I期非小细胞肺癌CT形态学征象、ERCC1及RRM1表达和预后的相关性研究
|
摘要
研究背景
肺癌是目前对人类健康和生命威胁最大的恶性肿瘤之一。在其他一些恶性肿瘤临床治疗取得突破性进展的时候,肺癌的死亡率并没有明显降低,5年生存率仅有10%～15%,因此加强肺癌预后危险因素的研究对于实施治疗计划就显得尤为重要。肺癌中80%是非小细胞肺癌(NSCLC),病理上以鳞癌、腺癌和大细胞癌为主,晚期的NSCLC治愈的机会很少,但Ⅰ期患者的生存率相对较高,5年生存率达60%-80%。2009年国际抗癌联盟(UICC)颁布了新的肺癌TNM分期(第七版)指南,其中Ⅰ期包括IA期(TINOM0)及IB期(T2aN0M0),T1：肿瘤最大直径<3cm,将T1细分为T1a(肿瘤最大直径<2cm)和T1b(2cm<肿瘤最大径≤3cm),并限于肺或脏层胸膜内未累及主支气管,或局限于支气管壁内的肿瘤；T2：将T2细分为T2a(3cm<肿瘤最大径≤5cm)及T2b；肿瘤累及主支气管但距隆突≥2cm,或肿瘤侵及脏层胸膜,或肿瘤导致肺段或肺叶不张或阻塞性肺炎；N0：没有淋巴结转移。M0：没有远处转移。
Ⅰ期NSCLC一般采用根治性手术切除,但术后约有30%～40%的患者出现远处转移和(或)局部区域性复发。如能筛选出这一高危人群,则既可考虑针对他们进行术后辅助治疗,以提高疗效,又可避免给予其他低危患者不必要的过度治疗,但目前还没有公认的标准可以预测。其次,对于IB期肿瘤术后是否需要化疗的问题仍然存在争议。多数学者认为IA期肺癌患者术后不需要辅助治疗,IB期术后倾向于辅助治疗,但2006年的研究结果存在争论(CALGB9633和ANITA均为阴性结果),这对于IB期术后需要辅助治疗的学者是一个打击。人们需要进一步研究肺癌的相关预后因素来为临床治疗方案的制订提供更确切和详细的依据,而影像学手段是人们正在探索并寄以热望的一条途径。CT在评估肺癌预后方面的价值初步体现在评价病灶的大小、密度、边缘情况及与邻近血管、胸膜的关系等。通过评价肺癌CT一些特征性表现准确预测其预后,或许能为早期肺癌的临床预后评估提供一种新方法,为临床个体化治疗提供新的理论依据。目前有关肺癌CT的数个形态学征象与Ⅰ期NSCLC预后的关系国外已有研究报道,主要通过5年生存率进行统计学相关性分析,国内未见相关报道。
CT上可以显示肺癌大体、宏观的表现,而有关肺癌CT特征表现与预后相关的分子生物学标记物的微观研究较少,目前分子标记物预测肺癌预后和指导治疗已成为另一种新的治疗模式。切除修复交叉互补组1(ERCC1)基因及核糖核苷酸还原酶M1(RRM1)基因均被认为是影响肺癌预后及铂类化疗疗效的基因,研究显示ERCC1、RRM1表达可作为预测早期NSCLC术后生存期的标志物。现在的基因研究都是从mRNA角度(转录水平)来反应基因的表达水平,但细胞中的基因和蛋白质并不存在绝对的线性关系,因此还需要从蛋白水平研究基因的表达。目前ERCC1的检测方法有基因多态性鉴定、mRNA检测、蛋白水平表达(免疫组织化学方法)三种。通过半定量免疫组化和定量PCR两种方法,同时结合ERCC1及RRM1表达水平与患者无病生存时间(DFS)和生存期(OS)的关系,评价两种检测方法对ERCC1、RRM1表达的功效；其次,IB期NSCLC术后化疗与否对其生存影响目前报道不一,本研究通过分析ERCC1、低、高表达组的DFS,初步评价化疗组间疗效是否存在差异。
研究NSCLC的CT表现和上述预后蛋白、基因表达的相关性,筛选出与Ⅰ期NSCLC预后密切相关的一些特征性CT表现,可提出CT预后评估标准。本研究可为临床提供一种简单、准确的预后评估方法,更有利于将影像学研究引向深入。因此,探讨Ⅰ期NSCLC CT形态学特征及其分子生物学基础的关系对于临床肺癌预后评估有着重要的指导意义。
研究目的
1.探讨Ⅰ期NSCLC CT形态学征象与预后的相关性研究。
2.Ⅰ期NSCLC的ERCC1及RRM1表达和预后的相关性研究。
方法
1.收集广州医学院第一附属医院2001年8月至2006年12月期间具有完整胸部CT检查及手术病理结果的161例Ⅰ期NSCLC患者的资料,根据2009年第七版国际抗癌联盟(UICC)肺癌分期标准进行术后病理分期。采用电话及查阅病例资料的方式进行随访,随访开始日期为手术日期,截止日期为2011年12月。本研究中所有患者均具备完整的患者的5年总生存期(overall survival,OS)的随访资料。术前接受放疗及化疗的患者、术后早期(30天内)死亡者、术后非肿瘤原因导致的死亡者及失访者被排除。我们拟通过螺旋CT显示的NSCLC病灶大小、密度改变、边缘情况及其与邻近血管、胸膜的关系,结合患者的5年总生存期OS,反映患者的预后情况。
2.通过半定量免疫组化和定量PCR两种方法,分析2009年1月至2010年12月190例Ⅰ期NSCLC患者肿瘤切除标本中的ERCC1蛋白表达、ERCC1及RRM1mRNA表达情况。本研究中所有患者均具备完整的患者的3年患者无病生存时间(DFS)和生存期(OS)的随访资料。
3.免疫染色结果的半定量评定：免疫染色强度分别由两位病理专家在不知道病人临床情况下单独进行评判。结果判断ERCC1以肿瘤细胞核中出现棕黄色颗粒着色为阳性。制定免疫组化标准：每例标本在400倍视野下随机选取500-1500个肿瘤细胞,观察阳性细胞染色强度,并计数阳性细胞百分数。按细胞染色强度记为0-3分：无着色为0分,淡黄色为1分,棕黄色为2分,深棕色或棕褐色为3分。按阳性细胞百分数的构成比记为0-3分：<10%为0分,10%～25%为1分,26%-50%为2分,>50%为3分。以染色强度记分和阳性细胞百分数记分相加所得总分进行判断,总分0-1分为阴性(-),2-3分为弱阳性(+),4-5分为中阳性(++),6分为强阳性(+++)。以一、±和+为表达程度低表达,++、+++为表达程度高表达。以上所有结果的判定均在双盲法下进行。
4.人类ERCC1、 RRM1基因表达水平检测试剂盒,以ERCC1、 RRM1基因、内参基因β-actin各自的4个梯度质控品分别作标准曲线,分别记录检测样品在ERCC1、 RRM1基因标准曲线上的数值C1,检测样品在内参基因β-actin标准曲线上的数值C2,再求相对比值=C1/C2。
5.统计学处理：应用Kaplan-Meier法进行生存数据分析并绘制生存曲线,Log-rank检验差异性,在单因素分析的基础上进行比例风险模型(Cox模型)多因素分析,筛选与肺癌相关的独立预后因素。比较不同组间差异用X2检验,利用Spearman等级相关分析进行统计学分析。全部的统计检验均为双侧概率检验,P<0.05为有显著性差异,有统计学意义。以上数据均采用SPSS13.0统计软件分析处理。结果
1.161例Ⅰ期NSCLC患者中,术后5年内患者生存115例,死亡46例,5年总生存率OS为71.4%；按照性别(男、女)分成两组,男性的5年生存率(65.7%)低于女性(80.6%),单因素生存分析差异具有统计学意义(P=0.041),而多因素COX回归分析差异没有统计学意义；按照年龄、肿瘤病理类型及发生部位进行分析,经单因素及多因素生存分析,差异均没有统计学意义(P>0.05)。
