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

Prognostic Factors of IIIAN2 Non-Small-Cell Lung Cancer after Complete Resection: A Systemic Review and Meta-analysis

METHODS

An extensive data search was conducted from all leading databases including PubMed, Google Scholar, Embase, and Cochrane. Fifteen studies were selected according to the PRISMA model of data selected to conduct this systemic review meta-analysis.

RESULTS

Total 4444 patients were evaluated among fifteen selected studies. A number of lymph nodes involved (n = 3965), level of lymph nodes (n = 3422), and complete tumor resection (n = 3255) were the most reported prognostic factors.

CONCLUSION

This study exhibits the overall significance of all prognostic factors of NSCLC IIIAN2 pathology for better patient management. However, other management strategies also play a significant contribution to achieving a better survival rate and less recurrence possibility.

Long-Term Survival According to N Stage Diagnosed by Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration in Non-Small Cell Lung Cancer

BACKGROUND

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the main procedure for mediastinal staging. However, long-term survival analyses according to cN stage diagnosed by EBUS-TBNA (abbreviated to eN stage) have not been reported. The value of EBUS-TBNA has not been assessed through an analysis of survival in false-negative EBUS-TBNA cases.

RESEARCH QUESTIONS

What is the prognostic impact of eN stage in non-small cell lung cancer (NSCLC)? What is the survival rate in false-negative EBUS-TBNA cases?

STUDY DESIGN AND METHODS

We retrospectively (January 2006-December 2011) reviewed the medical records of NSCLC patients who underwent EBUS-TBNA (± transesophageal approach) for initial staging (n=1,089). Mediastinoscopy was not performed for EBUS-TBNA negative cases. We performed 5-year survival analyses according to eN stage and treatment modality. Survival in false-negative EBUS cases was compared with that in pN0-1 patients, including 941 non-EBUS cases, during the same period.

RESULTS

Among 1,089 EBUS patients (eN0-1=681, eN2=314, eN3=94), we observed significant differences in survival between the eN stages [eN0-1 vs eN2; p <0.0001, eN2 vs eN3; p=0.0118, estimated 5-year overall survival (5YOS) rate: eN0-1=57.4%, eN2=23.2%, eN3=12.8%]. Surgery cases had better survival than non-surgery cases among eN0-1 and eN2 patients (eN0-1/surgery vs. eN0-1/no surgery; p<0.0001, eN2/surgery vs. eN2/no surgery; p<0.0001). Among eN0-1 patients, there were 55 false-negative cases (eN0-1/pN2-3, pN2=54, pN3=1). The 5YOS rates of pN0, pN1, and eN0-1/pN2-3 patients were 76.4%, 56.0% and 56.4%, respectively. eN0-1/pN2-3 patients had worse survival than pN0 patients (p=0.0061), whereas there was no significant difference compared with pN1 patients (p=0.9191).

INTERPRETATIONS

Long-term survival significantly differed according to eN stage in NSCLC, highlighting the importance of EBUS-TBNA in NSCLC staging. False-negative EBUS-TBNA cases had favorable survival which was similar to that of pN1 patients, which may provide a rationale for performing surgery after negative EBUS-TBNA results.

Long term and disease-free survival following surgical resection of occult N2 lung cancer

Background

Despite systematic investigation with computed tomography (CT), positron emission tomography (PET)/CT, CT or magnetic resonance imaging (MRI) brain imaging and supplementary investigation using endobronchial ultrasound guided biopsy (EBUS), endo-oesophageal ultrasound guided biopsy (EUS), fine needle aspiration (FNA), mediastinoscopy or mediastinotomy, there is an approximately 10% rate of occult N2 disease identified at pathological staging. It has been hypothesised that such occult disease, too small or inactive to be identified during pre-operative multi-modality staging, may represent low volume disease that may have equivalent survival to patients with similar stage at clinical, pre-operative assessment. We compared the long-term survival and disease-free survival of patients with the same clinical TNM stage with and without occult N2 disease.

Methods

We retrospectively analysed a database that prospectively captured information on all patients assessed and treated for lung cancer in our surgical unit. We reviewed data on patients who underwent lung cancer surgery with curative intent between January 2006 and August 2010.

