Prognostic significance of apoptotic index in completely resected non-small-cell lung cancer

Clearance of apoptotic cells by neutrophils in inflammation and cancer

When a cell dies of apoptosis, it is eliminated either by neighbouring cells or by attracted professional phagocytes. Although it was generally believed that neutrophils also have the ability to perform efferocytosis, their contribution to the clearance of apoptotic cells was considered less important compared with macrophages. Therefore, this ability of neutrophils remained unexplored for a long time. Over the past decade, it has been shown that during inflammation, neutrophils contribute significantly to the clearance of apoptotic neutrophils that accumulate in large numbers at the site of tissue damage. This "neutrophil cannibalism" is accompanied by inhibition of pro-inflammatory activities of these cells, such as respiratory burst and formation of neutrophil extracellular traps (NETs). Furthermore, efferocytosing neutrophils secrete anti-inflammatory mediators and mitogens including hepatocyte growth factor (HGF), fibroblast growth factor 2 (FGF2), vascular endothelial growth factors (VEGF), and transforming growth factor beta (TGFβ). Thus, efferocytosis by neutrophils is involved in resolution of inflammation. Recent research indicates that it plays also a role in cancer. Many different solid tumours contain aggregates of dead tumour cells that have undergone spontaneous apoptosis. Their extent correlates with poor clinical outcome in most cancer types. These clusters of apoptotic tumour cells are strongly infiltrated by tumour-associated neutrophils (TANs) that acquired an anti-inflammatory and pro-resolving polarization state. This review summarizes the potential consequences discussed in the current literature. Although the picture of the role of efferocytosis by neutrophils in inflammation and cancer is becoming clearer, many questions are still unexplored.

Apoptosis-induced nuclear expulsion in tumor cells drives S100a4-mediated metastatic outgrowth through the RAGE pathway

Most tumor cells undergo apoptosis in circulation and at the metastatic organ sites due to host immune surveillance and a hostile microenvironment. It remains to be elucidated whether dying tumor cells have a direct effect on live tumor cells during the metastatic process and what the underlying mechanisms are. Here we report that apoptotic cancer cells enhance the metastatic outgrowth of surviving cells through Padi4-mediated nuclear expulsion. Tumor cell nuclear expulsion results in an extracellular DNA-protein complex that is enriched with receptor for advanced glycation endproducts (RAGE) ligands. The chromatin-bound RAGE ligand S100a4 activates RAGE receptors in neighboring surviving tumor cells, leading to Erk activation. In addition, we identified nuclear expulsion products in human patients with breast, bladder and lung cancer and a nuclear expulsion signature correlated with poor prognosis. Collectively, our study demonstrates how apoptotic cell death can enhance the metastatic outgrowth of neighboring live tumor cells.

The prognostic impact of traditional Chinese medicine monomers on tumor-associated macrophages in non-small cell lung cancer

Non-small cell lung cancer (NSCLC) accounts for 80%-85% of all lung malignancies and good diagnosis and prognosis of NSCLC are critical to the increase of its survival rate. Tumor-associated macrophages (TAM) abundantly present in numerous cancer types, and the role of TAMs in tumor biology and their prognostic value in cancer become major topics of interest. After various stimulations in the tumor microenvironment, TAMs develop into a M1 (tumor-inhibitory) phenotype or M2 (tumor-promoting) phenotype. Recent studies show that traditional Chinese medicine (TCM) monomers have markedly inhibitory actions for NSCLC through M1/M2 modulation. Due to the TCM monomers mainly covered five categories, i.e. terpenoids, flavonoids, polysaccharides, natural polyphenols, and alkaloids. Thus, we will discuss the regulation of TCM monomers on TAM involve in these five parts in this review. In addition, the potential role of TAMs as therapeutic targets will be discussed.

Prognostic Value of XIAP Level in Patients with Various Cancers: A Systematic Review and Meta-Analysis

Background: X-linked inhibitor of apoptosis protein (XIAP) plays an important role in cancer pathogenesis, which has been found to be overexpressed in multiple human cancers and associated with survival rates. Herein, we performed a meta-analysis to explore the predictive value of XIAP level in patients with various solid tumors. Methods: Relevant articles exploring the relationship between XIAP expression and survival of cancer patients were retrieved in PubMed, PMC, EMBASE and Web of Science published from 2001 to 2018. The combined hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated to evaluate the significance. Results: A total of 6554 patients from 40 articles were included in this meta-analysis. It was shown in 37 studies with 4864 cases that the over-expression of XIAP was associated with poorer overall survival (OS) (combined HR=1.61, 95% CI: 1.33-1.96). Meanwhile, 8 studies with 1862 cases revealed that elevated XIAP level predicted shorter disease-free survival (DFS) (HR=2.17, 95% CI: 1.03-4.59). Subgroup analyses showed that higher XIAP detection was related to worse OS in gastric cancer (HR=1.42, 95% CI: 1.18-1.72) and head and neck cancer (HNC) (HR=2.97, 95% CI: 1.97-4.47). Conclusion: Our results suggested that elevated XIAP level seemed to represent an unfavorable prognostic factor for clinical outcomes in cancer patients. However, there were limited studies describing the association between XIAP expression and clinical prognosis in each different type of tumors. Therefore, concrete roles of XIAP in various cancers need to be further explored.

ROCK1 as a novel prognostic marker in vulvar cancer

Background

Vulvar carcinoma is an infrequent tumour, accounting for fewer than 3% of all malignant tumours that affect women, but its incidence is rising in the past few decades. In young women, the manifestation of the vulvar carcinoma is often linked to risk factors such as smoking and HPV infection, but most cases develop in women aged over 50 years through poorly understood genetic mechanisms. Rho-associated coiled-coil-containing protein kinase 1 (ROCK1) has been implicated in many cellular processes, but its function in vulvar cancer has never been examined. In this study, we aimed to determine the prognostic value of ROCK1 gene and protein analysis in vulvar squamous cell carcinoma (VSCC).

Methods

ROCK1 expression levels were measured in 16 vulvar tumour samples and adjacent normal tissue by qRT-PCR. Further, 96 VSCC samples were examined by immunohistochemistry (IHC) to confirm the involvement of ROCK1 in the disease. The molecular and pathological results were correlated with the clinical data of the patients. Sixteen fresh VSCC samples were analyzed by array-based comparative genomic hybridization (aCGH).

Results

In each pair of samples, ROCK1 levels were higher by qRT-PCR in normal tissue compared with the tumour samples (p = 0.016). By IHC, 100% of invasive front areas of the tumour and 95.8% of central tumour areas were positive for ROCK1. Greater expression of ROCK1 was associated with the absence of lymph node metastasis (p = 0.022) and a lower depth of invasion (p = 0.002). In addition, higher ROCK1 levels correlated with greater recurrence-free survival (p = 0.001). Loss of ROCK1 was independently linked to worse cancer-specific survival (p = 0.0054) by multivariate analysis. This finding was validated by IHC, which demonstrated enhanced protein expression in normal versus tumour tissue (p < 0.001). By aCGH, 42.9% of samples showed a gain in copy number of the ROCK1 gene.

Conclusions

ROCK1 is lower expressed in tumour tissue when compared with adjacent normal vulvar epithelia. In an independent sample set of VSCCs, lower expression levels of ROCK1 correlated with worse survival rates and a poor prognosis. These findings provide important information for the clinical management of vulvar cancer.