2.按照第七版肺癌新分期,按照T分期分类,T1a、 T1b及T2a期对应患者的5年OS分别为87.2%、70.7%和58.9%,根据T分期进行单因素生存分析显示5年总生存率OS具有统计学意义(P<0.05)；按照IA、IB期分类,对应5年OS分别为78.1%和58.9%,进行单因素及多因素生存分析,患者的5年OS具有统计学意义(P<0.05)。
3.肺癌的CT形态学特征方面,根据肿瘤的密度分类,患者的5年OS经多单因素预后分析,结果显示差异不具有统计学意义(P>0.05)；单因素预后分析结果显示肿瘤的边缘、周围情况及与邻近胸膜的关系方面,差异均具有统计学意义,多因素预后分析病灶毛刺征、胸膜凹陷征具有统计学意义(P<0.05)。
4.190例Ⅰ期NSCLC术后ERCC1蛋白水平与患者DFS存在相关性,高表达者术后预后效果较好(P<0.05)；ERCC1及RRM1mRNA表达水平均与患者DFS没有相关性(P>0.05)。
5.IB期NSCLC术后ERCC1低、高表达者分别接受化疗治疗,其疗效的差异没有统计学意义。
6. ERCC1蛋白水平呈高表达者(预后好)的肿瘤出现边缘不光滑、短毛刺征、胸膜凹陷征的比率较低。Logistic回归分析显示病灶边缘不清、欠规整及短毛刺征是与ERCC1表达具有显著相关性。
结论
1.CT上肿瘤的大小、短毛刺征、胸膜凹陷征是影响Ⅰ期非小细胞肺癌患者的独立预后因素。
2.Ⅰ期NSCLC术后ERCC1蛋白水平呈高表达者患者的预后效果好。
3.IB期NSCLC术后ERCC1(?)氏、高表达者接受化疗的疗效尚不确定。
4.CT上肺癌边缘不光滑、短毛刺征与ERCC1蛋白表达呈显著负相关。
Background
Lung cancer is a major cause of morbidity and mortality for people. Although notable progress has been made in the treatmentof NSCLC, it is still associated with a poor prognosis for most patients. The5-year survival rate for lung cancer is only10%-15%. Non-small-cell lung cancers (NSCLCs) accounted for85%of cases, and predominantly adenocarcinomas, squamous cell and large cell carcinoma. Overall5-year survival of patients with non-small-cell lung cancer (NSCLC) in stage I is around60%-80%. The recently approved TNM classification (7th edition) describes a different classification according to the tumor size. Tla:Tumor2cm in greatest dimension; Tib:tumor>2cm but<3cm in greatest dimension; T2:tumor>3cm diameter T2a:tumour>3cm but<5cm in greatest dimension; T2tumours also include tumours of any size with any of the following:involves main bronchus,2cm distal to the carina; invades visceral pleura; associated with atelectasis or obstructive pneumonitis that extends to the hilar region but does not involve the entire lung. Therapeutics strategies for patients are based in TNM staging. Excluding patients with nodal invasion or distant metastases.
Surgical resection is the main stay curative treatment modality for early-stage NSCLC. Despite surgery, approximately30-40%of patients with stage I NSCLC die of recurrent disease. In this early preoperative stage, prognostic factors play a key role in evaluating survival chances for each patient. If the high-risk groups can be found and be considered auxiliary treatment, and can enhance the curative effect, can avoid again to other patients with low risk of unnecessary excessive treatment, but there is still short of the accepted standards. In additional, No data lend support to the use of adjuvant treatment in patients with stage IA tumours as defined by conventional criteria Furthermore, use of such treatment in patients with stage IB disease is lent support by only controversial evidence.
