Kazue Yoneda

Circulating Tumor Cell as a Diagnostic Marker in Primary Lung Cancer

Purpose: To investigate the diagnostic performance of circulating tumor cells (CTC) in discrimination between primary lung cancer and nonmalignant diseases as well as in prediction of distant metastasis. Patients and Methods: We prospectively evaluated CTCs in 7.5-mL samples of peripheral blood sampled from patients with a suspicion or a diagnosis of primary lung cancer. A semiautomated system was used to capture CTCs with an antibody against epithelial cell adhesion molecule. Results: Of 150 eligible patients, 25 were finally diagnosed as having nonmalignant disease, and 125 were diagnosed as having primary lung cancer with (n = 31) or without (n = 94) distant metastasis. CTCs were detected in 30.6 of lung cancer patients and in 12.0 of nonmalignant patients. CTC count was significantly higher in lung cancer patients than in nonmalignant patients, but a receiver operating characteristic (ROC) curve analysis showed an insufficient capability of the CTC test in discrimination between lung cancer and nonmalignant diseases with an area under ROC curve of 0.598 (95 confidence interval, 0.488-0.708; P = 0.122). Among lung cancer patients, CTC count significantly increased along with tumor progression, especially with development of distant metastasis. The area under ROC curve for CTC count in prediction of distant metastasis was 0.783 (95 confidence interval, 0.679-0.886; P < 0.001). When patients with one or more CTCs were judged as having metastatic disease, sensitivity and specificity of the CTC test were 71.0 and 83.0, respectively. Conclusions: CTC is a useful surrogate marker of distant metastasis in primary lung cancer. (Clin Cancer Res 2009;15(22):69806)

Prognostic Impact of Circulating Tumor Cells in Patients with Small Cell Lung Cancer

Background: Enumeration of circulating tumor cells (CTCs) may be valuable for prognostic assessment in lung cancer patients. In this study, we report the clinical significance of CTCs in small cell lung cancer (SCLC). Methods: In total, 51 consecutive patients newly diagnosed as having SCLC and starting chemotherapy or chemoradiotherapy were prospectively enrolled. Blood samples were drawn at the baseline, after chemotherapy, and at relapse. CTCs were isolated using the CellSearch System (Veridex LLC). Thresholds of 1 to 100 cells at the baseline were systematically correlated with the overall survival. The optimal cutoff was determined by comparing the Cox proportional hazard ratios (HRs). Results: Two or more CTCs were detected at baseline in 35 patients (68.6%; 95% confidence interval, 55.0–79.7). The HR signifying the difference between the unfavorable (more than or equal to threshold) and favorable (less than threshold) groups was maximal at the threshold of 8 CTCs (HR, 3.50; 95% confidence interval, 1.45–8.60). Patients with ≥8 CTCs had worse survival than those with <8 CTCs at baseline (p = 0.0014). Patients with ≥8 CTCs posttreatment or at relapse also showed worse survival than those with <8 CTCs (p = 0.0096 and <0.0001). Patients whose baseline and posttreatment CTC levels remained <8 tended to show better survival than those whose CTC level converted from ≥8 to <8 cells (p = 0.0288) or whose posttreatment CTC level was ≥8 cells (p = 0.0047). Conclusions: CTCs were highly detectable in SCLC, and higher CTC levels were strongly associated with worse survival. Consistently favorable CTC levels were associated with favorable outcomes.

