Artificial intelligence-based recurrence prediction outperforms classical histopathological methods in pulmonary adenocarcinoma biopsies

INTRODUCTION

Between 10 and 50% of early-stage lung adenocarcinoma patients experience local or distant recurrence. Histological parameters such as a solid or micropapillary growth pattern are well-described risk factors for recurrence. However, not every patient presenting with such a pattern will develop recurrence. Designing a model which can more accurately predict recurrence on small biopsy samples can aid the stratification of patients for surgery, (neo-)adjuvant therapy, and follow-up.

MATERIAL AND METHODS

In this study, a statistical model on biopsies fed with histological data from early and advanced-stage lung adenocarcinomas was developed to predict recurrence after surgical resection. Additionally, a convolutional neural network (CNN)-based artificial intelligence (AI) classification model, named AI-based Lung Adenocarcinoma Recurrence Predictor (AILARP), was trained to predict recurrence, with an ImageNet pre-trained EfficientNet that was fine-tuned on lung adenocarcinoma biopsies using transfer learning. Both models were validated using the same biopsy dataset to ensure that an accurate comparison was demonstrated.

RESULTS

The statistical model had an accuracy of 0.49 for all patients when using histology data only. The AI classification model yielded a test accuracy of 0.70 and 0.82 and an area under the curve (AUC) of 0.74 and 0.87 on patch-wise and patient-wise hematoxylin and eosin (H&E) stained whole slide images (WSIs), respectively.

CONCLUSION

AI classification outperformed the traditional clinical approach for recurrence prediction on biopsies by a fair margin. The AI classifier may stratify patients according to their recurrence risk, based only on small biopsies. This model warrants validation in a larger lung biopsy cohort.

Lipid biomarkers that reflect postoperative recurrence risk in lung cancer patients who smoke: a case-control study

BACKGROUND

The risk of postoperative recurrence is higher in lung cancer patients who smoke than non-smokers. However, objective evaluation of the postoperative recurrence risk is difficult using conventional pathological prognostic factors because of their lack of reproducibility. Consequently, novel objective biomarkers that reflect postoperative risk in lung cancer patients who smoke must be identified. Because cigarette smoking and oncogenesis alter lipid metabolism in lung tissue, we hypothesized that the lipid profiles in lung cancer tissues are influenced by cigarette smoking and can reflect the postoperative recurrence risk in smoking lung cancer patients. This study aimed to identify lipid biomarkers that reflect the smoking status and the postoperative recurrence risk.

METHODS

Primary tumor tissues of lung adenocarcinoma (ADC) (n = 26) and squamous cell carcinoma (SQCC) (n = 18) obtained from surgery were assigned to subgroups according to the patient's smoking status. The ADC cohort was divided into never smoker and smoker groups, while the SQCC cohort was divided into moderate smoker and heavy smoker groups. Extracted lipids from the tumor tissues were subjected to liquid chromatography-tandem mass spectrometry analysis. Lipids that were influenced by smoking status and reflected postoperative recurrence and pathological prognostic factors were screened.

RESULTS

Two and 12 lipid peaks in the ADC and SQCC cohorts showed a significant positive correlation with the Brinkman index, respectively. Among them, in the ADC cohort, a higher lipid level consisted of three phosphatidylcholine (PC) isomers, PC (14:0_18:2), PC (16:1_16:1), and PC (16:0_16:2), was associated with a shorter recurrence free period (RFP) and a greater likelihoods of progressed T-factor (≥ pT2) and pleural invasion. In the SQCC cohort, a lower m/z 736.5276 level was associated with shorter RFP and greater likelihood of recurrence.

CONCLUSIONS

From our data, we propose three PC isomers, PC (14:0_18:2), PC (16:1_16:1), and PC (16:0_16:2), and a lipid peak of m/z 736.5276 as novel candidate biomarkers for postoperative recurrence risk in lung ADC and SQCC patients who are smokers.

Postoperative tegafur-uracil for stage I lung adenocarcinoma: first real-world data with an exploratory subgroup analysis

PURPOSE

The effect of postoperative tegafur-uracil on overall survival (OS) after resection of stage I adenocarcinoma has been shown in clinical trials. The purpose of this study was to investigate whether findings from randomized trials of adjuvant tegafur-uracil are reproducible in a real-world setting.

METHODS

A retrospective cohort study was performed using a multi-institutional database that included all patients who underwent complete resection of pathological stage I adenocarcinoma between 2014 and 2016. Survival outcomes for patients managed with and without tegafur-uracil were analyzed using the Kaplan-Meier method and a Cox proportional hazards model for the whole patient cohort and in a selected cohort based on eligibility criteria of a previous randomized trial. Propensity score matching was used to adjust for confounding effects.

RESULTS

After propensity score matching, the hazard ratios for OS were 0.57 (95% confidence interval (CI) 0.29-1.14, P = 0.11) in the whole cohort and 0.69 (95% CI 0.32-1.50, P = 0.35) in the selected cohort.

CONCLUSIONS

The effects of tegafur-uracil in this retrospective study appear to be consistent with those found in randomized clinical trials. These effects may be maximized in patients aged from 45 to 75 years.

[A Review on Pathological High-risk Factors and Postoperative Adjuvant Chemotherapy in Stage IA Lung Adenocarcinoma]

The survival rate needs to be improved in early stage non-small cell lung cancer patients. The risk of recurrence is relatively high in invasive adenocarcinoma patients with a solid or micropapillary component, lymphovascular invasion or tumor spread through air spaces. Systemic treatment options including radical surgical resection should be explored for this population. Adjuvant chemotherapy is not recommended for patients in stage IA in current guidelines. This article is a review on the research progress of the above pathological high-risk factors and the role of adjuvant chemotherapy in patients with pathological high-risk factors in stage IA lung adenocarcinoma.
.

Percentage of Newly Proposed High-Grade Patterns Is Associated with Prognosis of Pathological T1-2N0M0 Lung Adenocarcinoma

OBJECTIVE

To evaluate the prognostic value of the percentage of high-grade patterns (micropapillary, solid, and complex glands) in early-stage lung adenocarcinoma (LUAD).