We describe the prognostic value of the NSCLC morphologic characteristics obtainable by CT in the preoperative staging. Starting with the initial hypothesis that CT morphologic characteristics of NSCLC have a prognostic value. The accurate identification of prognostic factors pointing to unfavorable disease prognosis is thus potentially of great importance. The possibility to "filter" patients with bad prognosis within the same stage of the disease could lead to modification of routine therapeutic protocols and to individual approaches to each patient.
Modern techniques have facilitated the identification of genes and their products that may play a role in disease progression and patient response to therapy. Among these are the excision repair cross completing group1gene product (ERCC1) and the regulatory subunit of ribonucleotide reductase (RRM1). The ERCC1and RRM1have been reported as being prognostic of outcome and predictive of therapeutic efficacy in patients with non-small cell lung cancer. ERCC1is a component of the5' endonuclease of the nucleotide excision repair complex, and it is crucial for the repair of DNA damage caused by interstrand and intrastrand cross-links that prevent both replication and transcription. RRM1is a regula-tory component of ribonucleoside diphopsphate reductase, a key enzyme in DNA synthesis that catalyzes the formation of deoxyri-bonucleotides, by reducing ribonucleotides. The antimetabolite gemcitabine interferes with the function of RRM1by reducing the pool of deoxyribonucleotide5-diphosphate available for DNA-synthesis.
Both immunohistochemistry (IHC) and quantitative real-time reverse transcriptase polymerase chain reaction (qRT-PCR) are commonly used. Each one has different properties, but to our knowledge, their predictive capabilities have not been compared in a well defined patient population in lung cancer. Furthermore, a correlation between mRNA expression (qRT-PCR) and protein expression (IHC) have rarely been explored.
Objective
1. In this study, we describe the prognostic value of the NSCLC morphologic characteristics obtainable by CT in the preoperative staging. Starting with the initial hypothesis that CT morphologic characteristics of NSCLC have a prognostic value.
2. Relationship between expression of ERCC1and RRM1and prognosis in stage I non-small cell lung cancer.
Methods and materials
1. One hundred sixty-one patients aged18-75years with stage I NSCLC, who underwent complete surgical resection with curative intent between February2001and Octomber2006, were included in the study. We analyzed the preoperative CT scans and clinical data available for each patient retrospectively. Excluded were patients who (1) received chemotherapy or radiotherapy before surgery,(2) died as a direct consequence of surgical procedure, or (3) died as a consequence of any other nonmalignant disease. We recorded the gender and age Cancer classification. Morphologic tumor characteristics were obtained by analyzing CT images available for each patient. These CT morphologic characteristics were divided into5categories, as follows:size, tumor edges, structure, periphery of the tumor, and visceral pleura.
