Ann Thorac Surg 2000;69:1025-1029
© 2000 The Society of Thoracic Surgeons
ORIGINAL ARTICLES: GENERAL THORACIC
Clinicopathological and biological assessment of lung cancers with pleural dissemination
Yasuhiko Ohta, MDa,
Yoko Tanaka, PhDa,
Takuo Hara, MDa,
Makoto Oda, MDa,
Shun-ichi Watanabe, MDa,
Junzo Shimizu, MDa,
Yoh Watanabe, MDa
a First Department of Surgery, Kanazawa University School of Medicine, Kanazawa, Japan
Address reprint requests to Dr Ohta, First Department of Surgery, Kanazawa University School of Medicine, Takara-machi 13-1, Kanazawa 920-8641, Japan
e-mail: yohta{at}med.kanazawa-u.ac.jp
 |
Abstract
|
|---|
Background. This study provides the surgical outcome of lung cancer patients with pleural dissemination, with the assessment of the clinicopathological and biological prognostic factors.
Methods. Forty-three patients who underwent operations were studied. Vascular endothelial growth factor (VEGF) and autocrine motility factor receptor (AMFR/gp78) expression was immunohistochemically evaluated.
Results. In total, the overall 3 and 5-year survival rates were 31.4% and 13.1%, respectively. The patients who underwent the pleuropneumonectomy had a worse outcome than those who underwent limited operations (pleurectomy plus parenchymal resections were less than pneumonectomy). VEGF and AMFR/gp78 were highly expressed in primary tumors. Among the patients who underwent limited operations, pathological types other than adenocarcinoma and high expression of VEGF were significantly associated with a worse outcome. The pathological type was the only characteristic to retain a significant independent prognostic impact on overall survival.
Conclusions. The results imply the validation of limited operation for lung cancer with pleural dissemination for the local control. High frequency of VEGF and AMFR/gp78 expression conform to the interpretation that patients with pleural dissemination have a high-risk of systemic disease.
|
Introduction
|
|---|
Carcinomatosa pleuritis, ie, pleural dissemination with or without malignant pleural effusion secondary to primary lung cancer, is a locally advanced disease besieged by the pleura of a hemithorax. The most likely mechanism of the development of pleural metastasis is the extrapulmonary direct spread of cancer cells, however, the detailed mechanisms for the formation of this type of metastasis still remain unclear. Patients with this advanced disease belong to stage IIIB or IV, which causes poor therapeutic results despite the development of some innovative therapeutic devices, such as hypotonic cisplatin treatment [1], intrathoracic chemothermotherapy [2], and photodynamic therapy [3]. The management of the disease often concentrates on the control of pleural effusion, and very few patients with the disease generally survive beyond 1 year [4–6]. In terms of surgical treatment, an aggressive en block resection by pleuropneumonectomy appears to be invalid and ineffective against the disease because of a cumbersome problem that is relevant to the progression of distant metastases after the treatment [7, 8]. This locally advanced disease may have to be considered a systemically advanced disease with a high-risk of distant metastasis. This study provides the surgical outcomes of lung cancer patients with pleural dissemination together with the assessment of two biological factors that may pertain to the development of the disease: vascular endothelial growth factor (VEGF) and autocrine motility factor receptor (AMFR/gp78).