Results

A total of 312 lung cancer resections were performed [mean age 68 (range, 42-86) years old and male:female ratio 1.14:1]. Occult N2 disease was identified in 28 (8.7%) of 312 patients. There was no difference in the rate of N2 disease for different tumour histological types. Five-year survival with occult N2 disease was 35.8% vs. 62.5% without. Median survival was 34 months with occult N2 disease vs. 84 months without.

Conclusions

With contemporary staging techniques, so-called occult N2 disease, even with low volume and PET non-avid disease, does not have an indolent course and should still be considered a risk factor for poorer prognosis.

C-reactive protein-albumin ratio is an independent prognostic predictor of tumor recurrence in stage IIIA-N2 lung adenocarcinoma patients

OBJECTIVE

To systematically evaluate the prognostic value of nutrition/inflammation-based markers for recurrence-free survival (RFS) in pN2-stage IIIA lung adenocarcinoma patients.

MATERIALS AND METHODS

Data from 156 patients who had pathologically confirmed pN2-stage IIIA primary lung adenocarcinoma and received complete surgical resection from 2010 to 2014 were retrospectively analyzed. The data for Glasgow prognostic score (GPS), modified GPS (mGPS), high-sensitivity mGPS, C-reactive protein/albumin ratio (CAR), neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, and prognostic nutritional index were analyzed. Univariate and multivariate Cox proportional-hazards regression analyses were used to identify the prognostic factors associated with RFS.

RESULTS

The optimal cutoff value for the CAR was set at 0.6. A significant correlation was found between the CAR and RFS (P=0.001) by univariate analysis. Multivariate analysis between RFS and the factors selected from univariate analysis showed that ECOG performance status, pneumonectomy, multi-level N2, and high CAR were independent predictors of RFS.

CONCLUSION

The CAR was the best prognostic marker to predict tumor recurrence in pN2-stage IIIA lung adenocarcinoma patients among the 7 nutrition/inflammation-based markers. The preoperative CAR may identify patients with a high risk of postoperative tumor recurrence.

Definitive chemoradiation for non-small-cell lung cancer: could a consensus be reached?

AIMS AND BACKGROUND

There is currently no consensus as to which chemotherapy to combine with thoracic radiotherapy (TRT) in the setting of definitive chemoradiation for non-small-cell lung cancer (NSCLC). We aimed to retrospectively evaluate the efficacy and report outcome measures of cisplatin/etoposide with conventionally fractionated TRT over a 9-year period.

METHODS

Cisplatin 50 mg/m² on days 1, 8, 29, and 36 and etoposide 50 mg/m² on days 1-5 and 29-33 with conventionally fractionated conformal radiation therapy starting on day 1 was given to 201 eligible patients. Patient records were reviewed for overall survival (OS) and progression-free survival (PFS).

RESULTS

The 2-year OS and PFS were 53% and 47%, respectively, while the 3-year OS and PFS were 18% and 17%, respectively. No grade 4 or treatment-related deaths were recorded, and grade 3 hematologic toxicity occurred in only 22 patients (11%) in the form of granulocytopenia and thrombocytopenia. Multivariable analysis showed clinical stage and Eastern Cooperative Oncology Group performance status to statistically significantly affect PFS and OS.

CONCLUSIONS

Cisplatin and etoposide in these doses with conventionally fractionated TRT is a well-tolerated, effective treatment schedule in the definitive treatment of unresectable or inoperable NSCLC.

Prognostic value of pro-inflammatory cytokine and pro-angiogenesis factor in differentiating malignant from benign exudative effusion

BACKGROUND AND AIMS

The precise mechanism of pathogenesis in exudation of effusions is uncertain. Released factors in inflammation and malignancy of pleura are related to incremented permeability of the micro-pleural vessels. Angiopoietins (Ang) take part in development of angiogenesis and pleural inflammation. Interleukin-8 (IL-8) influences proliferation and tumor angiogenesis and it is expressed in cancer. The aims of this study were to investigate the relationship between inflammation, angiogenesis and etiologies of exudative effusions, and to evaluate the diagnostic value in differentiating malignant from benign.

METHODS

The study includes 49 pleural fluid (PF) samples. Ang-2 and IL-8 in PF and serum were estimated.