Necrosis and apoptotic index as prognostic factors in non-small cell lung carcinoma: a review

Necrosis and apoptosis represent two pathogenetically distinct types of cell death. Necrosis is associated with pathologic conditions while apoptosis is a physiological process of programmed cell death, which is associated with normal tissue growth and is frequently impaired in various forms of cancer. Tumor necrosis and apoptotic index (AI) have been previously evaluated as prognostic biomarkers in lung cancer, but their exact clinical value remains unclear. The aim of this study was to perform a systematic review of the MEDLINE literature on the prognostic significance of these histopathological markers in patients with non-small cell lung carcinoma (NSCLC). Although a substantial body of evidence suggests that tumor necrosis may be a strong predictor of aggressive tumor behavior and reduced survival in patients with NSCLC, the independent prognostic value of this biomarker remains to be firmly established. Furthermore, previous data on the prognostic significance of apoptotic index in NSCLC are relatively limited and largely controversial. More prospective studies are necessary in order to further validate tumor necrosis and AI as prognostic markers in NSCLC.

Apoptosis in adhesions and the adhesion-tendon gliding interface: relationship to adhesion-tendon gliding mechanics

PURPOSE

Adhesion formation is closely related to tendon-gliding function. We aimed to investigate apoptosis (programmed cell death) in adhesions and tendons and study its relationship to the mechanics of adhesions and healing tendons.

METHODS

The flexor digitorum profundus tendons of 30 long toes in 15 chickens were completely transected and repaired surgically. At postoperative weeks 4, 6, and 8, tendon-gliding excursions were tested and adhesion scores were recorded. Tendons and surrounding adhesions were then harvested for analysis of apoptosis using in situ terminal deoxynucleotidyl transferase dUTP (deoxyuridine triphosphate) nick end labeling assay. Three-dimensional image reconstruction was used to provide an overall view of cellular distribution in tendons and adhesions. Finally, we analyzed the correlation between the apoptotic index measured at the adhesions and the gliding excursions. Ten uninjured tendons served as normal controls.

RESULTS

Apoptosis was found to be a dominant cellular event in the adhesion tissues at both the adhesion-tendon gliding interface and the adhesion core. The apoptotic index in the adhesions was generally above 20% to 50%. The apoptotic index was significantly higher in the adhesions than in the junction region of the cut tendon ends at weeks 4, 6, and 8. A higher apoptotic index in the adhesions significantly correlated to lower tendon excursions at week 6.

CONCLUSIONS

Apoptosis in adhesions and at the adhesion-tendon interface is a prominent event in the tendon-healing process. The tendons exhibiting a lower tendon-gliding amplitude, meaning more severe adhesions, tended to have a greater apoptotic index in their adhesions during a certain period of the tendon-remodeling process.

CLINICAL RELEVANCE

Apoptosis in the adhesions and at the adhesion-tendon interface may contribute remarkably to the fate of adhesions and the restoration of the tendon gliding surface, which may be closely related to the tendon function.

Cellular apoptosis and proliferation in the middle and late intrasynovial tendon healing periods

PURPOSE

Cellular apoptosis might be an important molecular event in the middle or late healing periods of intrasynovial tendons, but this has not been studied. We aimed to investigate cellular apoptosis and corresponding cellular proliferation in the middle and late healing stages of intrasynovial tendons.

METHODS

The flexor digitorum profundus tendons of 48 long toes (24 chickens) were completely transected within the sheath region and were repaired surgically. At days 28, 42, 56, and 84 after surgery, tendons were harvested and sectioned. In situ terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) assay was performed to detect apoptotic cells. The sections were stained immunofluorescently with antibodies to proliferating cell nuclear antigen to assess proliferation and to Bcl-2 (an anti-apoptotic protein). Positively stained tenocytes were counted, and their distributional differences were verified in 3-dimensional images.

RESULTS

The repaired intrasynovial tendons exhibited generally greater apoptosis in the surface region than in the core. The differences were more remarkable in the extended region than in the junction region of the cut tendon. At the core of the junction site, apoptosis of tenocytes was pronounced at all time points, but it was less severe at the core of the extended region. The proliferating cell nuclear antigen-positive and Bcl-2-positive tenocytes decreased significantly and continually at days 28, 42, and 56, respectively; these tenocytes were at a minimum at days 56 and 84.

CONCLUSIONS

Apoptotic changes of tenocytes are most marked in the surface region and in the junction region of the healing tendon in the middle and late healing stages. Apoptosis in the core is less dramatic compared to that in the surface in the extended tendon regions. Cellular proliferation declines drastically and is minimal at days 56 and 84.

CLINICAL RELEVANCE

Tenocyte apoptosis in the middle and late stages might be an important event contributing to intrasynovial tendon remodeling, which affects the healing strength and formation of adhesions.

Activated Notch1 induces lung adenomas in mice and cooperates with Myc in the generation of lung adenocarcinoma

Notch1 encodes the canonical member of the mammalian Notch receptor family. Activating lesions frequently affect Notch1 in T-cell acute lymphoblastic leukemia (T-ALL) and, recently, have been found in non-small-cell lung cancer (NSCLC) as well. We explored the oncogenic potential of activated Notch1 in the lung by developing a transgenic mouse model in which activated Notch1 was overexpressed in the alveolar epithelium. The initial response to activated Notch1 was proliferation and the accumulation of alveolar hyperplasia, which was then promptly cleared by apoptosis. After an extended latency period, however, pulmonary adenomas appeared in the transgenic mice but failed to progress to become carcinomas. Interestingly, Myc and MycL1 were expressed in the adenomas, suggesting that selection for enhanced Myc activity may facilitate tumorigenesis. Using mice engineered to coexpress activated Notch1 and Myc, we found that supplementing Myc expression resulted in increased frequency of Notch1 intracellular domain (N1ICD)-induced adenoma formation and enabled progression to adenocarcinoma and metastases. Cooperation stemmed from synergistic activation of tumor cell cycling, a process that apparently countered any impedance to tumorigenesis posed by Myc and/or activated Notch1-induced apoptosis. Significantly, cooperation was independent of RAS activation. Taken together, the data suggest that activated Notch1 substitutes for RAS activation synergistically with Myc in the development of NSCLC. These tumor models should be valuable for exploring the role of activated Notch1 in the genesis of NSCLC and for testing therapies targeting either activated Notch1 or its downstream effectors.

Follicular apoptosis in the mussel (Mytella strigata) as potential indicator of environmental stress in coastal ecosystems

Follicular apoptosis in the tropical mussel Mytella strigata was assessed in three coastal lagoons located in the southern Gulf of California, Mexico. Mussels were collected from three coastal lagoons associated with different scenarios of anthropogenic stress during one year. The gonad of each mussel was dissected, weighed, and sampled for histology and apoptosis analysis by TUNEL labeling. Two apoptotic indices were used: the apoptotic index of cells (AIC) based on the number of follicular cells in apoptosis in one thousand cells counted per gonad, and the apoptotic index of follicles (AIF) based on the number of follicular cells per follicle per gonad. Both indices showed high association with each other for all developmental stages, although AIF seemed to better discriminate among sites. Higher AIF and AIC were observed at the Urias Estuary (1.6 and 1.5 respectively) ranked as highly polluted, followed by Ensenada del Pabellon (0.82 and 0.95 respectively), ranked as moderately polluted, and the Teacapan Estuary (0.57 and 0.76 respectively) ranked as slightly polluted. Our data indicate that the apoptotic index in tropical mussels could be a useful indicator of environmental stress in coastal ecosystems; however, the ecological relevance of follicular apoptosis in polluted environments needs further investigation.

