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Ann Thorac Surg 2000;69:882-886
© 2000 The Society of Thoracic Surgeons

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Original Articles

Molecular biologic substaging of stage I lung cancer according to gender and histology

^a Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina, USA

Address reprint requests to Dr D’Amico, Department of Surgery, Duke University Medical Center, Box 3496, Durham, NC 27710
e-mail: damic001{at}mc.duke.edu

Presented at the Forty-sixth Annual Meeting of the Southern Thoracic Surgical Association, San Juan, Puerto Rico, Nov 4–6, 1999.

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. This study is designed to assess molecular biologic substaging according to gender and histology in patients with stage I non-small cell lung cancer (NSCLC).

Methods. Pathologic specimens were collected from 408 consecutive patients after complete resection for stage I NSCLC, with follow-up of at least 5 years. A panel of nine molecular markers was chosen for immunohistochemical analysis of the tumor: recessive oncogenes p53 and bcl-2, the protooncogene erbB-2, KI-67 proliferation index, retinoblastoma oncogene (Rb), epidermal growth factor receptor (EGFr), angiogenesis factor viii, sialyl-Tn antigen (STN), and CD-44. Cox proportional hazards regression analysis was used to construct a risk model for cancer-specific survival according to marker status, gender, and histologic subtype.

Results. Among men, the only molecular marker associated with decreased cancer-specific survival is erbB-2; among women, there are four markers: p53, Rb, CD-44, and factor viii. Among patients with squamous cell carcinoma, the only molecular marker associated with decreased cancer-specific survival is erbB-2; among patients with adenocarcinoma (AC), there are three markers: p53, CD-44, and factor viii. Multivariable analysis of interactions among molecular markers, gender, and histology demonstrates two important relationships (hazard ratio): p53+/women (2.269) and CD-44+/AC (2.266).

Conclusions. Molecular biologic substaging of patients with stage I NSCLC demonstrates differential cancer-specific survival according to marker expression, gender, and histologic subtype.

	Introduction

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Lung cancer is the most common cause of death by malignancy in both men and women in the United States, and is more common than the next three causes combined [1]. The current staging system for non-small cell lung cancer (NSCLC) considers the size and location of the primary tumor (T), the involvement of regional lymph nodes (N), and the presence of distant metastases (M) [2]. The standard treatment of patients with stage I NSCLC (T1-2N0M0) is resection of the primary tumor (no adjuvant therapy). Survival for patients with stage I disease is only 67% [2]; thus, a significant portion of patients are actually understaged and may benefit from adjuvant therapy.

Molecular biologic substaging, the use of molecular markers as a strategy of risk stratification [3], has been validated in retrospective studies [4–10], and is under evaluation prospectively. Few reports have addressed differences in survival between men and women with stage I NSCLC [11–17], and the relationship between the expression of molecular markers, gender, and histology has not been addressed. This study analyzes a population of patients with stage I NSCLC according to expression of oncogenic markers, gender, and histologic subtype, with respect to cancer-specific survival. The purpose of this investigation is to identify subgroups of stage I patients with elevated risk of recurrence who might benefit from adjuvant therapy.

	Material and methods

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From January 1, 1980, until December 31, 1992, 6,510 consecutive patients with documented NSCLC were evaluated at the Comprehensive Cancer Center at Duke University Medical Center. Inclusion criteria for entry into the study population included pathologic stage I NSCLC (T1N0M0 or T2N0M0) by the International System of Staging for Lung Cancer [2], complete resection, no adjuvant therapy, minimum 60-day survival, and availability of pathologic material. During this period, 408 patients met these criteria, and all patients in this study have been followed for at least 5 years.

Each case was reviewed by a pathologist to ascertain tumor size and cell type, and to exclude involvement of hilar and mediastinal lymph nodes. Only squamous cell carcinoma (SCC), adenocarcinoma (AC), and large cell carcinoma variants are included in this analysis. The greatest dimension of the tumor was measured in centimeters; the primary lesion was carefully examined for the presence of visceral pleural involvement, lymphatic invasion, and vascular invasion.

Immunohistochemical analyses were performed on two paraffin blocks of resected lung tissue for each patient in the study, obtained after approval of the Human Subjects Review Committee protocol. The immunohistochemical analyses have been previously described [4]. In brief, after paraffin microtome sectioning (4 to 6 µm), slide labeling, and deparaffinization with xylene and ethanol, antigen retrieval was completed after microwaving and phosphate-buffered saline washing. The sections were incubated with primary monoclonal antibody to EGFr, erbB-2, p53, bcl-2, Rb, KI-67, factor viii, CD-44 (BioGenex Laboratories, San Ramon, CA), and STN (Dako, Carpinteria, CA). Incubation with the secondary antibody (horseradish peroxidase) was subsequently performed, followed by development with diaminobenzidine and counterstain with methyl green or hematoxylin.