RESULTS

Ten patients were transudative and 39 patients were exudative fluid, subdivided into 16 benign and 23 malignant effusion. Ang-2 and IL-8 either fluid level or ratio were in significantly high in exudative more than in transudative fluid (P = 0.002). Ang-2 and IL-8 in PF were in high level than in serum of exudative and transudative. Ang-2 fluid level and ratio were significantly high in benign exudative effusion (P = 0.01, P = 0.05, respectively), while IL-8 level was significantly high in malignant exudative effusion (P = 0.04). Cut-off points for PF Ang-2 and IL-8 in differentiating malignant from benign exudative were 15.67 ng/mL, 325.54 pg/mL, respectively.

CONCLUSION

Our results support the evidence that angiogenesis and inflammatory pathways are linked, and that inflammation and vascular permeability of pleura constitutes the pathogenic basis of the majority of exudative effusion.

Risk factors for recurrence after complete resection of pathological stage N2 non-small cell lung cancer

Background

Tumor recurrence is the most common cause of treatment failure, especially after complete resection of pathological stage N2 non-small cell lung cancer (NSCLC). In this study, we investigated the clinicopathological characteristics in order to identify independent risk factors for postoperative recurrence.

Methods

Between January 2001 and December 2013, 96 patients who underwent surgical resection for pathological N2 NSCLC were retrospectively reviewed. Recurrence-free survival (RFS) was calculated by the Kaplan-Meier method to explore risk factors, while the Cox proportional hazard model was used to assess independent predictors.

Results

The median and five-year RFS rates were 15 months and 27.4%, respectively. Univariate analysis showed a significantly poorer prognosis for non-regional N2 metastasis, more than three metastatic N2 lymph nodes, multiple N2 station, and multiple N2 zone involvement. Multivariate analysis demonstrated that non-regional N2 metastasis (hazard ratio [HR] 1.857, 95% confidence interval [CI] 1.061–3.249, P = 0.030) and more than three metastatic N2 lymph nodes (HR 2.555, 95% CI 1.164–5.606, P = 0.019) were independent risk factors for RFS. Additionally, the incidence of non-regional N2 metastasis was higher in patients with a primary tumor in the left lower (57.1%) or right lower lobe (48.1%), followed by left upper (31.8%), right middle (14.3%) and right upper lobe (7.7%).

Conclusion

The combination of the distribution and number of metastatic N2 lymph nodes provides a more accurate prediction for N2 NSCLC regarding recurrence. Non-regional N2 metastasis could occur with a primary tumor in any lobe, but occurs more frequently in the lower lobe.

Size of Stage IIIA Primary Lung Cancers and Survival: A Surveillance, Epidemiology and End Results Database Analysis

Size of early-stage lung cancer is important in the prognosis of patients. We examined the large population-based Surveillance, Epidemiology and End Results database to determine if tumor size was an independent risk factor of survival in patients undergoing lobectomy for N2 positive Stage IIIA nonsmall cell lung cancer (NSCLC). This study identified 1971 patients diagnosed with N2 positive Stage IIIA NSCLC, from 1998 to 2007, and who underwent lobectomy. Five tumor groups based on the seventh edition TNM lung cancer staging system (pathologic T1a 2 cm or less; T1b greater than 2 cm and 3 cm or less; T2a greater than 3 cm and 5 cm or less; T2b greater than 5 cm and 7 cm or less; T3 greater than 7 cm) were analyzed. Survival was reduced in patients with T3, T2a, and T2b tumors compared with patients with T1a and T1b ( P < 0.001). Survival estimates correlated with tumor size with poorer survival in T3 followed by T2b, T2a, and then T1b and T1a. Cohorts with T1a (hazard ratio [HR], 0.53; P = 0.01) and T1b (HR, 0.54; P = 0.01) were both found to have decreased hazard of death. Negative predictors of survival, in addition to increasing tumor size, included age and male gender, whereas positive predictors included tumor Grade I and upper lobe location. Increasing size of tumor is an independent negative risk factor for survival in patients undergoing lobectomy for N2 positive Stage IIIA NSCLC.

Sex and SUVmax: sex-dependent prognostication in early non-small cell lung cancer

The identification of robust prognostic factors for patients with early-stage non-small cell lung cancer (NSCLC) is clinically important. The International Association for the Study of Lung Cancer has identified both sex and the maximum standardized uptake value (SUVmax) of (18)F-FDG in the primary tumor as measured by PET as potential prognostic variables. We examined the prognostic value of SUVmax in a surgical cohort of patients with NSCLC and disaggregated the findings by sex.