Molecular events of cellular apoptosis and proliferation in the early tendon healing period

PURPOSE

Cellular proliferation is accompanied by cellular apoptosis. In the healing digital flexor tendon, molecular events concerning cellular apoptosis have not been investigated. This study aimed to investigate the relationship between cellular apoptosis and proliferation in early tendon healing.

METHODS

The flexor digitorum profundus tendons of 50 long toes in 25 chickens were transected and were repaired surgically. On postoperative days 3, 7, 14, 21, and 28, we subjected tendons to in situ terminal deoxynucleotide transferase dUTP nick end labeling (TUNEL) assay to detect apoptotic cells, immunofluorescence staining with antibodies to proliferating cell nuclear antigen to assess proliferation, and Bcl-2, an anti-apoptotic protein, to assess responses suppressive to apoptosis. The positively labeled tenocytes were counted microscopically and compared statistically. We also stained sections with hematoxylin and eosin to observe their healing status. An additional 12 tendons (6 chickens) served as day 0 controls.

RESULTS

Compared with tendons at day 0, the healing tendons had notably greater cellularity in both epitenon and endotenon areas. The total number of cells and number of TUNEL-positive cells peaked at day 3. At days 7 to 21, the number of proliferating cell nuclear antigen-positive cells peaked. At days 7 and 14, the cells positively stained with Bcl-2 peaked. At days 14 to 28, the total number of cells and TUNEL-positive cells decreased significantly compared with those at days 3 and 7, yet the numbers remained greater than those on day 0.

CONCLUSIONS

Apoptosis in the healing tendons peaks at day 3, followed about 10 days later by the peak proliferation period. Because Bcl-2 serves to inhibit apoptosis, a later increase in Bcl-2-positive cells indicates that tendon apoptosis is inhibited. These findings indicate that tenocyte apoptosis is accelerated within several days after injury, followed by increases in cellular proliferation and activation of molecular events to inhibit apoptosis in 2 to 4 weeks.

Stromal aminopeptidase N expression: correlation with angiogenesis in non-small-cell lung cancer

PURPOSE

Aminopeptidase-N (APN) is a membranebound protein that acts as a zinc-binding protease and participates in extracellular proteolysis. APN plays important roles in tumor progression through promoting invasion and metastasis, prolonging survival of tumor cells, and tumor angiogenesis.

METHODS

We evaluated APN expression in non-small-cell lung cancer patients by immunohistochemistry.

RESULTS

Of the 95 patients reviewed in the present study, 9 (9.5%), all with adenocarcinoma (Ad), showed positive APN expression on the tumors' cells. In all, 31 (32.6%) and 19 (20.0%) patients showed positive APN expression on the tumors' stromal cells (fibroblasts) and microvessels, respectively. APN expression on the tumors' stromal cells was more frequently observed in squamous cell carcinoma patients than in adenocarcinoma patients (P = 0.005). The mean microvessel density (MVD) for APNpositive tumor stromal cells was 59.9, which was significantly higher than that for APN-negative tumor stromal cells (mean MVD 27.4; P = 0.001). The 5-year survival rates for APN-positive and APN-negative tumor stromal cells were 66.0% and 69.8%, respectively, showing no difference in patient survival according to APN status on the tumors' stromal cells.

CONCLUSION

That APN expression on stromal cells was observed predominantly in squamous cell carcinoma may account for the efficacy of ubenimex in the postoperative adjuvant setting for squamous cell carcinoma.

Prognostic value of the apoptotic index analysed jointly with selected cell cycle regulators and proliferation markers in non-small cell lung cancer

In a previous small series of surgically treated non-small cell lung cancer patients (NSCLC), we found that higher apoptotic index (AI) negatively influenced survival (Dworakowska D, Jassem E, Jassem J, Karmolinski A, Dworakowski R, Wirth T, et al. Clinical significance of apoptotic index in non-small cell lung cancer: correlation with p53, mdm2, pRb and p21WAF1/CIP1 protein expression. J Cancer Res Clin Oncol 2005; 131:617-623.). In this study we attempted to verify our previous finding in larger group of 170 NSCLC cases, additionally correlating AI to selected cell cycle regulators as well as a proliferation marker. Apoptosis was assessed with the use of the TUNEL technique, whereas the expression of p53, pRb, mdm2, p21(WAF1/CIP1), cyclin D1 and PCNA were assessed immunohistochemically. The mean and the median AI was 12 and 8, respectively. The expression of p53, pRb, mdm2, p21(WAF1/CIP1) proteins and cyclin D1 was found in 47%, 71%, 37%, 65% and 40% of cases, respectively. The mean and the median PCNA labeling index (PCNA LI) was 34 and 35, respectively. AI was not correlated with any patient characteristic or other tumor markers. In uni- and multivariate analysis AI, analysed separately or jointly with cell cycle regulators and PCNA LI, did not influence disease-free or over-all survival. However, patients with "very high AI/very high PCNA LI" had a particularly poor prognosis (P=0.001). Patients with "very low AI/negative pRb" phenotype survived for a shorter time in comparison to others (P=0.04). In addition, patients with the highest PCNA LI had a worse outcome in comparison to patients with the lowest PCNA LI (P=0.04), especially those with concomitant p53 protein expression (P=0.026) or lacking pRb protein expression (P=0.04). This study demonstrates that joint analysis of several factors involved in apoptosis, proliferation and cell cycle regulation, but not AI alone, might provide additional prognostic information in NSCLC patients.

Perimembrane Aurora-A expression is a significant prognostic factor in correlation with proliferative activity in non-small-cell lung cancer (NSCLC)

Purpose

Aurora-A, also known as STK15/BTAK, is a member of the protein serine/threonine kinase family, and experimental studies have revealed that Aurora-A plays critical roles in cell mitosis and in carcinogenesis. However, no clinical studies on Aurora-A expression in non-small-cell lung cancer (NSCLC) have been reported. Thus, the present study was conducted to assess the clinical significance of Aurora-A status.

Experimental Design

A total of 189 consecutive patients with resected pathologic (p-)stage I-IIIA, NSCLC were retrospectively reviewed, and immunohistochemical staining was used to detect Aurora-A expression.

Results

Aurora-A expression was negative in 31 patients (16.4%); among Aurora-A positive patients, 124 patients showed pure diffuse cytoplasmic Aurora-A expression and the other 34 patients showed perimembrane Aurora-A expression. Perimembrane Aurora-A tumors showed the highest proliferative index (PI) (mean PIs for negative, diffuse cytoplasmic, and perimembrane tumors: 49.2, 41.7, and 63.5, respectively; P < .001). Five-year survival rates of Aurora-A negative, diffuse cytoplasmic, and perimembrane patients were 67.8%, 66.7%, and 47.6%, respectively, showing the poorest postoperative survival in perimembrane patients (P = .033). Subset analyses revealed that perimembrane Aurora-A expression was a significant factor to predict a poor prognosis in squamous cell carcinoma patients, not in adenocarcinoma patients. A multivariate analysis confirmed that perimembrane Aurora-A expression was an independent and significant factor to predict a poor prognosis.

Conclusions

Perimembrane Aurora-A status was a significant factor to predict a poor prognosis in correlation with enhanced proliferative activity in NSCLC.