2. Two experienced imaging specialists interpreted the CT images. Findings analyzed included the morphology, size, density, calcification, boundaries, and contrast enhancement of the lesions. If disagreement arose between them, consensus was reached by discussion.
3.We evaluated the predictive efficiency of qRT-PCR and immunohistochemical analysis on excision cross complementation group1(ERCC1) and ribonucleotide reductase subunit M1(RRM1). A semi-quantitative H-score for each tissue sample was calculated multiplying the staining intensity of tumour cells (0:no expression,1: weak expression,2:moderate expression,3:strong expression) by a proportion score based on the percentage of positive tumour cells. Omission and substitution of primary antibodies with unspecific IgG were used as negative control. In the event of discordance between the observers, the tissue section was reevaluated to reach consensus. The cut-off point was chosen a priori as the median value of the H-scores to separate biomarker-positive (H-score>median) tumours from biomarker negative (H-score≤median) ones.
Corresponding HE sections were evaluated for identification of the tumour tissue by two observers.4×20μm-thick unstained FFPE sections were cut and mounted on coated slides. The tissue sections were submerged in to70%ethanol. The tumour tissue was scraped in to1.5ml Eppendorf tubes for tissue digestion. The mRNA was extracted using the RecoverAllTM Total Nucleic Acid Isolation Kit according to manufactorer's instructions. RNA concentration was quantified using Nanodrop Spectrophotometer.
4. Survival probabilities were calculated by the product limit method of Kaplan and Meier. The prognostic significance of factors was tested in a univariate model by log-rank statistics for categorical covariates and by proportional hazards regression for continuous covariates. Proportions were compared by Chi-square test. Graphical illustrations of correlation between IHC-and qRT-PCR-biomarker quantification are shown as scatter-plots corrected for outliers. Spearman's rank correlation coefficients (rho) were calculated including two-tailed significance levels for correlations between genes as continuous and dichotomized variables. Survival curves are shown as Kaplan-Meier plots and compared by log-rank analyses.p Values below0.05were considered statistically significant. All statistical analyses were performed with the use of SPSS-software (SPSS version13.0).
Results:
1. The overall5-year survival rate of the series was71.4%.
2.161cases with stage I NSCLC, According to age, gender, pathologic type and location, COX survival analysis results weren't statistically significant (P>0.05).
3. According to the T stage classification of the seventh edition new stage lung cancer, Tla, T1b and T2a period of5years OS were87.2%,70.7%and58.9%, the5years OS are statistically significant (P<0.05); According to the IA, IB period,5years OS are78.1%and58.9%, respectively, Cox survival analysis are statistically significant (P<0.05).
4. Both tumor's edges and relation to visceral pleura were statistically significantly correlated with patient survival; Morphologic characteristics of tumor periphery were correlated to survival time with a P value below the0.002threshold, which is also statistically significant (P<0.05); Correlation of tumor density to survival of patients is not statistically significant (P>0.05); Cox survival analysis results show that tumors with pleural indentation and short spiculation sign are statistically significantly correlated with patient survival (P<0.05).
5.190cases were categorized into two groups according to high and low ERCC1and RRM1expression levels, respectively. There was a statistically significant difference between ERCC1high and low protein expression in disease-free survival patients (p=0.006). There were not statistically significant difference for the mRNA expression of ERCC1and RRM1in disease-free survival patients (P>0.05).
5. For stage IB NSCLC cases with the low and high ERCC1expression, Chemotherapy effects are uncertain (P>0.05).
6. Tumors with the unclear edge and short spiculation sign may indicate strong potential invasion in stage I NSCLC patients whose the low expression of ERCC1may suggest shorter survival time(P<0.05).
Conclusion
1. The tumor size, pleural indentation and short spiculation sign are independent prognostic factor for stage I NSCLC.
2. We conclude that resected stage I NSCLC patients with high ERCC1expression have a better survival when compared to patients with low ERCC1expression.
3. For stage IB NSCLC patients with the low and high ERCC1expression, Chemotherapy effects are uncertain.
4. Tumors with the unclear edge and short spiculation sign may indicate strong potential invasion in stage I NSCLC patients whose the low expression of ERCC1may suggest shorter survival time.