METHODS

Patients who had undergone a preoperative PET/CT scan and surgical resection with curative intent from 2001 to 2009 were identified from a prospective database. An SUVmax cutoff was calculated using receiver-operating-characteristic curves. Overall survival was correlated with SUVmax for the whole cohort and disaggregated by sex.

RESULTS

Inclusion criteria were met by 189 patients: 127 (67%) men and 62 (33%) women. Five-year survival was 54.6% for the whole cohort, 47.7% for men, and 68.2% for women. SUVmax correlated negatively with survival in a univariate analysis for the whole cohort (hazard ratio [HR], 2.51; 95% confidence interval [CI], 1.54-4.09; P < 0.001) and men (HR, 3.42; 95% CI, 1.94-6.05; P < 0.001) but not for women (HR, 1.61; 95% CI, 0.43-3.12; P = 0.77), using 8 as a cutoff. In multivariate analysis, SUVmax correlated with overall survival for the whole cohort (HR, 1.70; 95% CI, 1.05-2.99; P = 0.05) and men (HR, 2.40; 95% CI, 1.32-4.37; P = 0.004) but not for women (HR, 0.80; 95% CI, 0.15-4.47; P = 0.80).

CONCLUSION

SUVmax independently predicted overall survival for men but not for women in this surgical cohort. Our results suggest that SUVmax is an independent prognostic variable in men with surgically treated early NSCLC.

Prognostic factors in stage III non-small cell lung cancer: a review of conventional, metabolic and new biological variables

Lung cancer is one of the most frequently occurring neoplasms and usually has a poor prognosis because most of the patients present with advanced or metastatic disease at the time of diagnosis. Numerous prognostic factors (PFs) have been studied, but the two most prominent, having both prognostic and operational values, are disease stage and performance status. Even if the literature on PFs in lung cancer is impressive, the number of publications specifically dealing with PFs in stage III non-small cell lung cancer (NSCLC) is limited. We reviewed the literature on this topic and separated the available information into three groups: conventional PFs, metabolic criteria (standardized uptake value [SUV] measured on(18)F-FDG-PET) and new biomarkers. Performance status and the distinction between stage IIIA and IIIB confirmed their prognostic value in stage III NSCLC. Other conventional PFs have been suggested such as age, weight loss, response to treatment and some characteristics describing the locoregional extension of the tumour. There is a place for the SUV as a PF for survival in early NSCLC, but its role in stage III NSCLC has to be further assessed. Some new biomarkers involved in cell cycle regulation or in apoptosis have been shown to have potential value. Their role needs to be confirmed in large prospective studies including conventional PFs to determine their independent value as a PF in stage III NSCLC. In conclusion, few PFs have been well evaluated in stage III NSCLC. New studies, taking into account the modifications derived from the 7th international staging system of the UICC, have to be performed.

[The clinical value of routine preoperative surgical staging to mediastinal lymph nodes on lung cancer]

背景与目的

探讨肺癌术前常规纵隔淋巴结外科分期的临床价值。

方法

76例肺癌患者开胸术前常规行纵隔淋巴结活检，以术后病理为金标准，比对术前胸部CT和纵隔镜对肺癌纵隔淋巴结转移的诊断效能。

结果

术前胸部CT对纵隔淋巴结转移的诊断敏感性、特异性、准确性、阳性预测值和阴性预测值分别为68.5%、66.7%、68.4%、84.6%和16.7%。纵隔镜检查术则分别为87.5%、100%、84.2%、100%和60%。

结论

肺癌术前常规纵隔镜检查术对纵隔淋巴结分期的优势明显，具有极高的临床实用价值。

The angiogenetic pathway in malignant pleural effusions: Pathogenetic and therapeutic implications