METHODS

A total of 1049 patients undergoing radical surgery with pathological T1-2N0M0 LUAD were screened retrospectively, and 191 patients were involved in the final analysis. Disease-free survival (DFS) was evaluated using the Kaplan-Meier curve and Cox regression analysis. The optimal cut-off value was determined using maximally selected rank statistics.

RESULTS

The entire cohort was divided into quartile groups based on the percentage of high-grade patterns: Group 1 (≤ 30%), Group 2 (31-55%), Group 3 (56-85%), and Group 4 (≥ 86%). There were significant differences in smoking history (P = 0.041), EGFR mutations (P < 0.001), and ALK rearrangement (P = 0.010) between the four groups, but no significant differences in other clinicopathological features. Kaplan-Meier analysis showed that a higher percentage of high-grade patterns predicted worse DFS (P = 0.001), and multivariate analysis indicated that the percentage of high-grade patterns was an independent predictor (Group 2 vs. Group 1, HR = 2.136, P = 0.228; Group 3 vs. Group 1, HR = 3.355, P = 0.035; Group 4 vs. Group 1, HR = 5.147, P = 0.003, respectively). A cut-off value of 20% (P = 0.048) and 50% (P <0.001) for high-grade patterns were tested, and both revealed a significant difference in distinguishing DFS between subgroups.

CONCLUSIONS

The percentage of high-grade patterns is associated with the prognosis of early-stage invasive LUAD. A higher percentage indicates a worse prognosis.

Utility of Volumetric Metabolic Parameters on Preoperative FDG PET/CT for Predicting Tumor Lymphovascular Invasion in Non-Small Cell Lung Cancer

Background: Lymphovascular invasion (LVI) is an adverse prognostic indicator in non-small cell lung cancer (NSCLC) and serves as an indication for postoperative adjuvant chemotherapy recommendation after resection. Objective: To assess the utility of clinicopathologic factors and volumetric metabolic parameters from preoperative FDG PET/CT in predicting primary tumor LVI in NSCLC. Methods: This retrospective study included 161 patients (mean age, 61.8±8.1 years; 111 men, 50 women) with surgically-confirmed NSCLC who underwent preoperative FDG PET/CT between January 2018 and November 2020. Two nuclear medicine physicians used software to place automated volumes of interest delineating each tumor to record metabolic indices (SUVmax, SUVmean, and metabolictumor volume [MTV]), which in turn were used to calculate total lesion glycolysis (TLG). Measurements were first performed independently to determine interobserver agreement using intraclass correlation coefficients (ICCs) and then repeated in consensus. Associations of clinicopathologic and metabolic parameters with tumor LVI status were assessed using t test, Mann-Whitney U test, and chi-squared test. Diagnostic performance was assessed using ROC analysis. Multivariable logistic regression analysis was performed to identify independent predictors of tumor LVI. Results: A total of 23.6% (38/161) of patients had LVI. Interobserver agreement was ICC=1.000 for SUVmax, ICC=0.997 for SUVmean, and 0.999 for MTV. Tumors with LVI, compared with tumors without LVI, exhibited higher SUVmax (15.4±5.9 vs 11.7±7.5, p=.006), SUVmean (6.0±1.6 vs 5.1±2.0, p=.009), MTV (median 15.8 cm3 vs 5.5 cm3, p<.001), and TLG (median 88.8 vs 24.5, p<.001). Among the metabolic parameters, AUC was highest for MTV (0.704), with optimal MTV cutoff of 6.4 cm3 yielding sensitivity 92.1% (35/38), specificity 56.1% (69/123), PPV 39.3% (35/89), and NPV 95.8% (69/72) for LVI. Independent predictors (p<.05) of LVI were MTV (≥6.4 cm3, odds ratio [OR]=6.5), N1 (OR=6.4) or N2 (OR=4.0) disease, and T2 disease (OR=3.6). These factors combined achieved AUC of 0.854 for LVI. Conclusion: The volumetric metabolic parameter MTV from preoperative FDG PET/CT is an independent predictor of tumor LVI in NSCLC. Clinical Impact: Further studies are warranted to assess the potential role of preoperative prediction of LVI using FDG PET/CT to help guide clinical decision making in NSCLC.

Biomarker Potential of Preoperative Tumor Size in Determination of the Lymphovascular Invasion in Squamous Cell Lung Cancer and Lung Adenocarcinoma

INTRODUCTION

The invasion of blood and lymph vessels with tumor tissue represents a negative prognostic factor of the disease course in patients with non-small cell lung cancer.

AIM

The aim of the study was to determine the marker value of a preoperatively determined size of pulmonary squamous cell carcinoma and adenocarcinoma and its impact on lymphovascular invasion (LVI) in resected lung tissue.

MATERIALS AND METHODS

The conducted observational cross-sectional study included 322 patients with a complete resection of confirmed squamous cell lung carcinoma and lung adenocarcinoma. Preoperative size and type of tumor were determined by a preoperative chest computed tomography scan and cytological/histological analysis of obtained samples, while LVI status was determined by pathohistological analysis of resected tumor lung tissue. Receiver operating characteristic (ROC) curve analysis was performed to assess whether tumor size could serve as a reliable marker for LVI. P < 0.05 was considered statically significant.

RESULTS

A statistically significant difference in the frequency of tumor size (P = 0.580) along with LVI (P = 0.656) was not established between the patients with squamous cell lung cancer and lung adenocarcinoma. A ratio between the size of lung adenocarcinoma and LVI status (P < 0.001) was determined as statistically significant, while such a difference was not established in squamous cell lung cancer (P = 0.052). The ROC analysis revealed that tumor size >39 mm in patients with lung adenocarcinoma has obtained a sensitivity of 70.8% and a specificity of 60.9% to differentiate patients with a LVI (areas under the curve [AUC] = 0.70; 95% CI 0.60‒0.79; P < 0.001). A tumor size >4.6 cm in patients with squamous cell lung cancer obtained a sensitivity of 56.5% and a specificity of 60.3% to differentiate patients with a LVI (AUC = 0.59; 95% CI 0.50‒0.67; P = 0.043).