UFT (tegafur and uracil) as postoperative adjuvant chemotherapy for solid tumors (carcinoma of the lung, stomach, colon/rectum, and breast): clinical evidence, mechanism of action, and future direction

UFT (tegafur and uracil) is an oral anticancer drug that has been developed in Japan. Owing to its mild toxicity profile, UFT can be suitable in an adjuvant setting following a complete tumor resection, whereas its direct antitumor effect achieved may be insufficient for advanced unresectable disease. Therefore, a variety of adjuvant chemotherapy trials with UFT have been conducted, and results of well-designed randomized controlled trials have recently shown a survival benefit of postoperative UFT treatment in resected lung, gastric, colorectal, and breast cancer. In the present article, postoperative adjuvant trials with UFT-containing chemotherapy are reviewed, and the mechanism of action and future directions are also discussed.

Influence of apoptosis and cell cycle regulator proteins on chemotherapy response and survival in stage IIIA/IIIB NSCLC patients

BACKGROUND

Prognosis for non-small cell lung cancer (NSCLC) patients is very poor. Prediction of the response to treatment in individual patients may be possible using molecular biological alterations such as clinical biomarkers. We investigated the predictive value of apoptosis and cell cycle regulator proteins for neoadjuvant chemotherapy response in stage IIIA/IIIB NSCLC patients.

METHODS

We evaluated p53, bcl-2, p21WAF1/CIP1, p27Kip1, and Ki67 immunohistochemical expression and apoptotic index in mediastinal lymph node metastases from 23 IIIA and 10 IIIB NSCLC patients before treatment with neoadjuvant platinum-based chemotherapy. Univariate analysis was performed to evaluate the relationship between protein expression and survival or time to progression (TTP).

RESULTS

Median follow-up was 25 months (range, 4-112), median TTP was 11 months (range, 0-112), and median overall survival was 22 months (range, 4-112). Of 32 assessable patients, 18 (56%) had stable disease, 12 (38%) had a PR, and two (6%) had progressive disease. Of the 22 patients assessable for pN2 following chemotherapy, 16 (77%) were positive. Univariate analysis showed that shorter TTP correlated with progressive disease (p = 0.000), positive pN2 after chemotherapy (p = 0.026), high Ki67 (p = 0.022), and high p21WAF1/CIP1 (p = 0.038).

CONCLUSION

Our results suggest that in IIIA/IIIB NSCLC patients, a high level of p21WAF1 expression in mediastinal lymph node metastases before neoadjuvant platinum-based chemotherapy is associated with a poor outcome. Our results suggest that expression of p21WAF1, which plays a role in preventing apoptosis, may be significant when selecting chemotherapy for NSCLC patients.

Expression of tissue inhibitor of metalloproteinase-3 (TIMP-3) and its prognostic significance in resected non-small cell lung cancer

BACKGROUND AND OBJECTIVES

Tissue inhibitor of metalloproteinase-3 (TIMP-3) inhibits the activity of metalloproteinases that play important roles in development and progression of malignant tumors. We conducted a retrospective study of TIMP-3 expression in resected non-small cell lung cancer (NSCLC).

METHODS

TIMP-3 expression was examined immunohistochemically in primary tumor specimens from 143 patients who underwent complete resection for NSCLC. Correlations between TIMP-3 expression grade and tumor histology, TNM classification, MMP-2 and MMP-9 expression grade, VEGF expression grade, intra-tumoral microvessel density, proliferative index, apoptosis index, and prognosis were analyzed.

RESULTS

TIMP-3 expression was low in 40, moderate in 71, and high in 32 patients. Higher TIMP-3 expression was seen in squamous cell carcinoma than in adenocarcinoma (P = 0.001), and reduced TIMP-3 expression was significantly associated with nodal involvement (P = 0.016) and advanced pathologic stage (P = 0.036). MMP-2 expression was reduced along with enhanced TIMP-3 expression (P = 0.010). The 5-year overall survival rates of low, moderate, and high TIMP-3 patients were 53, 64, and 84%, respectively (P = 0.037). Multivariate analysis confirmed that enhanced TIMP-3 expression was an independent factor for a favorable prognosis (P = 0.037).

CONCLUSIONS

TIMP-3 expression status was significantly correlated with pathologic stage and nodal involvement, and was an independent prognostic factor in resected NSCLC.

Maspin Expression and Its Clinical Significance in Non-Small Cell Lung Cancer

BACKGROUND

Maspin is a member of the serpin (serine protease inhibitor) superfamily, and its exact function in the development and progression of malignant tumors remains controversial, though some experimental studies have revealed potential tumor-suppressor activities. In addition, there have been only a few clinical studies on maspin expression in malignant tumors including non-small cell lung cancer (NSCLC). The purpose of this study was to assess maspin expression and its clinical significance in NSCLC.

METHODS

A total of 210 consecutive patients with completely resected pathological (p-) stage I-IIIA NSCLC were retrospectively reviewed. Maspin expression along with intratumoral microvessel density, proliferative activity, and p53 status were evaluated immunohistochemically. The incidence of apoptotic cell death was also evaluated.

RESULTS

The incidence of strong maspin expression was significantly higher in lung squamous cell carcinoma (56/76, 73.7%; P < .001) than in other histological types. The incidence of aberrant expression of p53 was significantly higher in maspin-strong than in maspin-weak tumors (56.2% and 35.8%, respectively; P = .005). There was no difference in prognosis according to maspin status for all patients. However, for squamous cell carcinoma patients, univariate analysis showed that enhanced maspin expression was a significant factor in predicting a favorable prognosis (5-year survival rates, 70.1% for maspin-strong tumors and 41.5% for maspin-weak tumors; P = .014), which was confirmed in a multivariate analysis (hazard ratio = .475, 95% confidence interval .241-.936; P = .032).

CONCLUSIONS

Enhanced maspin expression was a significant and independent factor in predicting a favorable prognosis in lung squamous cell carcinoma.

Tailor-made chemotherapy for non-small cell lung cancer patients

The selection of the most effective chemotherapy treatment based on evaluation of biomarkers, that is, 'tailor-made chemotherapy', can improve the clinical outcome of non-small cell lung cancer patients, including early-stage tumors with a high metastatic potential and advanced-stage tumors with a low proliferation rate. Therefore, treatment would be chosen according to which drugs would be most effective in combating specific tumors. For example: 5-fluorouracil-derived agents would be used for tumors with a low expression of thymidylate synthase; gefitinib and erlotinib for tumors with epidermal growth factor receptor (EGFR) mutations or increased EGFR gene copy numbers; cisplatin and carboplatin for tumors with a low expression of excision repair cross complementing-1; and gemcitabine for tumors with a low expression of ribonucleotide reductase. The remaining populations of non-small cell lung cancers require chemotherapy using other drugs based on an evaluation of other targeted molecules.

Expression of MAGE-D4, a novel MAGE family antigen, is correlated with tumor-cell proliferation of non-small cell lung cancer

PURPOSE

MAGE-D4, originally termed MAGE-E1, is a novel MAGE family gene that is expressed at high levels in malignant tumors as compared to normal tissue. The present study was conducted to assess the clinical significance of MAGE-D4 expression in non-small cell lung cancer (NSCLC).

EXPERIMENTAL DESIGN

Expression of MAGE-D4 protein was estimated by immunohistochemistry and MAGE-D4 mRNA expression was investigated using quantitative reverse transcription-PCR (RT-PCR).