|
Patients and methods
|
|---|
Between 1975 and 1997, a total of 1,498 primary lung cancer patients underwent operations at Kanazawa University Hospital, 43 of whom were diagnosed with carcinomatosa pleuritis based on pathological findings and a resection of the primary tumor plus parietal pleurectomy was done. Among the patients with cacinomatosa pleuritis, 20 were men and 23 were women. The median age of patients with carcinomatosa pleuritis was 63 years (range 40 to 76). Operative procedures included partial resection of the lung plus parietal pleurectomy in 15 cases, segmentectomy plus parietal pleurectomy in 1 case, lobectomy plus parietal pleurectomy in 21 cases, and pleuropneumonectomy in 6 cases. The pathological stages according to the TNM classification [9] were, 34 cases in stage IIIB (16 cases in N0, 4 cases in N1, 12 cases in N2, and 2 cases in N3) and 9 cases in stage IV (7 cases of lung metastasis, 1 case of bone metastasis, and 1 case of skin metastasis). The pathological types were, 35 cases with adenocarcinoma, 5 cases with squamous cell carcinoma, 1 case with adenosquamous carcinoma, and 2 cases with large cell carcinoma. Twenty-seven patients (stage IIIB: 22 and IV: 5) received adjuvant chemotherapy after operation. Predominat regimen was CDDP and VDS. The basic clinical and pathological features of the patients are shown in Table 1. Although the patients in the pleuropneumonectomy group are younger than those in the limited operation group (partial resection plus parietal pleurectomy, segmentectomy plus parietal pleurectomy, lobectomy plus parietal pleurectomy), there were no significant differences as to gender, stage (IIIB vs IV), nodal metastasis, histological type, tumor size, or the percentage of the patients with postoperative adjuvant chemotherapy between the two groups.
Tumor tissue and immunohistochemical staining
Paraffin-embedded primary tumor samples were obtained from 38 patients with carcinomatosa pleuritis. Initially, we reviewed the hematoxylin and eosin stained slides of the tumor specimens, and then we selected blocks of the invasive edge in the tumor area. Consecutive 5-µm sections were prepared from each sample. Primary antibodies used in this study were a mouse monoclonal antibody at a 1:200 dilution for AMFR/gp78 (kindly donated by Dr H. Watanabe) and a mouse polyclonal antibody at a 1:100 dilution for VEGF (Santa Cruz Biotechnology, Santa Cruz, CA). Paraffin sections were deparaffinized, and immunohistochemical staining was done using the immunoperoxidase technique after predigestion and trypsinization. Endogenous peroxidase was blocked by treatment with 0.3% hydrogen peroxide in methanol for 10 minutes, and specimens were washed with Dulbecco phosphate-buffered saline (pH 7.2) without calcium ion or magnesium ion (PBS-). The sections were incubated with normal goat serum diluted 10-fold with PBS- for 15 minutes at room temperature for blocking. After incubation, they were washed with PBS-, and the sections were reacted with antibodies for 1 hour. Then they were washed with PBS- and reacted with biotin-labeled goat antimouse immunoglobulin (DAKO; Carpinteria, CA) for 30 minutes at room temperature. They were washed with PBS-, then avidin-biotin-peroxidase complex was added and color was developed by 3-3' diaminobenzidine (Sigma, St. Louis, MO) with 0.03% hydrogen peroxide. Counterstaining was done with hematoxylin. A negative control used all reagents with the exception of the primary antibody. The AMFR/gp78 and VEGF staining within tumor cells was considered positive when more than 10% of all tumor cells were stained. The immunoreactivities were graded as (-), (+), and (++) according to the staining intensity of the tumor cells: (-) representing zero to less than 10% of positive staining area, (+) representing 10% to 50% of positive staining area, and (++) representing the strongest stain of more than 50% at x200 magnification.
Statistics
Differences in age and tumor size were analyzed using the Mann-Whitney U test. The association between other different valuables was analyzed by the 
2 test. For univariate survival analysis, age was classified as being in the high or low group relative to the median value. For VEGF and AMFR/gp78, a tumor was included in the high-expressing group if the positive staining area in tumor cells was greater than 50%. Survival curves were obtained by the Kaplan-Meier method and compared univariately by the log-rank test. For multivariate analysis, the Cox proportional hazard regression, along with a stepwise procedure, was used. The criterion for statistical significance was p less than 0.05.
|
Results
|
|---|
In total, the overall 3-year and 5-year survival rates for the 43 patients who underwent operation were 31.4% and 13.1%, respectively, with a median survival of 17 months (Fig 1). Those in the partial resection plus pleurectomy group (n = 15) were both 25.5% and the median survival time of this group was 12 months. The 3-year and 5-year survival rates for the lobectomy plus pleurectomy group (n = 21) were 45.7% and 13.1%, respectively, with a median survival period of 20 months. There was no significant difference in survival between the two groups. On the other hand, in the pleuropneumonectomy group (n = 6), no patient survived beyond 1 year, and the median survival time was only 5 months, resulting in a statistically significant worse outcome compared to those of other two groups with limited operation (both p < 0.05) (Fig 2).
