Ultrastructural subtypes of pulmonary adenocarcinoma. A correlation with patient survival

Epidermal growth factor receptor mutations in lung cancers

In 2004, two groups reported somatic mutations in the gene for the epidermal growth factor receptor (EGFR) in patients with non-small cell lung cancer (NSCLC), which were highly correlated with the clinical response to the anticancer drug, gefitinib. Since then, a tremendous amount of knowledge has accumulated, and sheds light on significant oncological properties as well as the clinical relevance of this mutation, which could be applicable to other malignancies. The EGFR mutations are distributed throughout the kinase domain, but a deletion in exon 19 and the point mutation L858R in exon 21 account for approximately 90%, which confer a greater response to gefitinib treatment, compared with other types of EGFR mutations. These EGFR mutations in the tyrosine kinase domain are seldom acquired in cancers of the other organs and the mutations preferentially involve a subset of lung cancers, which are clinicopathologically characterized by female sex, non-smoking, adenocarcinoma histology and East Asian ethnicity. In Japan, the EGFR mutations are detected in approximately 30% of overall NSCLC and approximately 40% of surgically resected adenocarcinomas. The morphological features of adenocarcinomas harboring the mutations were reported to be frequent in those with bronchioloalveolar features, but it is suggested that the cellular lineage of the putative original cells of the cancers refines the subset more clearly. In the present study the current knowledge of EGFR mutations is reviewed, insights from which raise many further questions, and thus suggest new directions for future research.

Preferential induction of CYP1A1 and CYP1B1 in CCSP-positive cells

Both benzo[a]pyrene (BaP) and 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) are potent ligands of aryl hydrocarbon receptors (AhR). Although animal studies indicate that both compounds induce pathological changes in the peripheral lung, the specific cell type involved remains unclear. Clara cells, expressing Clara cell specific protein (CCSP) and abundant in cytochrome P450, are nonciliated bronchiolar epithelial cells in the peripheral lung. Here we explore the hypothesis that CCSP-positive Clara cells are highly responsive to AhR ligands and are the primary cell type involved in BaP- and TCDD-induced toxicities. The responsiveness to AhR ligands was evaluated by measuring the respective mRNA and protein levels of cytochrome P450 1A1 (CYP1A1) and 1B1 (CYP1B1) using real-time RT-PCR and immunocytochemistry assays. Two in vitro models were used: primary cultures of human small airway epithelial (SAE) cells and rat lung slice cultures. In the presence of calcium, human SAE cells differentiated into CCSP-positive cells. BaP- and TCDD-induced mRNA and protein levels of CYP1A1 and CYP1B1 levels were significantly elevated in CCSP-positive cell cultures. Similarly, AhR mRNA and protein levels were increased in CCSP-positive cell cultures, as determined by real-time RT-PCR and Western blot analysis. When rat lung slice cultures were treated with BaP or TCDD for 24 h, CYP1A1 and CYP1B1 proteins were strongly induced in Clara cells. These results indicate that, in the peripheral lung of both rats and humans, CCSP-positive cells (Clara cells) may be more sensitive to AhR ligands than other cell types.

EGFR Mutation Is Specific for Terminal Respiratory Unit Type Adenocarcinoma

We have previously reported that terminal-respiratory-unit (TRU) type adenocarcinoma is a distinct subset of lung adenocarcinoma in terms of molecular pathway for carcinogenesis and phenotypic profiles. This type of cancer shows TRU features, characterized by distinct cellular morphology and the expression of TTF-1 and surfactant proteins. Recently, two groups published novel mutations of the epidermal growth factor receptor (EGFR) that are closely associated with clinical response to gefitinib. The clinicopathologic features of gefitinib responders overlap with those of TRU-type adenocarcinoma, and the characteristics of TRU are likely to correspond to the bronchioloalveolar features reported as a predictor of gefitinib response. We therefore examined the characteristics of EGFR-mutated pulmonary adenocarcinomas with special reference to TRU-type adenocarcinoma. EGFR mutation was detected in 97 of 195 adenocarcinomas, 91 of 149 TRU-type adenocarcinomas and 6 of 46 tumors of other types. Conversely, 91 of 97 EGFR-mutated adenocarcinomas were categorized as TRU-type adenocarcinomas. This type-specific involvement was confirmed by logistic regression model. In addition, EGFR mutation was detected in some cases of atypical adenomatous hyperplasia, a preinvasive lesion of TRU-type adenocarcinoma. These findings further confirm that TRU-type-adenocarcinoma is a distinct adenocarcinoma subset in which a particular molecular pathway is involved.