RESULTS

We assessed MAGE-D4 expression in NSCLC tissues and was found to be up-regulated in tumor tissues compared with normal lung tissues (mean MAGE-D4/GAPDH values, 0.035 for tumor tissues and 0.009 for normal lung tissues; p=0.002). However, there was no significant difference in MAGE-D4 expression among different pathological stages. The proliferative activity of tumor cells was significantly higher in high MAGE-D4 tumors (mean proliferative indices, 58.3 for high MAGE-D4 tumor levels and 34.0 for low MAGE-D4 tumor levels; p<0.001). In addition, a high MAGE-D4 expression was more frequently seen in squamous cell carcinoma than in adenocarcinoma (p=0.008), and less frequently in well-differentiated tumors than in moderately to poorly differentiated tumors (p=0.036). There was no difference in the postoperative survival between low and high MAGE-D4 patients (5-year survival rates, 65% and 69%, respectively; p=0.742).

CONCLUSIONS

MAGE-D4 plays some roles in tumor cells proliferation in NSCLC, but MAGE-D4 expression status did not provided a prognostic significance.

Prognostic Significance of Reversion-Inducing Cysteine-Rich Protein With Kazal Motifs Expression in Resected Pathologic Stage IIIA N2 Non–Small-Cell Lung Cancer

BACKGROUND

Reversion-inducing cysteine-rich protein with Kazal motifs (RECK) is a novel membrane-anchored matrix metalloproteinase inhibitor, and experimental studies have shown that RECK can suppress tumor progression through angiogenesis inhibition. We have already revealed that enhanced RECK expression is significantly correlated with a favorable prognosis in non-small-cell lung cancer (NSCLC). In this study, further analyses focused on pN2 disease were conducted to assess the clinical significance of RECK expression.

METHODS

A total of 118 patients with completely resected pathologic stage IIIA N2 NSCLC were retrospectively examined. RECK expression in the primary tumor, along with involved N2 nodes, was examined immunohistochemically.

RESULTS

RECK expression in the primary tumor was strong in 53 patients (44.9%) and was weak in the other 65 patients. The 5-year survival rate of patients with RECK-strong tumor (42.9%) was significantly higher than that of patients with RECK-weak tumor (23.1%; P = .017). Reduced RECK expression significantly correlated with a poor prognosis for patients with a single N2 node involved (P = .019), but not for patients with multiple N2 nodes involved (P = .440). A multivariate analysis confirmed that reduced RECK expression was an independent and significant factor to predict a poor prognosis (P = .031). RECK expression in involved N2 nodes was significantly higher than in primary tumors (P < .001).

CONCLUSIONS

RECK status was a novel prognostic factor in pathologic stage IIIA N2 NSCLC.

Risk of recurrence after surgical resection of small-sized invasive lung adenocarcinoma

OBJECTIVE

It has been reported that small-sized invasive lung adenocarcinomas, i.e., those classified as type C through type F according to Noguchi's classification, may also recur even after complete resection. We evaluated the prognostic value of molecular biologic markers (apoptosis, Ki-67, p53, epidermal growth factor) and clinicopathological factors in patients with small-sized invasive lung adenocarcinomas.

METHODS

The clinical records of all patients who had had a peripheral adenocarcinoma surgically resected between 1996 and 2002, and histologically diagnosed as type C through type F according to Noguchi's classification were retrospectively reviewed. The apoptotic index (AI) was determined by the triphosphate biotin nick end-labeling method and the expression of Ki-67, aberrant p53 protein and epidermal growth factor receptor was determined by immunohistochemical staining.

RESULTS

Data from 28 patients who had been followed up for a mean period of 41.8 months (range: 16 to 89 months) were evaluated. During the follow-up period, recurrence was seen in 6 patients. The log-rank test showed that AI was a significant predictor of cancer recurrence. The 5-year disease-free survival rate of the 10 patients in the high AI group (AI > 0.3%) was 100%; while that of the 18 patients in the low AI group (AI < or = 0.3%) was 50.5% (p = 0.036). None of the other molecular biologic markers or clinicopathological factors were found to be a significant predictor of cancer recurrence.

CONCLUSION

Peripheral small-sized invasive lung adenocarcinomas with a low AI carry an increased risk of distant metastases, indicating that adjuvant chemotherapy after complete resection might be needed.

Expression of MDA-7/IL-24 and Its Clinical Significance in Resected Non–Small Cell Lung Cancer

Purpose: The melanoma differentiation-associated gene-7 (MDA-7) protein, also known as interleukin (IL)-24, is a novel candidate of tumor suppressor that can induce apoptosis experimentally in a variety of human malignant cells including lung cancer cells. However, only one clinical study has documented that MDA-7/IL-24 expression is down-regulated with progression of melanoma. Thus, the present study was conducted to assess the clinical significance of MDA-7/IL-24 expression in non–small cell lung cancer.

Experimental Design: A total of 183 consecutive patients with resected pathologic stage I-IIIA, non–small cell lung cancer were retrospectively reviewed, and immunohistochemical staining was used to detect MDA-7/IL-24 expression.

Results: MDA-7/IL-24 expression was high in 97 (53.0%) patients and low in the other patients. There was no significant correlation between MDA-7/IL-24 status and any patients' characteristic including pathologic stage. There was no significant difference in tumor angiogenesis or proliferative activity according to MDA-7/IL-24 status, but MDA-7/IL-24-high adenocarcinoma showed a significantly higher incidence of apoptotic tumor cell death than MDA-7/IL-24-low adenocarcinoma. MDA-7/IL-24-high patients seemed to show a favorable postoperative prognosis as compared with MDA-7/IL-24-low patients (5-year survival rates, 75.9% and 62.0%, respectively), although the difference did not reach a statistical significance (P = 0.061). Subset analyses showed that positive MDA-7/IL-24 expression was a significant factor to predict a favorable prognosis in adenocarcinoma (P = 0.033), which was confirmed by a multivariate analysis; there was no difference in the prognosis according to MDA-7/IL-24 status in squamous cell carcinoma.

Conclusions: MDA-7/IL-24 status was a significant prognostic factor in lung adenocarcinoma, not in lung squamous cell carcinoma.

Matrix Metalloproteinase-2 Status in Stromal Fibroblasts, Not in Tumor Cells, Is a Significant Prognostic Factor in Non–Small-Cell Lung Cancer

PURPOSE

The purpose is to assess clinical significance of matrix metalloproteinase (MMP)-2 and MMP-9 status, especially MMP-2 status, in stromal cells in non-small-cell lung cancer (NSCLC) because experimental studies have revealed that stromal MMP-2 plays important roles in progression of malignant tumors, but most clinical studies focused on tumoral MMP-2 expression, not stromal MMP-2 expression.

EXPERIMENTAL DESIGN

We conducted a retrospective study on MMP-2 and MMP-9 expression as evaluated immunohistochemically in a total of 218 consecutive patients with completely resected pathological stage I-IIIA, NSCLC.

RESULTS

Strong MMP-2 expression in tumor cells and stromal fibroblasts were documented in 54 (24.8%) and 132 (60.6%) patients, respectively. Strong MMP-2 expression in stromal fibroblasts was more frequently seen in squamous cell carcinoma (72.7%) than in adenocarcinoma (54.9%; P = 0.016). Tumors showing strong MMP-2 expression in stromal fibroblasts showed a significantly higher intratumoral microvessel density (IMVD) than weak stromal MMP-2 tumors (mean intratumoral microvessel density, 50.9 versus 32.4, P = 0.003). In addition, postoperative prognosis of strong stromal MMP-2 patients was significantly poorer than that of weak stromal MMP-2 patients (5-year survival rate, 77.5 versus 60.2%, P = 0.032), and the prognostic significance was enhanced in squamous cell carcinoma patients but disappeared in adenocarcinoma patients. Multivariate analyses confirmed that strong stromal MMP-2 expression was a significant factor to predict a poor prognosis in squamous cell carcinoma patients, not in adenocarcinoma patients. In contrast, MMP-2 or MMP-9 status in tumor cells was not a significant prognostic factor.