View larger version (9K):
[in this window]
[in a new window]
|
Fig 1. Kaplan-Meier survival plots for 43 lung cancer patients with pleural dissemination who underwent resection of the primary tumor plus parietal pleurectomy.
|
|
View larger version (13K):
[in this window]
[in a new window]
|
Fig 2. Kaplan-Meier survival plots for lung cancer patients with pleural dissemination stratified by operative procedures. The outcome of the patients who underwent pleuropneumonectomy was significantly worse than that of the patients with limited operations.
|
|
The VEGF and AMFR/gp78 expression was evaluated by immunohistochemistry. VEGF and AMFR/gp78 antigens were mainly identified in the cytoplasm of tumor cells (Fig 3). Both VEGF and AMFR/gp78 were highly expressed in primary lung tumors with pleural dissemination. The percentage of positive tumors was 97.4% (37 of 38) for both VEGF and AMFR/gp78. The percentages of tumors with the strongest stain (more than 50% of the staining area in tumor cells) were 50.0% (19 of 38) for VEGF, and 15.8% (6 of 38) for AMFR/gp78.
View larger version (71K):
[in this window]
[in a new window]
|
Fig 3. Examples of immunohistochemical staining for (A) VEGF and (B) AMFR/gp78. For VEGF, cytoplasmic staining was positive in tumor cells, and weak staining was also found in interstitial epithelial components. AMFR/gp78 antigen was mainly identified in the cell membrane and cytoplasm of tumor cells.
|
|
Using 37 patients who underwent limited operation (partial resection of the lung plus parietal pleurectomy, segmentectomy plus parietal pleurectomy, and lobectomy plus parietal pleurectomy), the authors assessed the prognostic impact of various clinicopathological parameters such as age, gender, pathological types, stages (IIIB vs IV), postoperative chemotherapy, type of carcinomatosa pleuritis (with or without malignant pleural effusion), and lymph node metastasis together with the two biological characteristics, VEGF and AMFR/gp78 expressions, on overall survival. In the assessment of biological markers, we used 34 primary tumor specimens from whom the paraffin-embedded samples could be obtained. According to an univariate assessment, pathological types other than adenocarcinoma (p = 0.0101) and high expression of VEGF (p = 0.0241) were significantly associated with a worse outcome (Table 2). No adjuvant chemotherapy after operation also had a weaker relationship (p = 0.0689) with poor outcomes. As a result of multivariate analysis, pathological type was the only characteristic to retain a significant independent prognostic impact on overall survival (Table 3).
View this table:
[in this window]
[in a new window]
|
Table 2. Prognostic Impact of Clinicopathological and Biological Factors on Overall Survival Among Patients With Pleural Dissemination Who Underwent Limited Operations (Univariate Analysis)
|
|
View this table:
[in this window]
[in a new window]
|
Table 3. Cox Proportional Hazard Regression Analysis Using the Patients With Pleural Dissemination Who Underwent Limited Operation
|
|
|
Comment
|
|---|
We previously reported the justification of limited operation by local excision plus parietal pleurectomy for lung cancer patients with pleural dissemination [7]. Although the data was not based on a randomized trial, the outcomes of limited operations (parietal pleurectomy plus tumor resection through parenchymal resections less than pneumonectomy) were superior to those of pleuropneumonectomy in our series. Owing to the small sample size, lymph node metastasis and/or distant metastasis at the point of operation had no statistically significant impact on survival. Among patients with limited surgeries, however, 5-year survival rate for N0M0 was superior to that for N1-2M0 disease (20.4% vs 13.3%). In addition, only 1 long-term survivor, beyond 5 years without recurrence, underwent limited operation (pleurectomy plus lobectomy) in N0M0 status. Among carefully selected stage III nonsmall cell lung cancer, Albain and colleagues [10] demonstrated that the absence of mediastinal nodal involvement was the strongest predictor of long-term survival after operation. The N0M0 status appears to be preferable for the selection of the patients for operation. As for pathological types, the patients with adenocarcinoma had significantly better outcomes compared to those with other types. Although the meaning of the difference is not clear, the squamous cell carcinoma was a dominant type among other types (5 of 9 cases) in our series. This observation indicated the possibility that the mechanisms of pleural metastasis are different among pathological types. In other words, the formation of the pleural metastasis may depend on not only direct spread of cancer cells, but also on blood and/or lymphatic routes. In squamous cell carcinoma originating the peripheral site just beneath the pleura, more aggressive behavior than that of adenocarcinoma may effect the development of the disease. The differences in outcomes among various pathological types need to be further studied using larger data sets.