Immunohistochemical data were recorded without knowledge of patient outcome. Analysis of p53, Rb, bcl-2, EGFr, erbB-2, STN, and CD-44 were analyzed by two independent observers. Known positive tumors and normal lung tissue were used as positive and negative controls, respectively. Blocks were graded positive when widespread staining was present, with an intensity of at least 2 (50% or more positive) on a scale of 0 to 3. Both observers had to rate a 2 or better for each block to be considered positive. The presence of nuclear staining of p53 was indication of mutation for the p53 gene [4]. The KI-67 proliferation index was determined by computerized static image cytometry of 10 consecutive high-powered fields, compared with a background established with control antibody. Analysis of angiogenesis factor viii included the center, the periphery, and the hottest area, using computerized static image cytometry of 10 consecutive high-powered fields.

Statistical analysis
All marker analyses were blinded to patient outcome. The log-rank test and Cox proportional hazards model were used to examine the relationship between cancer-specific survival and various potential prognostic factors individually, comprising immunostaining for Rb, EGFr, erbB-2, bcl-2, p53, CD-44, STN, KI-67 proliferation index, and factor viii microvessel count. Cancer-specific survival was defined as the time between surgery and last follow-up or cancer death. If a patient died without cancer recurrence, the patient’s survival time was censored at the time of death.

	Results

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Histologic subtype
There were 269 men (66%) and 139 women (34%) who met the study criteria (Table 1). AC accounted for 51%, SCC for 36%, and large cell undifferentiated carcinoma for 13%; only patients with AC and SCC are analyzed with respect to other variables in this study. The distribution of cell type is significantly different among men and women. A greater proportion of men had SCC (45%) compared with women (26%); a greater proportion of women had AC (62%) compared with men (45%). Smoking history is also different, with men having a significantly fraction of heavy smokers (Table 2).

Survival
There was no significant difference in survival according to gender or histologic subtype alone (Table 4). The relationship between gender and marker expression, with respect to survival, is illustrated in Table 5. Among women, four factors were associated with significantly increased risk of cancer-specific death; p53, CD-44, factor viii, and Rb. Among men, erbB-2 was the only significant risk factor.

	Comment

Top Abstract Introduction Material and methods Results Comment References

In this study of 408 patients with completely resected stage I NSCLC, a significantly greater proportion of men had SCC, and a greater proportion of women had AC. Many factors may contribute to this difference, including tobacco exposure, which was also significantly different among men and women.

The expression of molecular markers was significant as well. A greater proportion of men overexpressed KI-67, bcl-2, and CD-44. Among patients with SCC, there were five factors with differential overexpression, compared with AC: KI-67, bcl-2, CD-44, EGFr, and Rb. The proportion of patients with AC who overexpressed p53 was greater than that for SCC.

The relationship between the expression of molecular biologic markers by a particular tumor and the associated gender and histologic subtype is difficult to determine. The similarity in the expression of molecular markers in patients with SCC and among all men suggests a possible relationship; furthermore, SCC was significantly more prevalent among men. The parallel relationship between the expression of markers in patients with AC and in women is similarly supportive of a relationship. Finally, the contribution to smoking history, which is also significantly greater among men, bears investigation.

Nevertheless, the differential expression of molecular markers in these subgroups is significant and provides the potential for substaging. The current staging system supports no differential prognostic information nor therapeutic intervention on the basis of tobacco exposure, histology, or gender. The goal of molecular biologic substaging is to determine the relationships between oncogenic markers and other variables, and to assess whether these variables significantly alter prognosis and justify adjuvant therapy.

Analysis of cancer-specific survival according to gender and histologic subtype alone demonstrates no significant differences in this study. However, there are significant relationships among marker expression, gender, and histology. Among women, four factors were found to be associated with increased risk of cancer-specific death: p53, CD-44, factor viii, and Rb. Among men, there was only one significant risk factor: erbB-2. Among patients with AC, there were three significant predictors of cancer-specific death: p53, CD-44, and factor viii. Among patients with SCC, erbB-2 was the only factor with increased risk.

Assessing the complex relationships among the variables in this study (gender, histologic subtype, marker expression, survival) is difficult with conventional statistical methods. However, powerful relationships can be demonstrated. Among women, the absence of p53 mutation confers a significant survival advantage, as demonstrated by the 5-year survival (77%) and hazard ratio, compared with the entire study population (0.49). The presence of p53 mutation in women, in contradistinction, is associated with a significantly elevated risk of cancer-specific death: 5-year survival 49%, hazard ratio 2.27. Of note, in this study, p53 confers no significant prognostic information in men.