CONCLUSION

The preoperative size of lung adenocarcinoma could be an acceptable marker of LVI presence in resected lung tissue, while in the squamous cell lung cancer, a potential biomarker role of the preoperative size of the tumor was inadequate.

A single-arm, phase 2 study of adjuvant chemotherapy with oral tegafur-uracil for pathologically lymphovascular invasion positive stage IA non-small cell lung cancer: LOGIK0602 study

BACKGROUND

Lymphovascular invasion (LVI), which includes vascular or lymphatic invasions, is a representative prognostic factor even in patients with resected stage IA non-small cell lung cancer (NSCLC). Because tegafur-uracil is effective on cancers with LVI, we conducted a multi-center single-arm phase II study to estimate the efficacy of adjuvant tegafur-uracil in patients with LVI-positive stage IA NSCLC.

METHODS

Patients with completely resected LVI-positive stage IA NSCLC were registered. LVI was diagnosed by consensus of two of three pathologists. Adjuvant chemotherapy consisted of 2 years of oral tegafur-uracil at 250 mg/m²/day. Fifty-five patients from 7 institutions were enrolled from June 2007 to September 2012.

RESULTS

Among the 52 eligible patients, 36 (69.2%) completed the treatment course. There were 39 male and 13 female patients. The observation period was calculated as 562 to 3107 days using the reverse Kaplan-Meier method. The 5-year overall and relapse free survival rates were 94.2 and 88.5% respectively, which were significantly better than that of any other studies conducted on patients with LVI-positive stage IA NSCLC. Notably, the overall survival rate was 15% better than that of our prior retrospective study. The retrospective analysis of stage IA NSCLC patients who had received an operation in the same period revealed that the 5-year overall survival rate of the LVI positive group was 73.6% when adjuvant chemotherapy was not applied. Among 55 safety analysis sets, 4 cases of grade 3 hepatic function disorder (9.1%) and 5 cases of grade 2 anorexia (10.9%) were most frequently observed. No grade 4 adverse effects were encountered.

CONCLUSION

A 2-year course of oral tegafur-uracil administration is feasible and might have a significant benefit in the adjuvant treatment of LVI-positive stage IA NSCLC.

TRIAL REGISTRATION

UMIN identifier: UMIN000005921 ; Date of enrolment of the first participant to the trial: 19 June 2007; Date of registration: 5 July 2011 (retrospectively registered).

Nomograms for Predicting Overall and Recurrence-free Survival From Pathologic Stage IA and IB Lung Cancer After Lobectomy

BACKGROUND

Stage I non-small-cell lung cancer (NSCLC) is potentially curable with surgical resection. Significant proportions of patients may still experience recurrence and death despite undergoing curative surgery. This study describes predictive nomograms for recurrence-free (RFS) and overall survival (OS) after lobectomy.

PATIENTS AND METHODS

A total of 301 patients with the American Joint Committee on Cancer pathologic stage IA and IB NSCLC who underwent open, thoracoscopic, or robotic lobectomy from January 2011 to April 2017 were analyzed. Multivariate Cox proportional hazards regression models were used to create nomograms for OS and RFS. Kaplan-Meier survival curves were calculated for OS and RFS comparing high-risk and low-risk cohorts based on nomogram scores.

RESULTS

Histology (hazard ratio [HR], 0.24; 95% confidence interval [CI], 0.10-0.56; P = .002), lymphovascular invasion (HR, 0.46; 95% CI, 0.29-0.74; P = .001), smoking status (HR, 3.46; 95% CI, 1.25-9.55: P = .02), and total lymph nodes removed (HR, 1.05; 95% CI, 1.01-1.10; P = .021) were significant predictors for OS in a multivariate model. Lymphovascular invasion (HR, 0.55; 95% CI, 0.36-0.83; P = .0040), smoking status (HR, 2.56; 95% CI, 1.16-5.62; P = .02), total lymph nodes removed (HR, 1.04; 95% CI, 1.00-1.08; P = .029), and tumor size (HR, 1.30; 95% CI, 1.30-1.68; P = .047) were significant predictors of RFS in a multivariate model.

CONCLUSION

Nomograms can predict OS and RFS for pathologic stage IA and IB NSCLC after lobectomy regardless of operative approach. The risk for death and recurrence after stratification by the nomogram scores may provide guidance regarding adjuvant therapy and surveillance.

Sphingomyelin(d35:1) as a novel predictor for lung adenocarcinoma recurrence after a radical surgery: a case-control study

Background

To improve the postoperative prognosis of patients with lung cancer, predicting the recurrence high-risk patients is needed for the efficient application of adjuvant chemotherapy. However, predicting lung cancer recurrence after a radical surgery is difficult even with conventional histopathological prognostic factors, thereby a novel predictor should be identified. As lipid metabolism alterations are known to contribute to cancer progression, we hypothesized that lung adenocarcinomas with high recurrence risk contain candidate lipid predictors. This study aimed to identify candidate lipid predictors for the recurrence of lung adenocarcinoma after a radical surgery.

Methods

Frozen tissue samples of primary lung adenocarcinoma obtained from patients who underwent a radical surgery were retrospectively reviewed. Recurrent and non-recurrent cases were assigned to recurrent (n = 10) and non-recurrent (n = 10) groups, respectively. Extracted lipids from frozen tissue samples were subjected to liquid chromatography-tandem mass spectrometry analysis. The average total lipid levels of the non-recurrent and recurrent groups were compared. Candidate predictors were screened by comparing the folding change and P-value of t-test in each lipid species between the recurrent and non-recurrent groups.

Results

The average total lipid level of the recurrent group was 1.65 times higher than that of the non-recurrent group (P < 0.05). A total of 203 lipid species were increased (folding change, ≥2; P < 0.05) and 4 lipid species were decreased (folding change, ≤0.5; P < 0.05) in the recurrent group. Among these candidates, increased sphingomyelin (SM)(d35:1) in the recurrent group was the most prominent candidate predictor, showing high performance of recurrence prediction (AUC, 9.1; sensitivity, 1.0; specificity, 0.8; accuracy, 0.9).