In this study, we highlighted two biological markers that may be associated with the development of pleural dissemination. The first biological marker, VEGF, is the powerful endothelial cell-specific mitogen that is associated with tumor neovascularization. This novel angiogenic stimulator was originally detected as a vascular permeability factor in malignant ascites fluid [11]. In a study using 90 randomly selected primary lung cancer patients without distant metastasis, we previously reported that overexpression of VEGF in adjacent normal lung tissue was found in patients with an advanced disease, and some cases with pleural disseminations were included [12], suggesting the association of VEGF expression in host side with the development of pleural dissemination. We also confirmed that VEGF expression in tumor cells is also associated with recurrence after curative resections in stage I nonsmall cell lung cancer, probably through neovessels as a route for metastasis [13]. In this study, we assessed the VEGF expression in cancer cells by using immunohistochemistry, and found that the majority of primary tumors with pleural dissemination expressed VEGF (97.4%). The percentage of tumors with the strongest stain was also high (50%). In contrast to our previous data, the percentages of tumors with positive VEGF stain and of the strongest VEGF stain among lung cancer patients without pleural dissemination were 73.8% to 86.9% and 23.8% to 24.8%, respectively [13, 14]. Although VEGF expression was not an independent prognostic indicator in our series, in the definition that tumors with the strongest VEGF stain were included in the high expressing group, this factor seems to be involved in the development of pleural dissemination and metastasis.
The second marker, AMFR/gp78, has been identified as a cell surface glycoprotein of 78kDa, that is associated with cell migration and cell motility to facilitate metastasis [15, 16]. Interestingly, AMFR/gp78 expression was reported to be associated with peritoneal dissemination in gastric carcinoma [17]. To our knowledge however, no investigators have studied the relationship between AMFR/gp78 expression and pleural dissemination in lung cancer patients. In this study, although the percentage of tumors with the strongest AMFR/gp78 stain was not very high (15.8%) and we could not find the significant prognostic impact of AMFR/gp78 on overall survival, AMFR/gp78 was very highly expressed in primary tumor cells of lung cancer patients with pleural dissemination (97.4%). Incidentally, among lung cancer patients without pleural dissemination, the percentage of positive AMFR/gp78 tumors was 56.4% according to our study using 78 samples (data not shown). The promotion of cancer cell motility through AMFR/gp78 antigen in tumor cells themselves may also pertain to the development of the disease and metastasis.
In conclusion, the development of distant metastasis is a major problem for the surgical management of lung cancers with pleural dissemination, and our results have implications for the validation of limited operations against the disease. As biological markers, VEGF and AMFR/gp78 need to be explored further for possible mechanisms underlying pleural dissemination and for therapeutic molecular targets against the disease.
|
Acknowledgments
|
|---|
We thank Dr Hideomi Watanabe, Gumma University, Japan and Dr Avraham Raz, Karmanos Cancer Institute, Detroit, MI, for the kind gift of the primary antibody for AMFR/gp78.