Assessment of differentiation in adenocarcinoma cells from pleural effusion by peripheral airway cell markers and their diagnostic values

Ultrastructural studies have shown that Clara cell-type is a more common type of adenocarcinoma than alveolar type II cell-type, and that both types may provide better prognosis than other types, indicating an importance of differentiation toward peripheral airway cells. Pulmonary surfactant protein (SP)-A is a specific marker for both alveolar type II cells and Clara cells in peripheral lung tissues, while SP-C and Clara cell 10 kD protein (CC10) may be particularly and highly specific to alveolar type II cells and Clara cells, respectively. The aims of this study were to assess the differentiation of adenocarcinoma cells in pleural effusions by evaluating the expression of these cell markers and to evaluate their values as diagnostic tools for judging the cause of pleural effusion. We examined pleural effusions from 52 patients; 20 with primary lung adenocarcinomas, 6 with small cell lung carcinomas, 11 with metastatic malignant tumors and 15 with non-neoplastic diseases. The cell pellets from effusions were subjected to immunocytochemical staining for SP-A, proSP-C, a precursor of SP-C, and CC10. By this immunocytochemical study for SP-A and proSP-C, 10 (50%) and 6 (30%) of 20 adenocarcinomas, respectively, showed a positive immunoreactivity in their effusion cells, while none of them expressed CC10. Alveolar type II cells therefore may be the main progenitor cells of some adenocarcinomas. In pleural effusions from patients with primary lung adenocarcinomas, reverse transcriptase-polymerase chain reaction (RT-PCR) for SP-A mRNA showed a sensitivity of 83%, while, in all remaining patients, these assays were negative. In conclusion, we demonstrated that lung adenocarcinomas, which are partially differentiated toward alveolar type II cells, are not as rare as previously thought, and that both the RT-PCR and immunocytochemical analyses for SP-A and pro-SP-C could be worthy indicators of differential diagnosis.

Analysis of cell type and radiographic presentation as predictors of the clinical course of patients with bronchioalveolar cell carcinoma

STUDY OBJECTIVES

Bronchioloalveolar carcinoma is a primary lung neoplasm of variable histopathologic, radiologic, and clinical expression. There are three cell types described in bronchioloalveolar carcinoma: Clara cells, mucin-producing cells, and alveolar type II epithelial cells. It is unclear whether these three tumor cell types are associated with a specific radiologic presentation and clinical course. In this study, we investigated whether tumor cell type, identified by transmission electron microscopy, correlated with a specific radiologic pattern, and whether tumor cell type or radiologic presentation correlated with the patient's clinical course and outcome.

DESIGN

Transmission electron microscopy was used to restudy tissue blocks from the original surgical histopathologic specimens in 54 patients with primary bronchioloalveolar carcinoma diagnosed over a 10-year period (1980 to 1990). The pretreatment radiographs were reviewed in each case, and the first chest radiograph obtained at the time of the discovery of the tumor in each patient was compared with the results of the ultrastructural study. The medical records of each patient were examined to obtain pertinent radiologic, clinical, and patient outcome information.

MEASUREMENT AND RESULTS

There were 32 Clara cell tumors, 10 mucin-producing cell tumors, and 1 alveolar type II epithelial cell tumor in this series. Eleven additional tumors had mixtures of two or more cell types. No statistically significant relationship was detected between tumor cell type and radiologic presentation or patient mortality pattern. There was increased mortality among patients who presented radiologically with segmental, lobar, multifocal, or diffuse disease compared with those patients exhibiting a solitary pulmonary nodule at presentation.