肺癌是目前对人类健康和生命威胁最大的恶性肿瘤之一。在其他一些恶性肿瘤临床治疗取得突破性进展的时候,肺癌的死亡率并没有明显降低,5年生存率仅有10%～15%,因此加强肺癌预后危险因素的研究对于实施治疗计划就显得尤为重要。肺癌中80%是非小细胞肺癌(NSCLC),病理上以鳞癌、腺癌和大细胞癌为主,晚期的NSCLC治愈的机会很少,但Ⅰ期患者的生存率相对较高,5年生存率达60%-80%。2009年国际抗癌联盟(UICC)颁布了新的肺癌TNM分期(第七版)指南,其中Ⅰ期包括IA期(TINOM0)及IB期(T2aN0M0),T1：肿瘤最大直径<3cm,将T1细分为T1a(肿瘤最大直径<2cm)和T1b(2cm<肿瘤最大径≤3cm),并限于肺或脏层胸膜内未累及主支气管,或局限于支气管壁内的肿瘤；T2：将T2细分为T2a(3cm<肿瘤最大径≤5cm)及T2b；肿瘤累及主支气管但距隆突≥2cm,或肿瘤侵及脏层胸膜,或肿瘤导致肺段或肺叶不张或阻塞性肺炎；N0：没有淋巴结转移。M0：没有远处转移。
Ⅰ期NSCLC一般采用根治性手术切除,但术后约有30%～40%的患者出现远处转移和(或)局部区域性复发。如能筛选出这一高危人群,则既可考虑针对他们进行术后辅助治疗,以提高疗效,又可避免给予其他低危患者不必要的过度治疗,但目前还没有公认的标准可以预测。其次,对于IB期肿瘤术后是否需要化疗的问题仍然存在争议。多数学者认为IA期肺癌患者术后不需要辅助治疗,IB期术后倾向于辅助治疗,但2006年的研究结果存在争论(CALGB9633和ANITA均为阴性结果),这对于IB期术后需要辅助治疗的学者是一个打击。人们需要进一步研究肺癌的相关预后因素来为临床治疗方案的制订提供更确切和详细的依据,而影像学手段是人们正在探索并寄以热望的一条途径。CT在评估肺癌预后方面的价值初步体现在评价病灶的大小、密度、边缘情况及与邻近血管、胸膜的关系等。通过评价肺癌CT一些特征性表现准确预测其预后,或许能为早期肺癌的临床预后评估提供一种新方法,为临床个体化治疗提供新的理论依据。目前有关肺癌CT的数个形态学征象与Ⅰ期NSCLC预后的关系国外已有研究报道,主要通过5年生存率进行统计学相关性分析,国内未见相关报道。
CT上可以显示肺癌大体、宏观的表现,而有关肺癌CT特征表现与预后相关的分子生物学标记物的微观研究较少,目前分子标记物预测肺癌预后和指导治疗已成为另一种新的治疗模式。切除修复交叉互补组1(ERCC1)基因及核糖核苷酸还原酶M1(RRM1)基因均被认为是影响肺癌预后及铂类化疗疗效的基因,研究显示ERCC1、RRM1表达可作为预测早期NSCLC术后生存期的标志物。现在的基因研究都是从mRNA角度(转录水平)来反应基因的表达水平,但细胞中的基因和蛋白质并不存在绝对的线性关系,因此还需要从蛋白水平研究基因的表达。目前ERCC1的检测方法有基因多态性鉴定、mRNA检测、蛋白水平表达(免疫组织化学方法)三种。通过半定量免疫组化和定量PCR两种方法,同时结合ERCC1及RRM1表达水平与患者无病生存时间(DFS)和生存期(OS)的关系,评价两种检测方法对ERCC1、RRM1表达的功效；其次,IB期NSCLC术后化疗与否对其生存影响目前报道不一,本研究通过分析ERCC1、低、高表达组的DFS,初步评价化疗组间疗效是否存在差异。
研究NSCLC的CT表现和上述预后蛋白、基因表达的相关性,筛选出与Ⅰ期NSCLC预后密切相关的一些特征性CT表现,可提出CT预后评估标准。本研究可为临床提供一种简单、准确的预后评估方法,更有利于将影像学研究引向深入。因此,探讨Ⅰ期NSCLC CT形态学特征及其分子生物学基础的关系对于临床肺癌预后评估有着重要的指导意义。
研究目的
1.探讨Ⅰ期NSCLC CT形态学征象与预后的相关性研究。
2.Ⅰ期NSCLC的ERCC1及RRM1表达和预后的相关性研究。
方法
1.收集广州医学院第一附属医院2001年8月至2006年12月期间具有完整胸部CT检查及手术病理结果的161例Ⅰ期NSCLC患者的资料,根据2009年第七版国际抗癌联盟(UICC)肺癌分期标准进行术后病理分期。采用电话及查阅病例资料的方式进行随访,随访开始日期为手术日期,截止日期为2011年12月。本研究中所有患者均具备完整的患者的5年总生存期(overall survival,OS)的随访资料。术前接受放疗及化疗的患者、术后早期(30天内)死亡者、术后非肿瘤原因导致的死亡者及失访者被排除。我们拟通过螺旋CT显示的NSCLC病灶大小、密度改变、边缘情况及其与邻近血管、胸膜的关系,结合患者的5年总生存期OS,反映患者的预后情况。
2.通过半定量免疫组化和定量PCR两种方法,分析2009年1月至2010年12月190例Ⅰ期NSCLC患者肿瘤切除标本中的ERCC1蛋白表达、ERCC1及RRM1mRNA表达情况。本研究中所有患者均具备完整的患者的3年患者无病生存时间(DFS)和生存期(OS)的随访资料。
3.免疫染色结果的半定量评定：免疫染色强度分别由两位病理专家在不知道病人临床情况下单独进行评判。结果判断ERCC1以肿瘤细胞核中出现棕黄色颗粒着色为阳性。制定免疫组化标准：每例标本在400倍视野下随机选取500-1500个肿瘤细胞,观察阳性细胞染色强度,并计数阳性细胞百分数。按细胞染色强度记为0-3分：无着色为0分,淡黄色为1分,棕黄色为2分,深棕色或棕褐色为3分。按阳性细胞百分数的构成比记为0-3分：<10%为0分,10%～25%为1分,26%-50%为2分,>50%为3分。以染色强度记分和阳性细胞百分数记分相加所得总分进行判断,总分0-1分为阴性(-),2-3分为弱阳性(+),4-5分为中阳性(++),6分为强阳性(+++)。以一、±和+为表达程度低表达,++、+++为表达程度高表达。以上所有结果的判定均在双盲法下进行。