Conclusion

We propose SM(d35:1) as a novel candidate predictor for lung adenocarcinoma recurrence. Our finding can contribute to precise recurrence prediction and qualified postoperative therapeutic strategy for lung adenocarcinomas.

Trial registration

This retrospective study was registered at the UMIN Clinical Trial Registry (UMIN000039202) on 21st January 2020.

Prognostic Impact of Histopathologic Features in Pulmonary Invasive Mucinous Adenocarcinomas

OBJECTIVES

The prognostic significance of pathologic features and invasive size has not been well studied for invasive mucinous adenocarcinoma (IMA). This study evaluates the significance of pathologic features and invasive size in relation to clinical outcome.

METHODS

We reviewed the pathologic features in 84 IMAs, including histologic pattern, nuclear atypia, mitosis, necrosis, and lymphovascular invasion. The invasive size was calculated from the total size using the percentage of invasive components. Cases were subdivided into two pathologic grades based on five pathologic features, and the pathologic grade and adjusted T (aT) stage were correlated with disease-free and overall survival (OS).

RESULTS

Necrosis and N stage were significantly associated with aT stage, and a significant association was noted between OS and aT stage. Nuclear atypia, mitosis, and lymphovascular and pleural invasion also showed a significant association with OS. High-grade tumors showing a significantly worse OS compared with low-grade tumors, as well as pathologic grade (hazard ratio [HR], 2.337; P = .043) and aT stage (HR, 1.875; P = .003), were independent prognostic factors in multivariate analysis.

CONCLUSIONS

The pathologic grading system stratified IMAs into high- and low-grade tumors with significant differences in OS. Invasive size may provide a better prognostic stratification for OS.

Clinicopathological features of small-sized peripheral squamous cell lung cancer

Recent advances in imaging technology have enhanced the detection rate of small-sized peripheral lung cancers. The present study aimed to identify the clinicopathological differences between patients with small-sized peripheral squamous cell carcinoma (SCC) and adenocarcinoma (ADC). Patients with lung cancer who underwent radical surgical resection at Gunma University Hospital between July 2007 and October 2012 were retrospectively analyzed. Patients who exhibited small-sized peripheral tumors (pathological size, ≤2 cm) located within the outer-third of the lung field on preoperative computed tomography were enrolled in the present study. A total of 26 patients were diagnosed with SCC and 214 with ADC. The results revealed that patients with SCC exhibited higher rates of pleural invasion, vascular invasion and lymphatic invasion compared with ADC patients. Additionally, the rate of postoperative recurrence was higher in patients with SCC compared with ADC patients. Patients with ADC were subsequently into two groups: Solid ADCs (sADC) and non-solid ADCs (nsADC), which included pure ground glass nodules and part-solid ADCs. The results revealed that the incidence of pleural invasion, vascular invasion and lymphatic invasion, and the rate of postoperative recurrence in patients with sADCs were similar to those with SCC, but were also significantly higher when compared with nsADC patients. The present study concluded that patients with SCC and sADC may not be suitable candidates for sublobar resection, despite exhibiting small tumors that are located in the peripheral lung.

[Risk Factors of Nodal Upstaging in Clinical Ia Lung Adenocarcinoma]

背景与目的

即使是临床Ⅰa(cT1N0M0)期肺腺癌的患者, 部分预后也相对较差, 这可能与术后病理学淋巴结转移而导致的N升期有关。本研究旨在分析影响临床早期肺腺癌N分期上调的影像学及病理学因素。

方法

回顾性研究2012年5月-2016年12月于我院行手术治疗的297例临床Ⅰa期肺腺癌的患者, 分析N分期上调组及非上调组的临床一般资料、影像学及病理学资料的差异。

结果

297例cN0肺腺癌中, 250例(84.2%)被证实为pN0, 47例(15.8%)被证实为pN1和pN2。其中, 女性、吸烟史、脉管癌栓、微乳头和实体为主病理亚型的肺腺癌以及影像学中纯实性结节等, 均是N分期上调的影响因素(P < 0.05)。Logistic回归分析表明:影像学中实性肿瘤、微乳头及实体为主型腺癌和脉管癌栓是临床Ⅰa期腺癌的出现N分期上调的独立危险因素。

结论

病理学脉管癌栓、微乳头和实体为主的肺腺癌以及影像学中纯实性结节是Ⅰa期肺腺癌N分期上调的独立危险因素。临床Ⅰa期的肺腺癌其影像学表现为纯实性结节时, 应进行系统性淋巴结清扫。

Prognostic factors including lymphovascular invasion on survival for resected non-small cell lung cancer

OBJECTIVES

The aim of this study was to report on the influence of tumor lymphovascular invasion on overall survival and in patients with resected non-small cell lung cancer and identify prognostic factors for survival.

METHODS

This is a retrospective observational study of a consecutive series of patients who had surgical resection of non-small cell lung cancer in a single institution. The study covers a 3-year period. Overall survival was estimated by Kaplan-Meier method and multivariate Cox regression analysis was used to evaluate the relationship of lymphovascular invasion and other clinicopathologic variables. A multivariate regression was used to assess the relationship between tumor lymphovascular invasion and other clinical and pathologic characteristics.

RESULTS

A total of 524 patients were identified and included in the study. Two hundred twenty-five patients (43%) had tumors with lymphovascular invasion. Patients with tumor lymphovascular invasion had a lower overall survival (P < .0001). Tumor lymphovascular invasion was independently associated with visceral pleural involvement (P < .0001). In a multivariable model, lymphovascular invasion (hazard ratio [HR], 2.58; 95% confidence interval [CI], 1.63-4.09; P < .0001), parietal pleural invasion (HR, 45.4; 95% CI, 2.08-990; P = .015), advanced age (HR, 1.028; 95% CI, 1.009-1.048; P = .004), and N2 lymph node involvement (HR, 1.837; 95% CI, 1.257-2.690; P = .002) were independent prognostic factors for lower overall survival.