Circulating Tumor Cells in Pulmonary Venous Blood of Primary Lung Cancer Patients

BACKGROUND Circulating tumor cells in peripheral blood (CTC) is a potential surrogate of distant metastasis, which is the critical factor influencing decision making regarding therapy and prognosis of primary lung cancer patients. After our preliminary study showing that CTCs were detected in peripheral blood in 29.4% of resectable lung cancer patients, we conducted a prospective study on CTC in pulmonary vein (PV) blood because tumor cells apart from the primary tumor may circulate after passing through the drainage PV. METHODS A total of 30 consecutive lung cancer patients who underwent thoracotomy were included. The CTCs in peripheral blood and in PV blood from the primary tumor site were quantitatively examined with the CellSearch system, and the numbers of CTCs per 7.5 mL peripheral and PV blood in each patient were represented as periCTC count and pvCTC count, respectively. RESULTS Circulating tumor cell was detected in peripheral blood in 5 patients (16.7%; the periCTC count was 1 in 2 patients; and 2, 3, and 16 in 1 patient each), and the incidence of positive periCTC was higher in squamous carcinoma patients than in adenocarcinoma patients (p = 0.028). Circulating tumor cell was detected in PV blood in most patients (29 of 30, 96.7%), and the mean and median pvCTC counts were 1,195 and 81, respectively (range, 0 to 10,034). There was no significant correlation between pvCTC count and any other patient characteristic, including periCTC count. CONCLUSIONS In resectable lung cancer, CTC was positive in peripheral blood of some patients and in PV blood of most patients. A long-term follow-up study to clarify the clinical significance of pvCTC status is warranted.

Significant increase in circulating tumour cells in pulmonary venous blood during surgical manipulation in patients with primary lung cancer

OBJECTIVES Circulating tumour cells (CTCs) are tumour cells shed from a primary tumour and circulate in the peripheral blood after passing through the drainage vein. In previous studies, we showed that high numbers of CTCs were detected in the drainage pulmonary venous blood of most patients with resectable primary lung cancer, whereas only low numbers of CTCs were detected in the peripheral blood of some patients. Accordingly, this prospective study was conducted to assess changes in CTCs in the drainage pulmonary vein (PV) during lung cancer surgery. METHODS A total of 30 consecutive peripheral-type primary lung cancer patients who underwent lobectomy (or right upper and middle bilobectomy) through open thoracotomy were included. For each patient, 2.5 ml of blood was sampled from the lobar PV of the primary tumour site before and after surgical manipulation for lobectomy. The CTCs were evaluated quantitatively with the CellSearch® system. RESULTS Before surgical manipulation, CTCs were detected in PV blood in the majority of patients (22 of 30, 73.3%), although CTCs were detected in peripheral blood in only two patients (6.7%). The median number of CTCs in the PV (pvCTC-count) before surgical manipulation was 4.0 cells/2.5 ml, and there was no significant correlation between pvPV-count and any clinicopathological characteristic, including tumour size, progression and histological type. After surgical manipulation, at the time of completion of the lobectomy, the pvCTC-count significantly increased (median, 60.0 cells/2.5 ml; P = 0.001). The increase in pvCTC-count was significantly associated with microscopic lymphatic tumour invasion (ly); pvCTC-count significantly increased in ly-positive patients (pvCTC-count before and after surgical manipulation, 4.0 and 90.5 cells/2.5 ml, respectively; P = 0.006), but not in ly-negative patients (3.5 and 7.0 cells/2.5 ml, respectively; P = 0.153). The increase in pvCTC-count was not significantly associated with any other clinicopathological factor or with any surgical procedure, including the sequence of vessel interruption. CONCLUSIONS We documented a significant increase in CTC count in drainage PV blood after surgical manipulation, especially in tumours with lymphatic invasion. We are awaiting survival data at 5 year follow-up examination, which may provide clinical significance of the pvCTC-count.

Circulating tumor cells (CTCs) in lung cancer: current status and future perspectives

Primary lung cancer is the leading cause of cancer-related deaths in most industrialized countries, and it is important to detect and control metastases distant from the lungs for improvement of a patients prognosis. Circulating tumor cells (CTCs) are tumor cells that are shed from the primary site and circulate in the peripheral blood, and recent studies have shown that CTCs can be useful clinical markers in some solid tumors such as those of breast cancer. In primary lung cancer, the clinical significance of CTCs remains unclear, but some promising results have been recently reported. Here, we reviewed the current status and future perspectives of CTCs in primary lung cancer.