4.人类ERCC1、 RRM1基因表达水平检测试剂盒,以ERCC1、 RRM1基因、内参基因β-actin各自的4个梯度质控品分别作标准曲线,分别记录检测样品在ERCC1、 RRM1基因标准曲线上的数值C1,检测样品在内参基因β-actin标准曲线上的数值C2,再求相对比值=C1/C2。
5.统计学处理：应用Kaplan-Meier法进行生存数据分析并绘制生存曲线,Log-rank检验差异性,在单因素分析的基础上进行比例风险模型(Cox模型)多因素分析,筛选与肺癌相关的独立预后因素。比较不同组间差异用X2检验,利用Spearman等级相关分析进行统计学分析。全部的统计检验均为双侧概率检验,P<0.05为有显著性差异,有统计学意义。以上数据均采用SPSS13.0统计软件分析处理。结果
1.161例Ⅰ期NSCLC患者中,术后5年内患者生存115例,死亡46例,5年总生存率OS为71.4%；按照性别(男、女)分成两组,男性的5年生存率(65.7%)低于女性(80.6%),单因素生存分析差异具有统计学意义(P=0.041),而多因素COX回归分析差异没有统计学意义；按照年龄、肿瘤病理类型及发生部位进行分析,经单因素及多因素生存分析,差异均没有统计学意义(P>0.05)。
2.按照第七版肺癌新分期,按照T分期分类,T1a、 T1b及T2a期对应患者的5年OS分别为87.2%、70.7%和58.9%,根据T分期进行单因素生存分析显示5年总生存率OS具有统计学意义(P<0.05)；按照IA、IB期分类,对应5年OS分别为78.1%和58.9%,进行单因素及多因素生存分析,患者的5年OS具有统计学意义(P<0.05)。
3.肺癌的CT形态学特征方面,根据肿瘤的密度分类,患者的5年OS经多单因素预后分析,结果显示差异不具有统计学意义(P>0.05)；单因素预后分析结果显示肿瘤的边缘、周围情况及与邻近胸膜的关系方面,差异均具有统计学意义,多因素预后分析病灶毛刺征、胸膜凹陷征具有统计学意义(P<0.05)。
4.190例Ⅰ期NSCLC术后ERCC1蛋白水平与患者DFS存在相关性,高表达者术后预后效果较好(P<0.05)；ERCC1及RRM1mRNA表达水平均与患者DFS没有相关性(P>0.05)。
5.IB期NSCLC术后ERCC1低、高表达者分别接受化疗治疗,其疗效的差异没有统计学意义。
6. ERCC1蛋白水平呈高表达者(预后好)的肿瘤出现边缘不光滑、短毛刺征、胸膜凹陷征的比率较低。Logistic回归分析显示病灶边缘不清、欠规整及短毛刺征是与ERCC1表达具有显著相关性。
结论
1.CT上肿瘤的大小、短毛刺征、胸膜凹陷征是影响Ⅰ期非小细胞肺癌患者的独立预后因素。
2.Ⅰ期NSCLC术后ERCC1蛋白水平呈高表达者患者的预后效果好。
3.IB期NSCLC术后ERCC1(?)氏、高表达者接受化疗的疗效尚不确定。
4.CT上肺癌边缘不光滑、短毛刺征与ERCC1蛋白表达呈显著负相关。
Background
Lung cancer is a major cause of morbidity and mortality for people. Although notable progress has been made in the treatmentof NSCLC, it is still associated with a poor prognosis for most patients. The5-year survival rate for lung cancer is only10%-15%. Non-small-cell lung cancers (NSCLCs) accounted for85%of cases, and predominantly adenocarcinomas, squamous cell and large cell carcinoma. Overall5-year survival of patients with non-small-cell lung cancer (NSCLC) in stage I is around60%-80%. The recently approved TNM classification (7th edition) describes a different classification according to the tumor size. Tla:Tumor2cm in greatest dimension; Tib:tumor>2cm but<3cm in greatest dimension; T2:tumor>3cm diameter T2a:tumour>3cm but<5cm in greatest dimension; T2tumours also include tumours of any size with any of the following:involves main bronchus,2cm distal to the carina; invades visceral pleura; associated with atelectasis or obstructive pneumonitis that extends to the hilar region but does not involve the entire lung. Therapeutics strategies for patients are based in TNM staging. Excluding patients with nodal invasion or distant metastases.