CONCLUSION

Radiologic presentation, rather than tumor cell type, provides prognostic information that aids in predicting patient outcome.

Villin, cytokeratin 7, and cytokeratin 20 expression in pulmonary adenocarcinoma with ultrastructural evidence of microvilli with rootlets

Villin (V) is a glycoprotein of microvilli associated with rootlet formation. Most colonic adenocarcinomas have a V positive (+), cytokeratin (CK) 20 (+), CK7-negative (-) immunophenotype; most lung adenocarcinomas have a CK20(-), CK7(+) immunophenotype. The reports of villin immunoreactivity in lung adenocarcinoma range from 6% to 68% in studies using various fixations and varied anti-villin antibodies. Some lung adenocarcinomas have microvilli with rootlets leading to possible diagnostic confusion with metastatic colonic adenocarcinoma to lung. Nine primary lung adenocarcinomas with rootlets on ultrastructure (including four bronchioloalveolar carcinomas [BAC]), four metastatic lung adenocarcinomas with rootlets, nine metastatic colon adenocarcinomas to lung, and 10 randomly selected lung adenocarcinomas without rootlets (including five BAC), were immunostained with monoclonal antibodies to villin (1D2C3), CK7 (OV-TL12/30), and CK20 (Ks20.8) using a streptavidin peroxidase technique with heat-induced epitope retrieval. All primary lung adenocarcinomas with rootlets were CK7(+) CK20(-), and six of nine (67%) were V(+). Cytoplasmic villin positivity occurred in a diffuse--five of nine (56%), focal--two of nine (22%), or brush border pattern--two of nine (22%). Two of four metastatic lung adenocarcinomas with rootlets were V(+). One metastatic lung adenocarcinoma had a CK7(+), CK20(+), V(-) phenotype. All metastatic colonic adenocarcinomas were V(+), CK20(+), CK7(-), and 1 of 10 (10%) lung adenocarcinomas without rootlets was V(+), and all 10 were CK20(-), and CK7(+). In summary, villin positivity is more common in lung adenocarcinoma with rootlets (67%) than those without rootlets (10%). AU primary lung adenocarcinomas were CK7(+), CK20(-). The combination of villin, CK 7, and CK 20 is helpful in differentiating metastatic colon adenocarcinoma from lung adenocarcinoma with rootlets.

Divergent differentiative histogenetic lines in lung tumors: identification of histotypes with pure or mixed ultrastructural phenotype and their prognostic significance

We performed an electron microscopic study of 50 lung tumors, previously diagnosed by light microscopy, and compared the results of the two techniques. Data analysis identified two ultrastructural phenotypes: pure and mixed. The former was characterized by a constant differentiative pattern and the latter by diverging differentiative histogenetic lines. We observed six differentiative lines as follows: squamous, glandular, neuroendocrine, villopodial, intestinal, and apocrine sudoriparous. Features of divergent differentiative lines were observed in 36 cases (64%), throughout the histotypes, sometimes with coexpression of more than one differentiation in a single case and/or cell. Adenocarcinoma was the histotype most frequently observed in pure form whereas most squamous cell carcinomas showed a mixed phenotype. This suggests that the histotype of the different lung tumors arises from a single glandular pluripotent cell, able to differentiate toward divergent differentiative lines. The clinical stage at onset and at the end of the follow-up indicates that the biologic behavior of lung tumors varies according to whether the ultrastructural phenotype is pure or mixed.

Special subtypes of pulmonary adenocarcinomas indicated by different tumor cell HLA-expression and stromal infiltrates. A light, electron microscopic and immunohistologic study

