stages III and IV), which comprise the majority of cases. Current treatment regimens with standard chemotherapy offer only a limited survival benefit, and, therefore, the development of new therapeutic strategies is needed. Novel chemotherapeutic drugs such as the epothilones, MEN 10755 and S-1 are being studied in patients with advanced stages of disease. Furthermore, a large number of therapies targeted against critical biological abnormalities in NSCLC are being investigated in clinical trials. The latter approach includes inhibition of growth factors, interference with abnormal signal transduction, inhibition of angiogenesis and gene replacement therapy. Promising results have thus far been obtained with some of these therapies. This review describes the role of new therapeutic agents in the treatment of NSCLC.

The role of microvessel density on the survival of patients with lung cancer: a systematic review of the literature with meta-analysis

In order to determine whether angiogenesis is a prognostic marker in lung cancer, we performed a systematic review of the literature to assess the prognostic value on survival of microvessel count in patients with lung cancer. Published studies were identified by an electronic search in order to aggregate survival results, after a methodological assessment using a quality scale designed by the European Lung Cancer Working Party. To be eligible, a study had to deal with microvessel count assessment in lung cancer patients on the primary site and to provide survival analysis according to microvessel count expression. Microvessel count has been assessed on surgical samples by immunohistochemistry using factor VIII in 14 studies, CD34 in 10 and CD31 in eight. Respectively 1866, 1440 and 1093 non-small cell lung cancer patients were considered. The overall median quality scores were respectively 52, 59 and 59% for studies assessing microvessel count via factor VIII, CD34 and CD31, without significant difference between studies evaluable or not for meta-analysis nor between studies with significant or non significant results. Seven 'factor VIII' studies, nine 'CD34' and seven 'CD31' provided sufficient data allowing a meta-analysis on survival and were evaluable for results aggregation. This showed that a high microvessel count in the primitive lung tumour was a statistically significant poor prognostic factor for survival in non small cell lung cancer whatever it was assessed by factor VIII (HR: 1.81; 95% CI: 1.16-2.84), CD34 (HR: 1.99; 95% CI: 1.53-2.58) or CD31 (HR: 1.80; 95% CI: 1.10-2.96). Variations in survival among the individual studies can be explained in addition to patients selection criteria by the heterogeneous methodologies used to stain and count microvessels: different antibody clones, identification of 'hotspots', Weidner or Chalkey counting method, cut-off selection. Microvessel count, reflecting the angiogenesis, appears to be a poor prognostic factor for survival in surgically treated non small cell lung cancer but standardisation of angiogenesis assessment by the microvessel count is necessary.

Tumour necrosis is an independent prognostic marker in non-small cell lung cancer: correlation with biological variables

BACKGROUND

Tumour necrosis (TN) is recognized to be a consequence of chronic cellular hypoxia. TN and hypoxia correlate with poor prognosis in solid tumours.

METHODS

In a retrospective study the prognostic implications of the extent of TN was evaluated in non-small cell lung cancer (NSCLC) and correlated with clinicopathological variables and expression of epidermal growth factor receptor, Bcl-2, p53 and matrix metalloproteinase-9 (MMP-9). Tissue specimens from 178 surgically resected cases of stage I-IIIA NSCLC with curative intent were studied. The specimens were routinely processed, formalin-fixed and paraffin-embedded. TN was graded as extensive or either limited or absent by two independent observers; disagreements were resolved using a double-headed microscope. The degree of reproducibility was estimated by re-interpreting 40 randomly selected cases after a 4 month interval.

RESULTS

Reproducibility was attained in 36/40 cases, Kappa score = 0.8 P < 0.001. TN correlated with T-stage (P = 0.001), platelet count (P = 0.004) and p53 expression (P = 0.031). Near significant associations of TN with N-stage (P = 0.063) and MMP-9 expression (P = 0.058) were seen. No association was found with angiogenesis (P = 0.98). On univariate (P = 0.0016) and multivariate analysis (P = 0.023) TN was prognostic.

CONCLUSION

These results indicate that extensive TN reflects an aggressive tumour phenotype in NSCLC and may improve the predictive power of the TMN staging system. The lack of association between TN and angiogenesis may be important although these variables were not evaluated on serial sections.

Platelets and cancer

The presence of platelets in association with cancer deposits has been recognised for over 100 years; however, the recognition of a two-way interaction has been more recent. The link between cancer spread and platelet stimulation is pivotal to understanding of the hypercoagulable state found in most cancer patients. The assistance of platelets in cancer spread may provide opportunities to interrupt this relation, thus inhibiting metastasis.

Novel approaches to the treatment of non-small cell lung cancer

Prognosis of non-small cell lung carcinomas (NSCLC) remains poor, especially in advanced disease. The introduction of new cytotoxic agents in the past decade did only attain minor improvements in survival. It is rather clear that chemotherapy may have reached a plateau, and that it will be difficult to obtain better results in advanced NSCLC by chemotherapy alone. Novel treatment modalities are urgently needed in advanced NSCLC. Backed-up by advances in the understanding of tumor cell biology, a new generation of anticancer agents specifically directed at targets such as tyrosine kinases, farnesyl transferase, angiogenesis factors, matrixmetalloproteinases and oncogenes has been developed in recent years. In this review, we give a brief summary of the state-of-the-art treatment of NSCLC, highlighting its limitations. Novel systemic approaches are then discussed in detail with focus on their mechanistic rationale, stage of clinical development and possible drawbacks. Finally, perspectives of future applications and impact on the treatment of NSCLC are also discussed.

Serum endostatin correlates with progression and prognosis of non-small cell lung cancer

The relationship between non-small cell lung cancer and platelet counts, serum levels of vascular endothelial growth factor (VEGF) and endostatin, is unclear. Platelet counts and serum VEGF and endostatin levels were measured preoperatively in 99 patients with non-small cell lung cancer, and the relationship between these factors and clinicopathological features, including prognosis, was examined. Mean serum VEGF level was slightly higher in patients than in healthy subjects (P=0.23). Mean serum endostatin level was 42.4+/-40.4 ng/ml in patients compared to 16.3+/-10.3 ng/ml in healthy subjects (P=0.0003). Serum endostatin levels were significantly higher in patients with involvement greater than T2 or stage IB, compared to other patients. Platelet count and serum endostatin level greater than the median were associated with poor prognosis. Our results suggested that platelet count and serum endostatin level may be useful markers for non-small cell lung cancer.