Surgical resection is the main stay curative treatment modality for early-stage NSCLC. Despite surgery, approximately30-40%of patients with stage I NSCLC die of recurrent disease. In this early preoperative stage, prognostic factors play a key role in evaluating survival chances for each patient. If the high-risk groups can be found and be considered auxiliary treatment, and can enhance the curative effect, can avoid again to other patients with low risk of unnecessary excessive treatment, but there is still short of the accepted standards. In additional, No data lend support to the use of adjuvant treatment in patients with stage IA tumours as defined by conventional criteria Furthermore, use of such treatment in patients with stage IB disease is lent support by only controversial evidence.
We describe the prognostic value of the NSCLC morphologic characteristics obtainable by CT in the preoperative staging. Starting with the initial hypothesis that CT morphologic characteristics of NSCLC have a prognostic value. The accurate identification of prognostic factors pointing to unfavorable disease prognosis is thus potentially of great importance. The possibility to "filter" patients with bad prognosis within the same stage of the disease could lead to modification of routine therapeutic protocols and to individual approaches to each patient.
Modern techniques have facilitated the identification of genes and their products that may play a role in disease progression and patient response to therapy. Among these are the excision repair cross completing group1gene product (ERCC1) and the regulatory subunit of ribonucleotide reductase (RRM1). The ERCC1and RRM1have been reported as being prognostic of outcome and predictive of therapeutic efficacy in patients with non-small cell lung cancer. ERCC1is a component of the5' endonuclease of the nucleotide excision repair complex, and it is crucial for the repair of DNA damage caused by interstrand and intrastrand cross-links that prevent both replication and transcription. RRM1is a regula-tory component of ribonucleoside diphopsphate reductase, a key enzyme in DNA synthesis that catalyzes the formation of deoxyri-bonucleotides, by reducing ribonucleotides. The antimetabolite gemcitabine interferes with the function of RRM1by reducing the pool of deoxyribonucleotide5-diphosphate available for DNA-synthesis.
Both immunohistochemistry (IHC) and quantitative real-time reverse transcriptase polymerase chain reaction (qRT-PCR) are commonly used. Each one has different properties, but to our knowledge, their predictive capabilities have not been compared in a well defined patient population in lung cancer. Furthermore, a correlation between mRNA expression (qRT-PCR) and protein expression (IHC) have rarely been explored.
Objective
1. In this study, we describe the prognostic value of the NSCLC morphologic characteristics obtainable by CT in the preoperative staging. Starting with the initial hypothesis that CT morphologic characteristics of NSCLC have a prognostic value.
2. Relationship between expression of ERCC1and RRM1and prognosis in stage I non-small cell lung cancer.
Methods and materials
1. One hundred sixty-one patients aged18-75years with stage I NSCLC, who underwent complete surgical resection with curative intent between February2001and Octomber2006, were included in the study. We analyzed the preoperative CT scans and clinical data available for each patient retrospectively. Excluded were patients who (1) received chemotherapy or radiotherapy before surgery,(2) died as a direct consequence of surgical procedure, or (3) died as a consequence of any other nonmalignant disease. We recorded the gender and age Cancer classification. Morphologic tumor characteristics were obtained by analyzing CT images available for each patient. These CT morphologic characteristics were divided into5categories, as follows:size, tumor edges, structure, periphery of the tumor, and visceral pleura.