Increased permeability of the pleural microvasculature is generally attributed to the substances that are released in inflammatory and malignant pleural effusions, although the exact pathogenetic mechanisms of malignant pleural effusions are unclear. Current therapies used to prevent the re-accumulation of pleural fluid and relieve symptoms are of variable efficacy and may cause serious adverse effects. Understanding the mechanisms of fluid accumulation would hopefully permit the development of more specific, effective and safer treatment modalities. Angiogenesis, pleural vascular increased permeability and inflammation are considered central to the pathogenesis of malignant pleural effusions. Vascular endothelial growth factor (VEGF) is a member of the VEGF/platelet-derived factor gene family and consists of at least six isoforms. Since it was shown that VEGF contributes to the formation of malignant pleural effusions, there have been some attempts to implicate, therapeutically, this finding using different molecules (ZD6474, PTK 787 and bevacizumab). However, the role of the biological axis of VEGF and angiopoietins needs further investigation in both the pathogenesis and the treatment of malignant pleural effusion. In both non-small-cell lung carcinoma and breast cancer, it has been shown that the ligand for CXCR4, CXCL12 or SDF-1α, exhibited peak levels of expression in organs that were the preferred destination for their respective metastases. Recent findings imply that new therapeutic strategies aimed at blocking the SDF-1-CXCR4 axis may have significant applications for patients by modulating the trafficking of hemato/lymphopoietic cells and inhibiting the metastatic behavior of tumor cells as well. The purpose of this report is to review novel pathogenetic and therapeutic implications regarding the angiogenetic pathways in malignant pleural effusions.

Warburg revisited: imaging tumour blood flow and metabolism

In the 1930s, Otto Warburg reported that anaerobic metabolism of glucose is a fundamental property of all tumours, even in the presence of an adequate oxygen supply. He also demonstrated a relationship between the degree of anaerobic metabolism and tumour growth rate. Today, this phenomenon forms the basis of tumour imaging with fluorodeoxyglucose positron emission tomography (FDG-PET). More recently, Folkman has demonstrated that malignant growth and survival are also dependent on tumour vascularity which is increasingly evaluated in vivo using techniques such as contrast enhanced computed tomography or magnetic resonance imaging (MRI). Although it is reasonable to hypothesise that the metabolic requirements of tumours are mirrored by alterations in tumour haemodynamics, the relationship between tumour blood flow and metabolism is in fact complex. A well-developed tumour vascular supply is required to ensure a sufficient delivery of glucose and oxygen to support the metabolism essential for tumour growth. However, an inadequate vascularisation of tumour will result in hypoxia, a factor that is known to stimulate anaerobic metabolism of glucose. Thus, the balance between tumour blood flow and metabolism will be an important indicator of the biological status of a tumour and hence the tumour's likely progression and response to treatment. This article reviews the molecular biology of tumour vascularisation and metabolism, relating these processes to currently available imaging techniques while summarising the imaging studies that have compared tumour blood flow and metabolism. The potential for vascular metabolic imaging to assess tumour aggression and sub-classify treatment response is highlighted.

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.

Immunophenotypic profiling of nonsmall cell lung cancer progression using the tissue microarray approach

This study, using tissue microarrays, aimed at the immunomorphologic profiling of nonsmall cell lung cancer (NSCLC) cases to reveal clinically relevant disease groups and biomarkers associated with patients' survival and tumor progression including brain metastatic potential. Donor tissue blocks were form 59 patients, including 33 primary tumors without distant metastasis and 26 brain metastatic primary tumors as well as the brain metastases. Sections were immunostained for 29 markers targeting molecules of cell adhesion, cell growth, cell cycle, and apoptosis regulation. beta-Catenin expression was the only independent prognostic marker associated with better outcome. Elevated expression of collagen XVII, CD44v6, and caspase-9, and the reduced production of beta-catenin and cellular apoptosis susceptibility protein were significantly associated with the metastatic potential of primary NSCLC. Expression of positive cell cycle regulators cyclin D1 and cyclin D3 was also increased in metastatic primary tumors. Metastatic tumor progression into the brain was accompanied by prominent p16, syndecan-1, p53 (DO7), and caspase-3 protein levels. Hierarchical clustering of complex immunoprofiles based on the differentially expressed markers grouped NSCLCs of the poorest outcome with high correlation including 2/3 of brain metastases of mixed histology. The brain metastatic potential of NSCLCs may be linked to the elevated levels of cyclinD1, cyclinD3, p16, p53, caspase-3, caspase-9, CD44v6, and collagen XVII and the down-regulation of beta-catenin and cellular apoptosis susceptibility protein. Unsupervised immunoprofiles based on differentially expressed biomarkers may help selecting lung cancers with aggressive behavior.