CONCLUSIONS

Lymphovascular invasion is associated with a worse overall survival in patients with resected non-small cell lung cancer regardless of tumor stage. Parietal pleural involvement, N2 nodal disease, and advanced age independently predict poor overall survival.

Cell cycle progression score is a marker for five-year lung cancer-specific mortality risk in patients with resected stage I lung adenocarcinoma

Purpose

The goals of our study were (a) to validate a molecular expression signature (cell cycle progression [CCP] score and molecular prognostic score [mPS; combination of CCP and pathological stage {IA or IB}]) that identifies stage I lung adenocarcinoma (ADC) patients with a higher risk of cancer-specific death following curative-intent surgical resection, and (b) to determine whether mPS stratifies prognosis within stage I lung ADC histological subtypes.

Methods

Formalin-fixed, paraffin-embedded stage I lung ADC tumor samples from 1200 patients were analyzed for 31 proliferation genes by quantitative RT-PCR. Prognostic discrimination of CCP score and mPS was assessed by Cox proportional hazards regression, using 5-year lung cancer–specific mortality as the primary outcome.

Results

In multivariable analysis, CCP score was a prognostic marker for 5-year lung cancer–specific mortality (HR=1.6 per interquartile range; 95% CI, 1.14–2.24; P=0.006). In a multivariable model that included mPS instead of CCP, mPS was a significant prognostic marker for 5-year lung cancer–specific mortality (HR=1.77; 95% CI, 1.18–2.66; P=0.006). Five-year lung cancer–specific survival differed between low-risk and high-risk mPS groups (96% vs 81%; P<0.001). In patients with intermediate-grade lung ADC of acinar and papillary subtypes, high mPS was associated with worse 5-year lung cancer–specific survival (P<0.001 and 0.015, respectively), compared with low mPS.

Conclusion

This study validates CCP score and mPS as independent prognostic markers for lung cancer–specific mortality and provides quantitative risk assessment, independent of known high-risk features, for stage I lung ADC patients treated with surgery alone.

Nomograms for predicting recurrence and survival of invasive pathological stage IA non-small cell lung cancer treated by video assisted thoracoscopic surgery lobectomy

BACKGROUND

A considerable portion of pathological stage (p-stage) IA non-small cell lung cancer (NSCLC) patients suffered from death and recurrence after video assisted thoracoscopic surgery (VATS) lobectomy. The purpose of our study was to develop nomograms to predict which subgroup patients were more likely to suffer from recurrence or death.

METHODS

Data of invasive p-stage IA NSCLC patients who underwent VATS lobectomy at Peking University People's Hospital from September 2006 to April 2014 were analyzed. Multivariate Cox proportional hazards regression was used to develop nomograms. The performance of the nomograms was evaluated by Harrell's concordance index (C-index), calibration plots and risk group stratification.

RESULTS

A total of 422 patients with NSCLC of invasive p-stage IA were included in the study. The median follow-up time was 40 months. Age [hazards ratio (HR) =1.067, 95% confidential interval (CI): 1.006-1.131], lymphovascular invasion (LVI) (HR=4.062, 95% CI: 1.278-12.912) and differentiation (HR =5.747, 95% CI: 2.151-15.353) were independent prognostic factors to predict overall survival (OS). Tumor diameter (HR =3.299, 95% CI: 1.814-6.001), LVI (HR =3.260, 95% CI: 1.221-8.708) and differentiation (HR =3.607, 95% CI: 1.776-7.327) were independent predictors of recurrence free survival (RFS). The nomogram for predicting OS demonstrated stronger discriminatory power than the 7th and 8th T stage systems (C-index: 0.894 for the nomogram, 0.700 for the 7th T stage and 0.742 for the 8th T stage). Likewise, the C-index of the nomogram for predicting RFS was higher than that of the 7th and 8th T stage systems (0.838 for the nomogram, 0.670 for the 7th T stage and 0.723 for the 8th T stage).

CONCLUSIONS

We developed nomograms that could predict individual accurate prognosis for invasive p-stage IA NSCLC patients after VATS lobectomy. Risk stratification by the nomograms might guide further adjuvant chemotherapy and follow-up.

The importance of the lepidic component as a prognostic factor in stage I pulmonary adenocarcinoma

Background

Stage I pulmonary adenocarcinoma (PA) can offer an unfavorable prognosis. The aim of this study was to classify the prognosis of stage I PA on the basis of the lepidic component and to confirm whether the lepidic component can be used as a criterion for predicting the prognosis of stage I PA.

Methods

We conducted a retrospective study of patients who underwent curative surgery for stage I and IIA PA. Stage I disease was divided into three groups on the basis of the lepidic component: group 1, ≤10 %; group 2, >10 to 50 %; and group 3, >50 %. We compared recurrence-free survival (RFS) rates among groups 1, 2, and 3, and stage IIA disease. We also evaluated risk factors for disease recurrence with multivariate analysis.

Results

A total of 224 patients were included in our study; most patients (n = 201) had stage I disease. Three-year RFS rates in group 1 (n = 73), group 2 (n = 75), and group 3 (n = 53) were 74.1, 90.4, and 90.0 %, respectively. There was a significant difference in RFS between group 1 and group 2 (p = 0.009). The 3-year RFS rate in stage IIA disease was 61.4 %. There were no significant differences in RFS between group 1 and stage IIA disease (p = 0.163). In multivariate analysis, group 1 had the highest risk of recurrence (HR 5.806, p = 0.006) in stage I PA.

Conclusions

Stage I PA with a lepidic component ≤10 % was associated with an unfavorable prognosis that was similar to the prognosis of stage IIA disease. The prognosis for stage I PA should not be based on general criteria, but instead, the lepidic component should be evaluated and considered when determining disease prognosis.