Diagnosis of synchronous primary lung adenocarcinomas based on epidermal growth factor (EGFR) gene status: A case report.

The diagnosis of multiple primary lung cancer is sometimes difficult when multiple lung tumors with the same histologic type are identified. We now present a case of synchronous double primary lung adenocarcinomas (one in the right upper lobe and another in the right middle lobe) diagnosed based on mutational analysis of the epidermal growth factor receptor (EGFR) gene, although clinico-pathological findings suggested the diagnosis of intrapulmonary metastasis. After complete resection, pathological sections revealed the similar pathological features of two adenocarcinomas and unexpected subcarinal nodal metastasis. As the L858R mutation within exon 21 of the EGFR gene was identified in the middle-lobe tumor and the subcarinal node but not in the upper-lobe tumor, we diagnosed as double primary cancers. Local mediastinal recurrence after operation has been well-controlled with administration of gefitinib, a EGFR-tyrosine kinase inhibitor, and mutational analysis of the EGFR gene provided important information not only in the diagnosis of double primary cancers but also in decision-making of selection of chemotherapeutic agent.

Circulating tumor cells as a potential biomarker in selecting patients for pulmonary metastasectomy from colorectal cancer: report of a case.

Pulmonary metastasectomy is indicated for selected patients with metastatic colorectal cancer. A 43-year-old woman presented with solitary pulmonary metastasis from descending colon cancer and pulmonary metastasectomy was performed because of absence of any other active metastasis as well as normal serum carcinoembryonic antigen value. However, she died due to early development of nodal and bone metastases within 6 months after thoracotomy. The presence of circulating tumor cells (CTCs) in the peripheral blood (6 CTCs/7.5 ml) was the only factor to predict such a poor prognosis, suggesting that the CTC test is useful in selecting patients for pulmonary metastasectomy.

Prognostic impact of programmed death-ligand 1 expression in correlation with human leukocyte antigen class I expression status in stage I adenocarcinoma of the lung

Objective The study objective was to investigate the prognostic impact of programmed death‐ligand 1 expression in correlation with human leukocyte antigen class I expression on tumor cells in early‐stage adenocarcinoma of the lung, because both programmed death‐ligand 1 and human leukocyte antigen class I molecules play important roles in cancer immunity. Methods Ninety‐four patients with completely resected pathologic stage I lung adenocarcinoma were retrospectively reviewed. Programmed death‐ligand 1 expression on tumor cells was evaluated with immunohistochemistry in correlation with several clinicopathologic and molecular features, including human leukocyte antigen class I expression on tumor cells. Results Fifteen patients (16.0%) had tumor with positive programmed death‐ligand 1 expression (percentage of tumor cells expressing programmed death‐ligand 1, ≥5%), and the incidence was significantly higher in poorly differentiated tumors. There was no significant correlation between human leukocyte antigen class I expression and programmed death‐ligand 1 expression. Programmed death‐ligand 1 positivity was a significant factor to predict a poor survival (5‐year survival, 66.7% vs 85.9%; P = .049), which was enhanced in tumors with normal human leukocyte antigen class I expression (P = .029) but was not evident in tumors with reduced human leukocyte antigen class I expression (P = .552). Conclusions The prognostic impact of programmed death‐ligand 1 expression on tumor cells in early‐stage lung adenocarcinoma may be distinct according to concurrent human leukocyte antigen class I expression.