|
References
|
|---|
-
Ichinose Y., Hara N., Ohta M., et al. Hypotonic cisplatin treatment for carcinomatous pleuritis found at thoracotomy. J Thorac Cardiovasc Surg 1993;105:1041-1046.[Abstract]
-
Kodama K., Doi O., Higashiyama M., Yokouchi H., Tatsuta M. Long-term results of postoperative intrathoracic chemothermotherapy for lung cancer with pleural dissemination. Cancer 1993;72:426-431.[Medline]
-
Baas P., Murrer L., Zoetmulder F.A., et al. Photodynamic therapy as adjuvant therapy in surgically treated pleural malignancies. Br J Cancer 1997;76:819-826.[Medline]
-
Martini N., Bains M.S., Beattie E.J. Indications for pleurectomy in malignant effusion. Cancer 1975;35:734-738.[Medline]
-
Reshad K., Inui K., Takeuchi Y., et al. Treatment of malignant pleural effusion. Chest 1985;88:393-397.[Abstract/Free Full Text]
-
Webb W.R., Ozmen V., Moulder P.V., et al. Iodized talc pleurodesis for the treatment of pleural effusions. J Thorac Cardiovasc Surg 1992;103:881-886.[Abstract]
-
Shimizu J., Oda M., Morita K., et al. Comparison of pleuropneumonectomy and limited surgery for lung cancer with pleural dissemination. J Surg Oncol 1996;61:1-6.[Medline]
-
Rusch V.W., Albain K.S., Crowley J.J., et al. Neoadjuvant therapy. Ann Thorac Surg 1994;58:290-295.[Abstract]
-
Sobin L.H., Wittekind C. TNM classification of malignant tumours. New York: Wiley-Liss, 1997.
-
Albain K.S., Rusch V.W., Crowley J.J., et al. Concurrent cisplatin/etoposide plus chest radiotherapy followed by surgery for stages IIIA (N2) and IIIB non-small cell lung cancer. J Clin Oncol 1995;13:1880-1892.[Abstract/Free Full Text]
-
Senger D.R., Galli S.J., Dvorak A.M., Perruzzi C.A., Harvey V.S., Dvorak H.F. Tumor cells secrete a vascular permeability factor that promotes accumulation of ascites fluid. Science 1983;219:983-985.[Abstract/Free Full Text]
-
Ohta Y., Watanabe Y., Murakami S., et al. Vascular endothelial growth factor and lymph node metastasis in primary lung cancer. Br J Cancer 1997;76:1041-1045.[Medline]
-
Ohta Y., Tomita Y., Oda M., Watanabe S., Murakami S., Watanabe Y. Tumor angiogenesis and recurrence in stage I nonsmall cell lung cancer. Ann Thorac Surg 1999;67:1034-1038.
-
Ohta Y., Endo Y., Tanaka M., et al. Significance of vascular endothelial growth factor messenger RNA expression in primary lung cancer. Clin Cancer Res 1996;2:1411-1416.[Abstract]
-
Liotta L.A., Mandler R., Murano G., et al. Tumor cell autocrine motility factor. Proc Natl Acad Sci USA 1986;83:3302-3306.[Abstract/Free Full Text]
-
Watanabe H., Carmi P., Hogan V., et al. Purification of human tumor cell autocrine motility factor and molecular cloning of its receptor. J Biol Chem 1991;266:13442-13448.[Abstract/Free Full Text]
-
Taniguchi K., Yonemura Y., Nojima N., et al. The relation between the growth patterns of gastric carcinoma and the expression of hepatocyte growth factor receptor (c-met), autocrine motility factor receptor, and urokinase-type plasminogen activator receptor. Cancer 1998;82:2112-2122.[Medline]
Accepted for publication October 19, 1999.
This article has been cited by other articles:
|
|
|
|
 
K. Kameyama, M. Takahashi, K. Ohata, H. Igai, A. Yamashina, T. Matsuoka, T. Nakagawa, and N. Okumura
Evaluation of the new TNM staging system proposed by the International Association for the Study of Lung Cancer at a single institution.
J. Thorac. Cardiovasc. Surg.,
May 1, 2009;
137(5):
1180 - 1184.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. Riquet, C. Foucault, and F. Souilamas
Lung cancer with pleural dissemination: why not operation?
Ann. Thorac. Surg.,
November 1, 2002;
74(5):
1750 - 1750.
[Full Text]
[PDF]
|
|
|
|
|
|
|
N. Sawabata
Reply
Ann. Thorac. Surg.,
November 1, 2002;
74(5):
1750 - 1750.
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