Among patients with AC, overexpression of CD-44 is also a powerful predictor of cancer-specific death: 5-year survival 27%, hazard ratio 2.27. In this group of patients, molecular biologic substaging was more important than nodal status, predicting survival that is comparable with patients with stage IIB or stage IIIA NSCLC.

Molecular biologic substaging according to gender and histologic subtype in patients with completely resected stage I NSCLC demonstrated relationships with important prognostic information. Similar molecular marker expression suggests a relationship between men and patients with SCC and between women and patients with AC. Among certain subgroups, women with p53 mutations and patients with AC who overexpress CD-44, risk stratification according to oncogenic expression is more powerful than the absence of lymph node metastases. The ability to define subgroups with risk of cancer-specific death that supercedes the current staging system may allow for the prospective validation of this risk model and for prospective, randomized trials involving adjuvant therapy based on molecular biologic substaging.

	References

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1. Landis S.H., Murray T., Bolden S., Wingo P.A. Cancer statistics, 1999. CA Cancer J Clin 1999;49:8-31.[Abstract/Free Full Text]
2. Mountain C.F. Revisions in the International System for Staging Lung Cancer. Chest 1997;111:1710-1717.[Abstract/Free Full Text]
3. Lau CL, D’Amico TA, Harpole DH. Staging and prognosis: clinical and molecular prognostic factors and models for non-small cell lung cancer. In: Pass HI, Mitchell JB, Johnson DH, Turrisi AT, Minna JD, eds. Lung cancer: principles and practice, 2nd ed. Philadelphia: Lippincott, Williams and Wilkins, 1999 (in press).
4. D’Amico T.A., Massey M., Herndon J.E., et al. A biological risk model for stage I lung cancer. J Thorac Cardiovasc Surg 1999;117:736-743.[Abstract/Free Full Text]
5. Harpole D.H., Jr, Herndon J.E., II, Young W.G., Wolfe W.G., Sabiston D.C., Jr Stage I non-small cell lung cancer. Cancer 1995;76:787-796.[Medline]
6. Harpole D.H., Jr, Herndon J.E., II, Wolfe W.G., Iglehart J.D., Marks J.R. A prognostic model of recurrence and death in stage I non-small cell lung cancer utilizing presentation, histopathology, and oncoprotein expression. Cancer Res 1995;55:51-56.[Abstract/Free Full Text]
7. Harpole D.H., Jr, Richards W.G., Herndon J.E., II, Sugarbaker D.J. Angiogenesis and molecular biologic substaging in patients with stage I non-small cell lung cancer. Ann Thorac Surg 1996;61:1470-1476.[Abstract/Free Full Text]
8. Strauss G.M., Kwiatkowski D.J., Harpole D.H., Lynch T.J., Skarin A.T., Sugarbaker D.J. Molecular and pathologic markers in stage I non-small cell carcinoma of the lung. J Clin Oncol 1995;13:1265-1279.[Abstract]
9. Kwiatkowski D.J., Harpole D.H., Jr, Godleski J., et al. Molecular pathologic substaging in 244 stage I non-small cell lung cancer patients. J Clin Oncol 1998;16:2468-2477.[Abstract]
10. Pastorino U., Andreola S., Tagliabue E., et al. Immunocytochemical markers in stage I lung cancer. J Clin Oncol 1997;15:2858-2865.[Abstract]
11. Andrews J.L., Bloom S., Balogh, Beamis J.F. Lung cancer in women. Cancer 1985;55:2894-2898.[Medline]
12. Canver C.C., Memoli V.A., Vanderveer P.L., Dingivan C.A., Mentzer R.M. Sex hormone receptors in non-small cell lung cancer in human beings. J Thorac Cardiovasc Surg 1994;108:153-157.[Abstract/Free Full Text]
13. Baldini E.H., Strauss G.M. Women and lung cancer. Chest 1997;112(Suppl):229-234s.[Abstract/Free Full Text]
14. Ouellette D., Desbiens G., Emond C., Beauchamp G. Lung cancer in women compared to men. Ann Thorac Surg 1998;66:1140-1143.[Abstract/Free Full Text]
15. Sekine I., Nishikawa Y., Yokose T., Nagai K., Suzuki K., Kodama T. Young lung cancer patients in Japan. Ann Thorac Surg 1999;67:1451-1455.[Abstract/Free Full Text]
16. Barbone F., Bovenzi M., Cavallieri F., Stanta G. Cigarette smoking and histologic subtype of lung cancer in men. Chest 1997;112:1474-1479.[Abstract/Free Full Text]
17. Fujisawa T., Iizasa T., Saitoh Y., et al. Smoking before surgery predicts poor long-term survival in patients with stage I non-small cell lung carcinomas. J Clin Oncol 1999;17:2086-2091.[Abstract/Free Full Text]

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