A total of 31 human peripheral adenocarcinomas (AC) of the lung were subclassified by light and electron microscopy according to their phenotypic characteristics. The expression of HLA-A,B,C and HLA-DR on tumor cells, and the degree of subclassified mononuclear cell infiltration were determined using immunohistologic and morphometric methods. The study shows that pulmonary AC can be subdivided in two main types with different properties. The first type is characterized by mucin production comparable to that of bronchial goblet cells. These mucinous AC of type I show nearly no expression of HLA-DR; the tumor volume fraction with HLA-A,B,C expression is greatest in highly differentiated AC I, and decreases significantly with lower grades of differentiation. The AC of type II, possibly originating from the bronchioloalveolar transitional zone, show properties of Clara cells and of type II-pneumocytes by light and electron microscopy. These features include apically located electron-dense granules and lamellar bodies occurring often simultaneously. Both groups of HLA-antigens, HLA-A,B,C and HLA-DR, are homogeneously distributed in a similar phenotypic fashion to Clara cells and pneumocytes II of the normal lung. The significant differences in mononuclear cell infiltration between the two tumor types are possibly induced by the different HLA-DR expression, which have not been seen in AC from other sites. In AC II with homogeneous HLA-DR expression in the tumor epithelium, the numbers of tumor-infiltrating Langerhans cells, and T- and B-lymphocytes are significantly higher than in AC I, possibly indicating better host immunologic defense mechanisms against these tumors.

Heterogeneous subcellular morphology of lung adenocarcinoma cells: identification of different cytotypes on cytological material

We performed an electron microscopic study of cytologic material from 20 cases of primary lung adenocarcinoma (pleural effusion, 13 cases; fine needle aspiration biopsy, 7 cases). Ultrastructural characteristics related to secretory and storing activity of adenocarcinoma cells were evaluated semiquantitatively. Data analysis identified three basic cell types (secretory, well or poorly differentiated; storing; and indifferent). We could classify our cases in five groups of pure or mixed cytotypes. Our results demonstrated a subcellular morphological heterogeneity manifested by the presence of different basic cell types: secretory, storing or indifferent features (or both); and different secretory and storage products in the same cell. This heterogeneity of lung adenocarcinoma cells suggests that the neoplasm could arise from a single cell type capable of differentiating along different lines. Cases lacking secretory differentiation seemed to be characterized by more aggressive biologic behavior. A clear correlation between the ultrastructural cytotypes identified and the clinical and prognostic data on the patients was not observed. This may be due to the fact that 75% of the patients were in clinical stage III at the time of diagnosis; also, in this series only five cases did not have characteristics that indicated secretory activity.

Ultrastructural heterogeneity of pulmonary scar adenocarcinomas: correlation with patients' survival

A prospective study of 24 pulmonary scar adenocarcinomas was conducted to evaluate a potential correlation between patients' survival, propensity to metastasize, and subtypes of pulmonary scar adenocarcinomas as determined by ultrastructural examination. Ultrastructural studies of pulmonary adenocarcinomas have shown three types of cells: mucus, Clara, and alveolar, with neoplasms exhibiting these cellular components either singly or in combination. Previous studies of adenocarcinomas have revealed that tumors with Clara and alveolar cell differentiation have a better prognosis than those with a mucus cell component. The present study emphasizes clinico-pathologic correlations and indicates that pulmonary scar adenocarcinomas represent a heterogeneous group with a similar cell distribution as has been found in other pulmonary adenocarcinomas. The previously established correlation between cell types and survival remains true in this group of pulmonary adenocarcinomas. Light microscopic growth patterns and special stains (PAS and mucicarmine) were not predictable in identifying the different varieties of pulmonary adenocarcinomas.

Pulmonary adenocarcinoma: review of 106 cases and proposed new classification

The gross and microscopic appearances of 106 resected pulmonary adenocarcinomas were reviewed and correlated with postoperative survival. Instead of using an established classification based on histological pattern, the tumours were categorised by cellular morphology and site as either parenchymal adenocarcinoma (67%), bronchial adenocarcinoma (13%), or adenocarcinoma of uncertain origin (20%). Despite their pleomorphic appearance parenchymal adenocarcinomas should be regarded as a single entity, derived from multipotential cells of the distal airway; bronchial adenocarcinomas were generally, but not invariably, associated with short postoperative survival; those tumours that could not be reclassified on histological grounds were large adenocarcinomas consisting mainly of mucus cells. Tumours of this type carry a poor prognosis.