CONCLUSIONS

MMP-2 status in stromal fibroblasts, not in tumor cells, was a significant prognostic factor associated with angiogenesis in NSCLC.

Clinical significance of VEGF-C status in tumour cells and stromal macrophages in non-small cell lung cancer patients

Recent experimental studies have revealed that tumour-associated stromal macrophages as well as tumour cells express vascular endothelial growth factor C (VEGF-C), which plays important roles in lymphangiogenesis, which is a critical factor in the progression of many malignant tumours including non-small-cell lung cancer (NSCLC). However, no clinical study on VEGF-C expression in both stromal macrophages and tumour cells has been reported, and we conducted the present study to address the issue in resected NSCLC. A total of 206 patients with completely resected pathologic stage I-IIIA NSCLC were retrospectively reviewed. Expression of VEGF-C in primary lung tumour was assessed immunohistochemically. Expression of VEGF-C in tumour cells was high in 125 patients (60.7%), and that in stromal macrophages was positive in 136 patients (71.2%). The status of VEGF-C in tumour cells or in stromal macrophages was not correlated with nodal status or angiogenesis. The 5-year survival rate of high tumoral VEGF-C patients (60.7%) was significantly lower than that of low tumoral VEGF-C patients (39.3%) (P=0.046), and a multivariate analysis confirmed that tumoral VEGF-C status was a significant and independent prognostic factor. Moreover, tumour showing high VEGF-A and VEGF-C expression in tumour cells showed the poorest prognosis (5-year survival rate, 45.1%). The status of VEGF-C in stromal macrophages was not correlated with the prognosis. In conclusion, tumoral VEGF-C status, not stromal VEGF-C status, was a significant prognostic factor in resected NSCLC.

Expression of a novel matrix metalloproteinase regulator, RECK, and its clinical significance in resected non-small cell lung cancer

The reversion-inducing-cysteine-rich protein with Kazal motifs (RECK) was initially isolated as a transformation-suppressor gene by expression cloning and found to encode a membrane-anchored regulator of the matrix metalloproteinases (MMPs). Experimental studies have shown that RECK can suppress tumour - invasion, metastasis and angiogenesis. However, the clinical impact of RECK remains unclear. To assess the clinical significance of RECK-expression in non-small cell lung cancer (NSCLC), a total of 171 patients with completely resected pathological stage (p-stage) I-IIIA NSCLC were retrospectively examined. Expression of RECK and vascular endothelial growth factor (VEGF) in tumour tissues was assessed by immunohistochemical staining (IHS). Intratumoural microvessel density (IMVD), a measurement of angiogenesis, was also determined by IHS using an anti-CD34 antibody. A significant inverse correlation between RECK-expression and tumour angiogenesis was documented; the mean IMVD in tumours with strong RECK-expression (157.1) was significantly lower than that observed in tumours with weak RECK-expression (194.5; P = 0.008). Interestingly, this inverse correlation was seen only when VEGF was strongly expressed, which suggests that RECK could suppress the angiogenesis induced by VEGF. The 5-year survival rate for patients with tumours with strong RECK-expression (75.8%) was significantly higher than that for patients with weakly expressing tumours (54.3%; P = 0.016). Subset analyses showed that the prognostic impact of RECK-status was evident in patients with either adenocarcinoma, poorly differentiated tumours, or p-stage IIIA disease. A multivariate analysis confirmed that reduced RECK-expression was an independent and significant factor in predicting a poor prognosis (P = 0.009; Hazard ratio (HR), 0.474 with a 95% Confidence interval (CI) of 0.271-0.830). In conclusion, RECK-status is a significant prognostic factor correlated with tumour angiogenesis in NSCLC patients.

Prognostic Factors in Resected Pathologic (p-) Stage IIIA-N2, Non-Small-Cell Lung Cancer

BACKGROUND

Postoperative prognosis for patients with pathologic (p-) stage IIIA-N2 non-small-cell lung cancer (NSCLC) is poor, and significant factors that influence the prognosis remain unclear.

METHODS

A total of 99 patients who underwent complete resection for p-stage IIIA-N2 NSCLC without any preoperative therapy were retrospectively reviewed. Biological features such as tumor angiogenesis (intratumoral microvessel density [IMVD]), proliferative activity (proliferative index [PI]), and p53 status were also evaluated immunohistochemically.

RESULTS

Univariate analysis revealed that the number of involved N2 stations was a significant prognostic factor; 5-year survival rates for a tumor with metastases in single N2 stations, tumor with metastases in two N2 stations, and tumor with metastases in 3 or more N2 stations were 41.6%, 35.3%, and 0.0%, respectively (P =.041) In addition, the 5-year survival rate for cN0-1 disease was significantly higher than that for cN2 disease (41.9% and 25.5%, respectively; P =.048) Tumor angiogenesis and proliferative activity were the most significant prognostic factors; 5-year survival rates for lower-IMDV tumor and higher-IMVD tumor were 53.6% and 15.9%, respectively (P =.002), and those for lower-PI tumor and higher-PI tumor were 47.0% and 20.4%, respectively (P =.019) There was no difference in the postoperative survival between tumor showing aberrant p53 expression and tumor showing no aberrant p53 expression. These results were confirmed by a multivariate analysis.

CONCLUSIONS

P-stage IIIA-N2 NSCLC cases represented a mixture of heterogeneous prognostic subgroups, and the number of involved N2 stations, cN status, PI, and IMVD were significant predictors of the survival.

Expression of thymidylate synthase is correlated with proliferative activity in non-small cell lung cancer (NSCLC)

Many experimental studies have revealed that enhanced thymidylate synthase (TS) expression is significantly correlated with higher proliferative activity of tumor cells, which may account for a poor prognosis of high-TS patients. However, only a few clinical studies have focused on the correlation between TS status and cell proliferation. Therefore, we assessed the correlation between TS expression and proliferative index (PI) as a marker of cell proliferation or p53 status in a total of 109 patients with completely resected pathologic stage I, non-small cell lung cancer (NSCLC). PI was defined as the percentage of tumor cells with positive staining against proliferative cell nuclear antigen (PCNA). The mean PIs of TS-high and TS-low tumors were 48.2% and 34.4% respectively, showing a significantly higher proliferative activity of TS-high tumor (P=0.020); when stratified according to histological type, the difference was significant in adenocarcinoma (P=0.038), but not in squamous cell carcinoma. There was no significant correlation between TS expression and p53 status. In conclusion, tumor cells with higher TS expression have higher proliferative activity in NSCLC, especially in adenocarcinoma.