Survival Prediction Model Using Clinico-Pathologic Characteristics for Nonsmall Cell Lung Cancer Patients After Curative Resection

The current TNM staging system did not provide disease relapse information. The aim of study was try to establish a predictive survival model for disease and overall survival in nonsmall cell lung cancer patients who presented as resectable disease and to develop a reference for follow-up imaging tool selection.From January 2005 to December 2011, 442 patients who initially presented as resectable disease (stages I-IIIa) and received anatomic resection and mediastinal lymph node dissection were included in the study.Medical charts were thoroughly reviewed and clinico-pathologic factors were collected and analyzed.Visceral pleural invasion, tumor size >5 cm, and postoperative adjuvant therapy were identified as risk factors for poorer disease-free survival. The 5-year disease-free survival from score 0 to 3 was 68.7%, 46.6%, 31.9%, and 26.1%, respectively. The disease relapse percentage for scores 0 to 3 were 26.49%, 50.61%, 65.05%, and 73.81%, respectively. For analysis of overall survival, age >60 years, tumor size >3 cm, and total metastatic lymph node ratio >0.05 were correlated to worse overall survival. Because greater age may be correlated with poor general condition, we re-scored risk factors that correlated to disease severity that ranging from 0 to 2. The 5-year overall survival range from score 0 to 2 was 56.3%, 43.1%, and 13.1%, respectively.Poor prognostic factors correlated to disease-free survival were tumor size >5 cm, visceral pleural invasion, and patients needing to receive postoperative adjuvant therapy. Disease-free survival of resectable nonsmall cell lung cancer patients and disease relapse can be stratified by these 3 factors. Chest tomography may be recommended for patients with 1 or more poor disease-free survival risk factors.

F-18 FDG uptake on positron emission tomography as a predictor for lymphovascular invasion in patients with lung adenocarcinoma

PURPOSE

To evaluate the contributory value of Fluorine-18 fluorodeoxyglucose (F-18 FDG) positron emission tomography/computed tomography (PET/CT) in the prediction of lymphovascular tumor invasion in patients with lung adenocarcinoma.

MATERIALS AND METHODS

We evaluated F-18 FDG-PET/CT images in 84 patients with histopathologically proven lung adenocarcinoma (37 men and 47 women, age range 39-83 years, mean age 67.0 ± 8.9 years). The maximum standardized uptake values (SUVmax) of the carcinomas were measured from the PET images. The Mann-Whitney U test was conducted to compare the median SUVmax between the tumor groups with and without lymphovascular invasion. In the subgroup patients with no lymph-node metastasis, we also compared the median SUVmax between the tumor groups with and without lymphatic invasion.

RESULTS

The tumors with lymphovascular invasion had a significantly (P < 0.0001) greater median SUVmax than those without invasion. In the subgroup patients with no lymph-node metastasis, the median SUVmax was higher in tumors with lymphatic invasion than those without (P = 0.0004). The sensitivity, specificity, and area under the receiver operating characteristic curve for the detection of tumors with lymphovascular invasion were 89, 75 %, and 0.82, respectively, with a cutoff SUVmax value of 2.32.

CONCLUSION

The SUVmax of lung adenocarcinoma is a potential imaging biomarker for predicting tumor lymphovascular invasion.

Little things make big things happen: angiolymphatic invasion and tumor necrosis prognosticate the outcome of locally advanced non-small cell lung cancer treated with a prior induction therapy

OBJECTIVES

Size, invasion of thoracic structures, and ipsilateral mediastinal lymph node involvement (pN2) are well-known prognostic factors that configure the staging of resectable, locally advanced non-small cell lung cancer (LA-NSCLC). The prognostic impact of angiolymphatic invasion (ALI) and tumor necrosis (TN) has been barely explored in LA-NSCLC treated with prior induction therapies.

METHODS

We retrospectively reviewed 47 resected LA-NSCLCs treated with a prior platin-based chemotherapy or chemoradiation. The impact of ALI, TN, and other pathologic features on survival was analyzed.

RESULTS

ALI was presented in 23.4% of cases and TN in 29.8%. Disease-free and overall survival decreased when ALI, TN, or pN2 was present. The incidence of ALI was lower in LA-NSCLC with a good response to induction.

CONCLUSION

Our series is the first to report the prognostic impact of ALI and TN in induction-treated LA-NSCLC. The presence of ALI and TN should be included in the pathologic reports.

Impact of extratumoral lymphatic permeation on postoperative survival of non-small-cell lung cancer patients

Introduction:

Lymphatic permeation has been reported as a prognostic factor for patients with resected non–small-cell lung cancer (NSCLC). Lymphatic canals are located in both intratumoral and extratumoral areas. Since 2001, we have prospectively evaluated lymphatic permeation based on its location. The purpose of this study was to determine the survival impact of extratumoral lymphatic permeation in patients with resected NSCLC by analyzing the long-term follow-up data.

Methods:

We reviewed 1069 consecutive patients with NSCLC who underwent complete resection between 2001 and 2006. Lymphatic permeation was classified as follows: ly0, absence of lymphatic permeation; ly1, intratumoral; and ly2, extratumoral.

Results:

There were 845 patients (79%) with ly0, 134 (12%) with ly1, and 90 (9%) with ly2. Ly2 was more frequently observed in patients with advanced disease and intrapulmonary metastases than ly0–1. The 5-year overall survival (OS) rates of the ly0, ly1, and ly2 groups were 75%, 63%, and 34%, respectively. The OS rate was significantly worse in the ly2 group compared with OS rate in the ly0 (p < 0.01) and ly1 groups (p < 0.01). In multivariate analyses, ly2 proved to be an independent poor prognostic factor (hazard ratio, 1.73; p < 0.01). OS and recurrence-free survival of patients with T1 and T2 tumors with ly2 were not statistically different from that of the patients with T3 tumor (OS, p = 0.43 and p = 0.77; recurrence-free survival, p = 0.94 and p = 0.94, respectively).

Conclusions:

The adverse prognostic impact of lymphatic permeation was remarkably different whether it is detected in intratumoral or extratumoral lymphatic canals. We recommend that lymphatic permeation in resected NSCLC should be evaluated by considering its location.

Sublobar resection versus lobectomy in solid-type, clinical stage IA, non-small cell lung cancer

BACKGROUND

Recent studies have demonstrated that sublobar resection is not inferior to lobectomy for peripheral early lung cancer with ground-glass opacification. However, the effect of sublobar resection on solid-type early lung cancer is controversial. The aim of this study was to compare clinical outcomes of patients who have undergone sublobar resection or lobectomy for solid-type, early-stage, non-small cell lung cancer (NSCLC).