Abstract 380: Capture of EpCAM-negative circulating tumor cells (CTCs) with a “Universal CTC-Chip”

Background: Circulating tumor cell (CTC) can be a potentially useful clinical marker in early diagnosis and monitoring therapeutic effects for patients with malignant tumors. Our previous study showed that CTC detected by an EpCAM (epithelial cell adhesion molecule) based immuno-magnetic separation system “CellSearch” was useful in the diagnosis of malignant pleural mesothelioma (MPM), and also useful in the prognosis of epithelioid type MPM (Yoneda K, et al. Ann Surg Oncol. 2013). However, EpCAM-negative tumor cells cannot be principally captured with the system. Therefore, we have developed EpCAM-independent “Universal CTC-Chip System”, and assessed its capture capability. Methods: PC-9 (lung cancer cell line) was employed as EpCAM-positive cells, ACC-MESO-1 and ACC-MESO-4 (mesothelioma cell lines) were employed as EpCAM-negative cells. The expression of cell surface antigen was confirmed by flow cytometry. A microfluidic devices made of resin was coated in two steps with bridging antibody and capture antibody. It is possible to use any antibody to capture. In this study, we use anti-EpCAM antibody, anti-podoplain antibody, anti-mesothelin antibody, and isotype control. First, we verified capture capability of this system using samples which were spiked tumor cells labeled with CFSE in PBS containing 5% BSA. Then, we measured in the same manner by adding the cells to the blood of healthy donor, and calculated capture rate. Results: The expression analysis of cell surface antigens, PC-9 was EpCAM-positive, podoplanin, mesothelin were negative. On the other hand, MESO-1, 4 was EpCAM negative, podoplanin, mesothelin were positive. The capture efficiency in PBS containing 5% BSA with each cell using anti-EpCAM antibody, anti-podoplanin antibody and anti-mesothelin were PC-9: 101.1% / 2.3% / 2.9%, MESO-1: 3.5% / 52.7% / 4.3%, MESO-4: 3.0% / 78.3% / 5.4%, respectively. In the study of blood, each of the capture rate using anti-EpCAM antibody and anti-podoplanin antibody were PC-9: 88.0/ 6.9%, MESO-1: 4.0%/ 12.7%, MESO-4: 2.2%/ 38.4%, respectively. Conclusions: The capture efficiency using this device depends on the expression intensity of cell surface antigens. In experiments with PBS samples, it was possible to capture targeting specific cell surface antigen. Mesothelioma cells in the blood ware captured with combination of this CTC-Chip system and anti-podoplanin antibody. Citation Format: Kazue Yoneda, Yasuhiro Chikaishi, Eri Kawashima, Tomoko So, Hidetaka Uramoto, Takashi Ohnaga, Fumihiro Tanaka. Capture of EpCAM-negative circulating tumor cells (CTCs) with a “Universal CTC-Chip”. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 380. doi:10.1158/1538-7445.AM2015-380

Practical approaches to diagnose and treat for T0 malignant pleural mesothelioma: a proposal for diagnostic total parietal pleurectomy

Malignant pleural mesothelioma (MPM) remains suffering poor prognosis in spite of recent diagnostic and therapeutic progress. Although there is currently no established evidence, early diagnosis and early intervention may play a key role to improve prognosis of MPM, similarly to other malignancies. As pleural effusion is usually the first clinical sign of MPM, pleural effusion cytology is often the first diagnostic examination to be carried out. Since the sensitivity of pleural effusion cytology is approximately 60%, however, false-negative diagnosis is given to almost half of true MPM patients at this clinical step. One practical way to reduce the number of misdiagnosed MPM is to encourage performing thoracoscopic pleural biopsy unless definitive diagnosis other than MPM is established. There still remain a considerable number of patients with radiological/thoracoscopic T0 MPM who are misdiagnosed with nonspecific pleuritis after a complete investigation including thoracoscopic biopsies. Such patients will turn out to be malignant during follow-up period, although they have the best opportunity for long-term survival if only early therapeutic intervention is given. Currently, we are performing diagnostic total parietal pleurectomy in highly selected patients, who are characterized with strong clinical suspicion, positive pleural effusion cytology but uncertain pathological diagnosis, excellent cardiopulmonary reserve, and with written informed consent for highly invasive diagnostic surgery for pathologically unproven disease.