Correlation between apoptotic index and angiogenesis in non-small cell lung cancer: comparison between CD105 and CD34 as a marker of angiogenesis

Only a few clinical studies have documented a significant correlation between intratumoral microvessel density (IMVD), a measurement of angiogenesis, and apoptotic index (AI), an incidence of apoptosis, although many experimental studies have confirmed that insufficient angiogenesis induces accelerated apoptotic cell death. In the present study, therefore, to assess AI in correlation with IMVD in resected non-small cell lung cancer, a total of 236 patients with pathologic stage I to IIIa were reviewed. IMVDs were determined immunohistochemically with an antibody against a pan-endothelial marker, CD34 (CD34-IMVD), and an antibody against a proliferation-related endothelial marker, CD105 (CD105-IMVD). AI was defined as the number of tumor cells positive for the terminal deoxynucleotidyl tranferase-mediated dUTP-biotin nick end-labeling staining per 1000 tumor cells. When CD34 was used as a marker of angiogenesis, the mean AIs for the lower-IMVD and the higher-IMVD patients were 20.1 and 17.5, respectively, demonstrating no significant difference between the lower- and the higher-IMVD patients. In contrast, when CD105 was used, the mean AI for the lower-IMVD patients was significantly higher than that for the higher-IMVD patients (22.0 and 15.6, respectively; P=0.019). There was no significant correlation between proliferative activity and CD34-IMVD or CD105-IMVD. These results demonstrated that that decreased angiogenesis may induce enhanced apoptotic tumor-cell death without affecting cell proliferation.

Primary lung carcinoma arising from emphysematous bullae

To clarify clinical characteristics and biological features of primary lung carcinoma arising from emphysematous bullae (EB), a total of 50 patients (49 males and one female) among all 1478 patients who underwent operation for primary lung carcinoma cases were reviewed; biological features were examined in 31 patients whose resected specimens were available for immunohistochemical staining (IHS). Thirty-one patients (62.0%) had pathologic stage I disease, and 30 cases (60.0%) had poorly differentiated tumor, demonstrating earlier pathologic stages and poorer cell differentiation of lung carcinoma with EB as compared with that without EB. The mean proliferative index (PI) for carcinoma with EB was 64.0%, which was significantly higher than that for carcinoma without EB (47.2%, P = 0.001); no significant difference in Apoptotic index (AI) was demonstrated. Aberrant p53 expression was less frequent in carcinoma with EB (29.0%) than in carcinoma without EB (47.9%, P = 0.043). Five-year survival rates for carcinoma with and that without EB were 50.3 and 46.9%, respectively, showing no significant difference. Multivariate analysis did not demonstrate that association of EB was a significant prognostic factor. In conclusion, although with the poorer cell differentiation and accelerated proliferative activity of lung carcinoma arising from EB, this does not have a significantly different prognosis than primary lung carcinoma not associated with bullae.

Clinical significance of p21 expression in non-small-cell lung cancer

PURPOSE

The clinical significance of p21 expression remains unclear, whereas many experimental studies have demonstrated that p21, the product of the WAF1/CIP1/SDI1 gene, plays an important role in regulation of the cell cycle as an inhibitor of cyclin-dependent kinases. The purpose of this study was to clarify the clinical significance in resected non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

A total of 233 consecutive patients with completely resected pathologic stage I to IIIA NSCLC were retrospectively reviewed. Expression of p21 and the status of p53 were examined immunohistochemically. Proliferative activity was also evaluated immunohistochemically. The incidence of apoptotic cell death was evaluated by terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate-biotin nick end-labeling staining.

RESULTS

Expression of p21 was positive in 120 patients (51.5%). The 5-year survival rate of p21-positive patients was 73.8%, significantly higher than that of p21-negative patients (60.7%; P =.006). Aberrant expression of p53 was positive in 98 patients (42.1%). When combined with p53 status, the prognostic value of p21 status was enhanced: the 5-year survival rate of p21-positive and p53-negative patients was 80.7%, markedly higher than that of p21-negative and p53-positive patients (50.0% for both; P =.001). Multivariate analysis confirmed that positive expression of p21 was a significant factor for predicting a favorable prognosis. There was no significant correlation between p21 expression and p53 status, proliferative activity, or incidence of apoptosis.

CONCLUSION

p21 expression was shown to be an independent prognostic factor in NSCLC.

Prognostic factors in non-small cell lung cancer: a decade of progress

STUDY OBJECTIVES

To provide a systematic overview of the literature investigating patient and tumor factors that are predictive of survival for patients with non-small cell lung cancer (NSCLC), and to analyze patterns in the design of these studies in order to highlight problematic aspects of their design and to advocate for appropriate directions of future studies.

DESIGN

A systematic search of the MEDLINE database and a synthesis of the identified literature.

MEASUREMENTS AND RESULTS

The database search (January 1990 to July 2001) was carried out combining the MeSH terms prognosis and carcinoma, nonsmall cell lung. Eight hundred eighty-seven articles met the search criteria. These studies identified 169 prognostic factors relating either to the tumor or the host. One hundred seventy-six studies reported multivariate analyses. Concerning 153 studies reporting a multivariate analysis of prognostic factors in patients with early-stage NSCLC, the median number of patients enrolled per study was 120 (range, 31 to 1,281 patients). The median number of factors reported to be significant in univariate analyses was 4 (range, 2 to 14 factors). The median number of factors reported to be significant in multivariate analyses per study was 2 (range, 0 to 6 factors). The median number of studies examining each prognostic factor was 1 (range, 1 to 105 studies). Only 6% of studies addressed clinical outcomes other than patient survival.

CONCLUSIONS

While the breadth of prognostic factors studied in the literature is extensive, the scope of factors evaluated in individual studies is inappropriately narrow. Individual studies are typically statistically underpowered and are remarkably heterogeneous with regard to their conclusions. Larger studies with clinically relevant modeling are required to address the usefulness of newly available prognostic factors in defining the management of patients with NSCLC.

Characteristics of long-term survivors of untreated lung cancer

Non-small cell lung cancer (NSCLC) is a malignant tumor with poor prognosis. Although the prognostic variables determining short-term survival have been well described, relatively little attention has been paid to factors associated with long-term survival. In search of these factors we studied the expression of several molecular markers in NSCLC. Only tumor samples of patients with squamous cell carcinomas and stage III tumors with a postoperative survival of at least 5 years and those of patients who died within 2 years after resection were selected for this study. The expression of several parameters including oncogene and suppressor gene products, proliferative, apoptotic, angiogenic and resistance-related factors were investigated and the differences in these two extreme populations were determined by the Wilcoxon rank sum test. Factors involved in proliferation (ras, fos, erbB-1, jun, cyclin A) were downregulated whereas factors involved in apoptosis (p53, bcl-2, CD95) were upregulated in the long survival group. Direct measurement of parameters of proliferation (cell cycle analysis by flow cytometry, PCNA index) revealed a lower proliferative activity in tumors of the long survivors compared to short survivors. In conclusion, tumors of the long survival group are characterized by a downregulation of factors involved in proliferation and an upregulation of factors involved in apoptosis. These tumors may grow more slowly and this may influence long-term survival of patients with NSCLC.

Apoptotic tumor-cell death in response to cell proliferation is influenced by p53 status in resected non-small cell lung cancer

To evaluate the influence of p53 status on postoperative survival and incidence of apoptosis (apoptotic index, AI) in non-small cell lung cancer (NSCLC), a total of 185 pathologic stage I patients were retrospectively analyzed. It was demonstrated by univariate and multivariate analyses that aberrant expression of p53 was a significant factor to predict a poor prognosis, which was caused by a significantly higher proliferative index (PI) in tumor with aberrant expression of p53 (52.7%) than that in tumor without aberrant expression of p53 (37.9%, P < 0.001). In addition, for tumor without aberrant expression of p53, mean AIs of the lowest-, the lower-, the higher-, and the highest-PI groups were 12.6, 12.9, 31.3, and 35.1, respectively, showing that incidence of apoptosis was markedly increased in response to cell proliferation (P = 0.002). In contrast, for tumor with aberrant expression of p53, no increase in incidence of apoptosis in response to cell proliferation was documented. These results clearly demonstrated that active cell proliferation and reduced apoptotic cell death in response to cell proliferation resulted in the poor postoperative prognosis in tumor with aberrant expression of p53.