Immunoreactivity of surfactant-apoprotein in adenocarcinomas, large cell and small cell carcinomas of the lung

Fifty seven adenocarcinomas, 43 large cell and 30 small cell lung carcinomas were immunohistochemically examined using monospecific IgG against pulmonary surfactant apoprotein. Six peripheral adenocarcinomas and one peripheral large cell carcinoma were found to be histogenetically related to type II pneumocytes. They showed an acinar, papillary or solid growth pattern. The immunohistochemical study using anti-surfactant apoprotein IgG gave a granular reaction product in both the cytoplasm and nucleus of tumor cells whose intensity was variable. Intranuclear inclusions were generally the most densely stained structures. These results suggest that lung carcinomas derived from alveolar type II cells are found not only in bronchioloalveolar tumors, but are also found in other types of adenocarcinoma and in large cell carcinomas.

Bronchioloalveolar carcinomas. Cell types, patterns of growth, and prognostic correlates

Forty-five bronchioloalveolar carcinomas were studied, including 27 cases by electron microscopy. Bronchioloalveolar carcinomas can be classified by routine sections or by diastase-digested periodic acid-Schiff (PAS) stains, but electron microscopy is useful in confirming Clara cell or type II pneumocyte (nonmucinous) differentiation and excluding metastases. Mucinous bronchioloalveolar carcinoma can mimic metastatic adenocarcinoma histologically and ultrastructurally. Of the nine tumors with mucinous differentiation, eight had aerogenous dissemination (multifocal or with pneumonic spread), and seven of those eight were fatal. Twenty-four of 36 nonmucinous bronchioloalveolar tumors had aerogenous spread; all of the 24 patients died or were living with distant metastases. The 12 nonmucinous tumors without aerogenous dissemination had a 5-year survival rate of 61%. Among these, the smaller tumors had a better prognosis. The presence of alveolar spread, rather than cell type, was the most important feature predicting survival.

Scar adenocarcinoma of the lung: a light and electron microscopic study

Five well differentiated peripheral adenocarcinomas of the lung were investigated, using light and electron microscopy. Each tumour contained a central nidus of fibrous tissue and fulfilled the criteria for "scar cancer." One tumour also had a focus of lamellated collagenous tissue, suggestive of an old tuberculous granuloma. Electron microscopy showed the features of Clara cells, with characteristic dense bodies in the apical cytoplasm and scattered microvilli on the luminal surface. It was concluded that this variant of scar cancer was a carcinoma of Clara cells, which was sufficiently distinctive in appearance to be recognised on light microscopy alone. It remains uncertain, however, whether the central fibrous area is a desmoplastic response to tumour growth or a pre-existing scar.

The pathobiologic features of carcinomas of type II pneumocytes. An immunocytologic study

Adenocarcinomas of the lung without squamous differentiation or obvious mucus production from 51 patients were studied. Twenty-eight tumors (55%), when stained with rabbit anti-human surfactant apoprotein antiserum by the peroxidase-antiperoxidase method, demonstrated characteristic nuclear inclusions. Most of these tumors could be identified histochemically by the presence of eosinophilic, periodic acid-Schiff (PAS)-positive nuclear inclusions. In patients with apoprotein-immunoreactive tumors there were nine deaths due to tumor (32%) within 5 years of diagnosis. Eight of the nine deaths occurred in patients whose tumors exceeded 3 cm in diameter; an equal number of patients were smokers. The average age of patients with apoprotein-positive tumors was 67.3 years, a figure greater than that for patients with apoprotein-negative tumors (61.4 years). Five of the 23 patients with apoprotein-negative tumors died of their neoplasms; in two of the subjects the tumors exceeded 3 cm in diameter. In that no significant difference in survival was observed in patients with apoprotein-positive and apoprotein-negative tumors, it was concluded that subclassification of adenocarcinomas of the lung as apoprotein-positive, i.e., type II pneumocytic, or as apoprotein-negative, is of no clinical or prognostic significance. Nonetheless, peripheral tumors measuring less than 3 cm in size and showing neither squamous differentiation nor obvious mucus production should be recognized as a prognostically favorable group in comparison with other types of lung carcinomas.