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.

Levels of soluble vascular endothelial growth factor receptor 1 are elevated in the exudative pleural effusions

PURPOSE

Vascular endothelial growth factor (VEGF) plays a critical role in the production of malignant pleural effusions. In the present study, we examined the levels of soluble VEGF receptor-1 (sVEGFR-1) and angiopoietin-2 (Ang-2), as possible regulators of VEGF activity, in transudative and exudative pleural effusions.

METHODS

Forty-two patients were included in this study: 4 with transudative pleural effusions due to heart failure (HF), 38 with exudative pleural effusions (lung cancer [LC], 22; other malignant diseases [MD], 10; tuberculosis [TB], 6). The levels of VEGF, Ang-2, and sVEGFR-1 in the pleural effusions were measured by an enzyme-linked immunosorbent assay.

RESULTS

The levels of VEGF, Ang-2, and sVEGFR-1 in exudative effusions were higher than those in transudative effusions. Interestingly, the levels of VEGF and Ang-2 in bloody effusions were significantly higher than those in non-bloody effusions (p < 0.05), but the level of sVEGFR-1 in bloody effusions was lower than that in non-bloody effusions. The levels of VEGF and Ang-2 were significantly higher in the malignant effusions, compared with effusion from HF and TB (p < 0.05). In addition, sVEGFR-1 was significantly higher in the effusion from LC, MD, and TB compared with effusion from HF (p < 0.05). In the malignant effusions, direct correlations were observed among VEGF, sVEGFR-1, and Ang-2.

CONCLUSIONS

The sVEGFR-1 levels were elevated in exudative pleural effusions, and were lower in bloody effusions than in non-bloody effusions, thus suggesting the regulatory role of sVEGFR-1 in the exudative pleural effusions.

Immunohistochemical markers of prognosis in non-small cell lung cancer: a review and proposal for a multiphase approach to marker evaluation

Characteristics of the tumour that affect and predict the survival outcome of patients with cancer are prognostic markers for cancer. In non-small cell lung carcinoma (NSCLC), stage is the main determinant of prognosis and the basis for deciding options for treatment. Patients with early-stage tumour are treated by complete surgical resection, which is curative in 40-70% of patients. That there are other factors important in determining the biology of these tumours, especially genes that have a role in metastasis, is indicated. Such factors could potentially be used to further classify patients into groups according to substages that may be treated differently. During the past decade, a large number of proteins that are putatively important in carcinogenesis and cancer biology have been studied for their prognostic value in NSCLC, but none of them have been proved to be sufficiently useful in clinical diagnosis. Several markers (epidermal growth factor receptor, human epidermal growth factor receptor 2, Ki-67, p53 and Bcl-2) have been studied exhaustively. Ki-67, p53 and Bcl-2 are suggested to be important but weak prognostic markers, by meta-analyses of the results. Cyclin E, vascular endothelial growth factor A, p16(INK4A), p27(kip1) and beta-catenin are promising candidates, but require further study in large randomised clinical trial samples by using standardised assays and scoring systems. Some issues and inconsistencies in the reported studies to date are highlighted and discussed. A guideline for a multi-phase approach for conducting future studies on prognostic immunohistochemistry markers is proposed here.

High serum concentrations of Sialyl Lewisx predict multilevel N2 disease in non-small-cell lung cancer

BACKGROUND

The purpose of this study was to analyze the clinical significance of serum Sialyl Lewisx (SLX) concentrations as a predictor of N2 disease in patients with non-small-cell lung cancer.

METHODS

The study included 272 patients with non-small-cell lung cancer who underwent pulmonary resection in our institution between January 1998 and December 2003. Of 272 patients, the serum concentrations of SLX were measured by using a commercially available radioimmunoassay kit.

RESULTS

The 5-year survival rates of patients with concentrations of SLX > 38 U/mL and those with lower concentrations were 32% and 69%, respectively (P < .0001). The median serum concentration of SLX in patients with multilevel N2 or N3, single-level N2, and N0/1 disease were 44, 30, and 27 U/mL, respectively. The concentrations of serum SLX in patients with multilevel N2 disease were significantly higher than those in patients with single-level N2 or those with N0/1 disease (Mann-Whitney U-test; P < .0001). Although the sensitivity of SLX for identifying patients with non-small-cell lung cancer was only 24% in all patients, the sensitivity of SLX increased as the N-factor increased; the sensitivity of N0/1 disease was 15%, that of single-level N2 disease was 22%, and that of multilevel N2 or N3 disease was 71%.