METHODS

This study was a retrospective review of the records of patients who underwent lobectomy or sublobar resection between March 2000 and September 2010 for clinical stage IA NSCL. Patients with pure ground-glass opacities or death within 30 days after surgery were excluded. Disease-free interval, survival, and prognostic factors were analyzed.

RESULTS

Thirty-one patients and 133 patients underwent sublobar resection and lobectomy, respectively. There were significant differences in age (P < 0.001), cardiovascular disease (P = 0.001), and diffusing capacity of the lung for carbon monoxide (DLCO) (P < 0.001). The patients with lobectomy had a significantly longer disease-free interval (P < 0.001) and survival (P = 0.001). By multivariate analysis, sublobar resection (P = 0.011), lymphatic vessel invasion (P = 0.006), and number of positive lymph nodes (P = 0.028) were predictors for survival. Sublobar resection (P < 0.001), visceral pleural invasion (P = 0.002), and lymphatic vessel invasion (P < 0.001) were predictors for disease-free interval.

CONCLUSIONS

Lobectomy should remain the standard surgical procedure for solid-type, clinical stage IA, NSCLC.

Prognostic significance of claudin 4 in completely resected adenocarcinoma of the lung

Background

The development of diagnostic techniques and an awareness of health examinations can bring about an early diagnosis of lung cancer. However, appropriate postoperative management and adjuvant chemotherapy remain under debate in postoperative therapeutic strategy. The present study was conducted to assess the clinicopathologic factors that influence recurrence and prognosis after complete resection of lung cancer.

Methods

The present study analyzed 62 patients with lung cancer who underwent complete resection of diagnosed adenocarcinoma between 1994 and 2007. In addition to conventional factors, which include staging factor and histological evaluation, the present study also performed univariate and multivariate analyses to consider claudin, a cell adhesion molecule, as a prognostic factor by immunohistochemical staining.

Results

There was no correlation between conventional factors, including lymphatic and vascular invasion, and recurrence. However, there was a significant correlation between high expression of claudin 4 and cancer recurrence. In particular, there was a correlation between high expressions of claudin 1, 4, and 5 and a reduction of disease-free survival.

Conclusion

Increased expressions of claudin 4 were negative prognostic factors in adenocarcinoma of the lung and thus could be used to identify high-risk patients for adjuvant chemotherapy, even if they had early-stage lung cancer. The present findings collectively suggest that consideration of claudin as a prognostic factor in the active postoperative treatment in patients at high risk will lead to better therapeutic outcomes with fewer side effects.

D2-40-positive lymphatic vessel invasion is not a poor prognostic factor in stage I lung adenocarcinoma

The present study investigates whether lymphatic vessel invasion (LVI) detected by D2-40 staining is a prognostic factor for stage I adenocarcinoma of the lung. We retrospectively reviewed 124 patients who underwent complete resection for stage I adenocarcinoma of the lung from January 1983 to June 2003. LVI was microscopically evaluated using D2-40 immunostaining. The median follow-up was 71 months. The LVI positive rate was 37%. The 5-year cancer-specific survival rates of the D2-40 positive LVI and negative groups were 88.8% and 84.3%, respectively (P = 0.630). The stage I lung adenocarcinoma patients who were determined to be LVI positive based on D2-40 immunostaining did not have a significantly poorer prognosis than the LVI negative cases. Thus, lymphatic microinvasion may not be a prognostic indicator in early lung cancer, although advanced LVI does appear to correlate with survival. It is therefore unnecessary to use D2-40 immunostaining to diagnose LVI in practical settings, and Hematoxylin-Eosin and Elastica van Gieson staining should continue to be used to predict the prognosis of patients with stage I lung adenocarcinoma.

The utility of the proposed IASLC/ATS/ERS lung adenocarcinoma subtypes for disease prognosis and correlation of driver gene alterations

BACKGROUND

The present study aimed to determine the ability of the revised International Association for the Study of Lung Cancer (IASLC)/American Thoracic Society (ATS)/European Respiratory Society (ERS) classification of lung adenocarcinoma to predict patient survivals and driver gene alterations.

PATIENTS AND METHODS

A reclassification of 904 surgically resected adenocarcinomas was performed. The results were statistically analyzed to examine the correlation between the classification and overall survival (OS) using Cox regression analyses, and integrated discrimination improvement (IDI) analyses.

RESULTS

The 5-year OS rates for adenocarcinomas in situ (AIS) or minimally invasive adenocarcinoma (MIA) were 98%. Five-year OS rates of Lepidic-, acinar-, papillary-, micropapillary-, and solid-predominant adenocarcinomas was 93%, 67%, 74%, 62%, and 58%, respectively. The IDI estimates revealed that classification of ADC into the 7 subgroups had a higher estimated (0.0175) than did the combined histological grouping (AIS + MIA, lepidic + acinar + papillary, micropapillary + solid + others) (0.0111). Epidermal growth factor receptor mutations, KRAS gene mutations, and anaplastic lymphoma kinase gene alterations were statistically prevalent in papillary-predominant (P = 0.00001), invasive mucinous (P = 0.00001), and micropapillary- and acinar-predominant (P = 0.00001) adenocarcinomas, respectively.

CONCLUSIONS

The new classification reflects disease prognosis, and was also associated with driver gene alterations.

High expression of CHRNA1 is associated with reduced survival in early stage lung adenocarcinoma after complete resection

BACKGROUND

Non-small cell lung cancer (NSCLC) is the leading cause of cancer deaths around the world, and a high recurrence rate after complete resection is an important issue reducing the cure rate and survival of patients with early stage NSCLC. Several pathologic biomarkers are associated with recurrence in early stage lung cancer after complete resection.

METHODS

We evaluated the expression and prognostic value of the α1 subunit of the nicotinic acetylcholine receptor (CHRNA1) as well as other pathologic features of tumor tissues resected from patients with stage I adenocarcinoma of the lung.