Clinical significance of nm23 expression in resected pathologic-stage I, non-small cell lung cancer

BACKGROUND

Clinical significance of the status of nm23 gene, originally identified as an antimetastatic gene, in non-small cell lung cancer remains unestablished, whereas many clinical studies have demonstrated that reduced nm23 expression is correlated with tumor progression and poor prognosis in a variety of malignant tumors such as breast carcinoma.

METHODS

nm23 expression was examined immunohistochemically in a total of 117 patients with completely resected pathologic stage I non-small cell lung cancer.

RESULTS

nm23 expression was positive in 73 (62.4%) patients, and there was no correlation between nm23 expression and age, sex, performance status, pathologic T factor, histologic type, or degree of cancer cell differentiation. The 5-year survival rates of nm23-positive and nm23-negative patients were 79.7% and 57.8%, respectively, demonstrating a significantly poorer prognosis in nm23-negative patients (p = 0.013), which was confirmed by a multivariate analysis. nm23 was not correlated with the incidence of apoptosis, proliferative activity, or p53 status.

CONCLUSIONS

nm23 expression was a significant factor for predicting a favorable prognosis, suggesting antimetastatic potential of the nm23 gene in non-small cell lung cancer.

Angiogenesis and antiangiogenic agents in non-small cell lung cancer

Tumour angiogenesis is the result of the imbalance between a large number of mediators with angiogenic and antiangiogenic activity. It may be a very early process in vivo and it may follow different pathways in different organs. Moreover, different roles of angiogenic molecules have been observed in normal and neoplastic lung and striking differences between non-small cell lung carcinomas (NSCLC) and SCLC have been observed. Contradictory results are reported in the literature on the association of angiogenesis with poor prognosis in NSCLC. Among the currently available antiangiogenic therapies, the inhibitors of vascular endothelial growth factor (VEGF), and their receptor (VEGFR) and matrix metallo-proteinase (MMP), some antivascular agents and the antiangiogenic scheduling of chemotherapy are beginning to show clinical efficacy. The best use of the antiangiogenic therapies will probably be in presence of low tumour burdens and in association with chemotherapy. However, new surrogate markers of tumour response have to be defined.

Prognostic factors in stage I/II non-small cell lung cancer

Even in localized stages of non-small cell lung cancer, which are amenable to curative surgery, prognosis has remained disappointing over the last decades. Thus, in these tumor stages, adjuvant therapy strategies are discussed. In the last decade, numerous prognostic factors have been investigated, which might select patients for additional treatment. In this review, the prognostic impact of individual tumor cell dissemination, tumor cell proliferation, apoptosis, several parameters of angiogenesis (microvessel density, VEGF, bFGF, VEGF receptors), p53, bcl-2, ras, p27(Kip1), erbB-2, telomerase as well as the retinoblastoma tumor suppressor gene is analysed. Up to now, none of these factors has gained a sufficient selectivity to serve as an exclusive discriminator for adjuvant therapy. Nevertheless, a combination of several parameters might contribute to characterize patient subgroups with localized non-small cell lung cancer at high risk for distant relapse.

Prognostic factors in patients with resected pathologic (p-) T1-2N1M0 non-small cell lung cancer (NSCLC)

OBJECTIVES

To clarify prognostic factors in resected pathologic (p-) T1-2N1M0 non-small cell lung cancer (NSCLC).

METHODS

A total of 95 consecutive patients who underwent complete tumor resection and mediastinal dissection for pT1-2N1M0 NSCLC between 1976 and 1997 were retrospectively reviewed. p53 status and proliferative activity were evaluated immunohistochemically.

RESULTS

The extent of N1 stations and p53 status proved to be significant prognostic factors. The 5-year survival rate for tumor without hilar node (#10) involvement was 66%, significantly higher than that for tumor with #10 involvement (39%, P<0.01). The 5-year survival rate for tumor with aberrant p53 expression was 37%, significantly lower than that for tumor without aberrant p53 expression (74%, P<0.01). There proved to be no significant difference in the prognosis between pT1 disease and pT2 disease; the 5-year survival rates for pT1 and pT2 diseases were 62 and 56%, respectively. Age, gender, performance status, grade of tumor differentiation, histological type, or proliferative activity were not significant factors. Multivariate analysis of prognostic factors using Cox's proportional hazard model confirmed these results.

CONCLUSIONS

Involvement of the hilar node and aberrant p53 expression were significant factors to predict a worse prognosis in resected T1-2N1M0 NSCLC.

Apoptosis and p53 status predict the efficacy of postoperative administration of UFT in non-small cell lung cancer

To examine whether efficacy of postoperative oral administration of UFT, a 5-fluorouracil derivative chemotherapeutic agent, may be influenced by incidence of apoptosis (apoptosis index) or apoptosis-related gene status (p53 and bcl-2) of the tumour, a total of 162 patients with pathologic stage I non-small cell lung cancer were retrospectively reviewed. UFT was administrated postoperatively to 44 patients (UFT group), and not to the other 118 patients (Control group). For all patients, 5-year survival rate of the UFT group (79.9%) seemed higher than that of the Control group (69.8%), although without significant difference (P = 0.054). For patients with higher apoptotic index, 5-year survival rate of the UFT group (83.3%) was significantly higher than that of the Control group (67.6%, P = 0.039); for patients with lower apoptotic index, however, there was no difference in the prognosis between these two groups. Similarly, UFT was effective for patients without p53 aberrant expression (5-year survival rates: 95.2% for the UFT group and 74.3% for the Control group, P = 0.022), whereas not effective for patients with p53 aberrant expression. Bcl-2 status did not influence the efficacy of UFT. In conclusion, apoptotic index and p53 status are useful factors to predict the efficacy of postoperative adjuvant therapy using UFT.

Biological features and preoperative evaluation of mediastinal nodal status in non-small cell lung cancer

BACKGROUND

To examine whether biological features of primary tumor can help preoperative evaluation of mediastinal nodal status in non-small cell lung cancer.

METHODS

A total of 450 patients who underwent tumor resection and mediastinal dissection were reviewed. p53 status and proliferative fraction (PI) were evaluated immunohistochemically.

RESULTS

The accuracy of preoperative evaluation of mediastinal nodal status with computed tomography (CT) was 72.2%; mediastinal nodal metastases had not been revealed until operation in 59 patients (13.1%) (false-negative), and no metastasis was revealed in 66 patients (14.7%) although mediastinal nodal enlargement had been demonstrated by CT (false-positive). The number of false-negative patients was significantly larger when p53 aberrant expression was positive or when PI was higher. Combined with p53 status and PI, there were 27 false-negatives (24.1%) among patients with aberrant p53 expression and higher PI, whereas only two false-negatives (1.5%) among those with negative p53 expression and lower PI.

CONCLUSIONS

Mediastinoscopy may be recommended for tumor showing aberrant p53 expression and higher PI, even when CT demonstrates no mediastinal nodal enlargement.