CONCLUSIONS

High serum concentrations of SLX predicted multilevel N2 disease and the associated poor outcome. Although the sensitivity of serum SLX is not acceptable for use as a screening tumor marker, we suggest that the serum concentration of SLX is useful as a staging marker to determine the strategy of treatment.

Blood flow–metabolic relationships are dependent on tumour size in non-small cell lung cancer: a study using quantitative contrast-enhanced computer tomography and positron emission tomography

PURPOSE

The purpose of this study was to undertake dual assessment of tumour blood flow and glucose metabolism in non-small cell lung cancer (NSCLC) using contrast-enhanced computed tomography (CE-CT) and (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) in order to assess how the relationships between these parameters vary with tumour size and stage.

METHODS

Tumour blood flow and glucose metabolism were assessed in 18 NSCLCs using quantitative CE-CT and FDG-PET respectively. Contrast enhancement and FDG uptake were both normalised to injected dose and patient weight to yield correspondingly the standardised perfusion value (SPV) and standardised uptake value (SUV). Tumour area was measured from conventional CT images.

RESULTS

The ratio of SUV to SVP and the metabolic-flow difference (SUV-SVP) correlated with tumour size (r=0.56, p=0.015 and r=0.60 and p=0.008 respectively). A metabolic-flow difference of greater than 4 was more common amongst tumours of stages III and IV (odds ratio 10.5; 95% confidence limits 0.24-32.1). A significant correlation between SUV and SPV was found only for tumours smaller than 4.5 cm2 (r=0.85, p=0.03).

CONCLUSION

Blood flow-metabolic relationships are not consistent in NSCLC but depend upon tumour size and stage. Quantitative CE-CT as an adjunct to an FDG study undertaken using integrated PET-CT offers an efficient way to augment the assessment of tumour biology with possible future application as part of clinical care.

Maspin nuclear localization is linked to favorable morphological features in pulmonary adenocarcinoma

Maspin, a mammary homologue of Serine Protease Inhibitors, has been shown to inhibit tumor progression and metastasis. Recently, its biological functions have been linked to its subcellular localization. Specifically, a nuclear, opposed to a combined nuclear and cytoplasmic localization has been associated with increased survival in human malignancies, including non-small cell lung cancer (NSCLC). However, it is not known whether transformation affects maspin expression during lung carcinogenesis, and whether its subcellular localization correlates with the morphological features of NSCLC. To address these questions, we studied maspin expression in a model of transformation of bronchial epithelial cells and in resected NSCLC. We found that decreased maspin accompanied chemical transformation of normal immortalized bronchial epithelial cells BEAS 2B. Immunohistochemistry revealed maspin expression to be virtually universal in NSCLC, occurring in 72/77 Adenocarcinoma (ACa), and 46/46 squamous cell carcinoma (SqCCa). SqCCa showed almost exclusively a combined nuclear-cytosolic stain. In contrast, nuclear maspin, but not combined nuclear-cytoplasmic maspin significantly correlated with low histological grade, lower proliferative rate, absence of invasion, and negative p53 stain in ACa. These data support the hypothesis that nuclear localization of maspin may stratify subtypes of NSCLC with favorable clinical-pathological features.

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.

Genomics of lung cancer may change diagnosis, prognosis and therapy

Despite significant improvements in tumor management in general, the prognosis of lung cancer patients remains dismal. It is a hope that our increasing knowledge in molecular aspects of tumor development, growth and progression will open new targets for therapeutic interventions. In this review we discuss some of the more recent results of this field. This includes the susceptibility factors, an association between genetic changes in EGFR pathway and tyrosine kinase inhibitors, the role of gene hypermethylation and genetic profiling, as well as different molecular aspects of tumor progression. Available data all support that lung cancer is a group of diseases with not only distinct histological but with similarly different genetic characters. Accordingly, the diagnosis, prognosis and therapy must accommodate this heterogeneity.