RESULTS

A high ratio (173/185) of CHRNA1 expression (93.5 %) was found in stage I lung adenocarcinoma. In the multivariate survival analysis, tumor necrosis, angiolymphatic invasion, perineural invasion, and CHRNA1 expression were independent poor prognostic factors for both recurrence-free and overall survival (OS). Patients expressing CHRNA1 had worse median recurrence-free survival (60.6 vs. 77.9 months, P = 0.03) and OS (65.1 vs. 77.9 months, P = 0.04) compared with CHRNA1-negative patients.

CONCLUSIONS

CHRNA1 expression could be directly tested from the tumor after complete resection. In early stage NSCLC, it could be a useful prognostic factor for recurrence and survival.

Clinical significance and role of lymphatic vessel invasion as a major prognostic implication in non-small cell lung cancer: a meta-analysis

Background

Lymphatic vessel invasion (LVI) exerts an important process in the progression and local spread of cancer cells. However, LVI as a prognostic factor for survival in non-small cell lung cancer (NSCLC) remains controversial.

Methodology/Principal Findings

A meta-analysis of published studies from PubMed and EMBASE electronic databases was performed to quantity the effects of LVI on both relapse-free survival and overall survival for patients with NSCLC. Hazard ratios (HRs) with 95% confidence intervals (95% CIs) were used to assess the strength of these effects. This meta-analysis included 18,442 NSCLC patients from 53 eligible studies. LVI appeared in 32.1% (median; range, 2.8% to 70.9%) of tumor samples. In all, patients with LVI were 2.48 times more likely to relapse by univariate analysis (95% CI: 1.92–3.22) and 1.73 times by multivariate analysis (95% CI: 1.24–2.41) compared with those without LVI. For the analyses of LVI and overall survival, the pooled HR estimate was 1.97 (95% CI: 1.75–2.21) by univariate analysis and 1.59 (95% CI: 1.41–1.79) by multivariate analysis. Multivariate analysis showed a risk was 91% higher for recurrence (HR  = 1.91, 95% CI: 1.14–2.91) and 70% higher for mortality (HR = 1.70, 95% CI: 1.38–2.10) in LVI-positive I stage patients compared with LVI-negative I stage patients. Subgroup analyses showed similar significant adjusted risks for recurrence and death in adenocarcinomas, and a significant adjusted risk for death in studies that utilized elastic staining with or without immunohistochemistry in defining LVI.

Conclusions/Significance

The present study indicates that LVI appears to be an independent poor prognosticator in surgically managed NSCLC. NSCLC patients with LVI would require a more aggressive treatment strategy after surgery. However, large, well-designed prospective studies with clinically relevant modeling and standard methodology to assess LVI are required to address some of these important issues.

Angiolymphatic invasion exerts a strong impact on surgical outcomes for stage I lung adenocarcinoma, but not non-adenocarcinoma

Angiolymphatic invasion (ALI), representing lymphatic invasion (Ly) and intratumoral vascular invasion (V), is considered to be a useful prognostic factor for pathological stage I non-small cell lung carcinoma (NSCLC). However, the types of tumor for which prognoses are most influenced by ALI positivity have not previously been discussed, nor has the question of whether these findings should influence postoperative therapeutic decision-making after complete resection. The present study investigated 195 cases of stage I NSCLC treated by potentially curative surgical resection of the primary tumor and systematic lymphadenectomy. ALI-positive (ALI(+)) results were found in 31.8% of tumors, and 5.1% exhibited both Ly(+) and V(+). Five-year recurrence-free survival was significantly lower in ALI(+) cases (50.6%) than in ALI(-) cases (85.9%; p<0.0001, log-rank test). In particular, 5-year recurrence-free survival rate was only 10.0% for Ly(+)V(+) cases. ALI(+) correlated with high age, male sex, tumor size (>2.0 cm), elevated preoperative serum carcinoembryonic antigen level (≥5.0 ng/mL), high maximum standard uptake value (SUVmax) on (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) (≥5.0), pleural invasion, and histological classification of non-adenocarcinoma (ADC). According to histopathological subset analyses, ALI(+) was associated with shorter recurrence-free survival than ALI(-) only among ADC patients (p<0.0001, log-rank test), and not among non-ADC patients (p=0.7710). High preoperative serum CEA level, high SUVmax on FDG-PET, pleural invasion, Ly(+), and V(+) were significant risk factors for recurrence in univariate Cox survival analysis among stage I ADC patients. Importantly, Ly(+) and V(+) were identified as independent risk factors for recurrence by multivariate analysis. Histopathological detection of ALI as a risk factor for recurrence should be considered for inclusion in the staging criteria and as additional information for determining postoperative adjuvant treatment of stage I NSCLC, particularly among ADC patients, but not among non-ADC patients.

Prognostic significance of lymphovascular invasion for patients with stage I non-small cell lung cancer

AIMS

This study retrospectively investigated the clinical significance of lymphovascular invasion (LVI) following a complete resection for stage I non-small cell lung cancer (NSCLC).

METHODS

A total of 226 patients who underwent a complete resection for pathological stage I NSCLC were examined.

RESULTS

Lymphatic invasion was pathologically diagnosed as ly0 in 156 patients, ly1 in 65, and ly2 in 5 patients. The pathological vascular invasion was diagnosed as v0 in 178 patients, v1 in 35, v2 in 10, and v3 in 3 patients. The 5-year survival rate after surgery of the patients with and without lymphatic invasion was 76.8 and 90.6%, respectively. There was a significantly more unfavorable prognosis in patients with lymphatic invasion (p = 0.042). The 5-year survival rate of the patients with vascular invasion was also significantly more unfavorable (67.8%) than that of patients without vascular invasion (90.4%; p = 0.004). LVI was found to significantly correlate with tumor size and the presence of pleural invasion.

CONCLUSION

The LVI of NSCLC is a significant prognostic factor in patients with stage I tumors. In future clinical trials, it is necessary to evaluate the efficacy of adjuvant therapy for the selection of patients according to this criterion.