2. Two experienced imaging specialists interpreted the CT images. Findings analyzed included the morphology, size, density, calcification, boundaries, and contrast enhancement of the lesions. If disagreement arose between them, consensus was reached by discussion.
3.We evaluated the predictive efficiency of qRT-PCR and immunohistochemical analysis on excision cross complementation group1(ERCC1) and ribonucleotide reductase subunit M1(RRM1). A semi-quantitative H-score for each tissue sample was calculated multiplying the staining intensity of tumour cells (0:no expression,1: weak expression,2:moderate expression,3:strong expression) by a proportion score based on the percentage of positive tumour cells. Omission and substitution of primary antibodies with unspecific IgG were used as negative control. In the event of discordance between the observers, the tissue section was reevaluated to reach consensus. The cut-off point was chosen a priori as the median value of the H-scores to separate biomarker-positive (H-score>median) tumours from biomarker negative (H-score≤median) ones.
Corresponding HE sections were evaluated for identification of the tumour tissue by two observers.4×20μm-thick unstained FFPE sections were cut and mounted on coated slides. The tissue sections were submerged in to70%ethanol. The tumour tissue was scraped in to1.5ml Eppendorf tubes for tissue digestion. The mRNA was extracted using the RecoverAllTM Total Nucleic Acid Isolation Kit according to manufactorer's instructions. RNA concentration was quantified using Nanodrop Spectrophotometer.
4. Survival probabilities were calculated by the product limit method of Kaplan and Meier. The prognostic significance of factors was tested in a univariate model by log-rank statistics for categorical covariates and by proportional hazards regression for continuous covariates. Proportions were compared by Chi-square test. Graphical illustrations of correlation between IHC-and qRT-PCR-biomarker quantification are shown as scatter-plots corrected for outliers. Spearman's rank correlation coefficients (rho) were calculated including two-tailed significance levels for correlations between genes as continuous and dichotomized variables. Survival curves are shown as Kaplan-Meier plots and compared by log-rank analyses.p Values below0.05were considered statistically significant. All statistical analyses were performed with the use of SPSS-software (SPSS version13.0).
Results:
1. The overall5-year survival rate of the series was71.4%.
2.161cases with stage I NSCLC, According to age, gender, pathologic type and location, COX survival analysis results weren't statistically significant (P>0.05).
3. According to the T stage classification of the seventh edition new stage lung cancer, Tla, T1b and T2a period of5years OS were87.2%,70.7%and58.9%, the5years OS are statistically significant (P<0.05); According to the IA, IB period,5years OS are78.1%and58.9%, respectively, Cox survival analysis are statistically significant (P<0.05).
4. Both tumor's edges and relation to visceral pleura were statistically significantly correlated with patient survival; Morphologic characteristics of tumor periphery were correlated to survival time with a P value below the0.002threshold, which is also statistically significant (P<0.05); Correlation of tumor density to survival of patients is not statistically significant (P>0.05); Cox survival analysis results show that tumors with pleural indentation and short spiculation sign are statistically significantly correlated with patient survival (P<0.05).
5.190cases were categorized into two groups according to high and low ERCC1and RRM1expression levels, respectively. There was a statistically significant difference between ERCC1high and low protein expression in disease-free survival patients (p=0.006). There were not statistically significant difference for the mRNA expression of ERCC1and RRM1in disease-free survival patients (P>0.05).
5. For stage IB NSCLC cases with the low and high ERCC1expression, Chemotherapy effects are uncertain (P>0.05).
6. Tumors with the unclear edge and short spiculation sign may indicate strong potential invasion in stage I NSCLC patients whose the low expression of ERCC1may suggest shorter survival time(P<0.05).
Conclusion
1. The tumor size, pleural indentation and short spiculation sign are independent prognostic factor for stage I NSCLC.
2. We conclude that resected stage I NSCLC patients with high ERCC1expression have a better survival when compared to patients with low ERCC1expression.
3. For stage IB NSCLC patients with the low and high ERCC1expression, Chemotherapy effects are uncertain.
4. Tumors with the unclear edge and short spiculation sign may indicate strong potential invasion in stage I NSCLC patients whose the low expression of ERCC1may suggest shorter survival time.
引文
[1]NCCN非小细胞肺癌临床实践指南(中国版)专家组,NCCN肿瘤学临床实践指南(中国版)2011年第一版(NSCLC)
[2]Goldstraw P, Crowley J, Chansky K, et al.International Association for the Study of Lung Cancer International Staging Committee, Participating Institutions. The IASLC Lung Cancer Staging Project:proposals for the revision of the TNM stage groupings in the forthcoming (seventh) edition of the TNM Classification of malignant tumours. J Thorac Oncol.2007,2(8):706-714
[3]J. L. Mulshine, D. C. Sulliran. Lung cancer screening. N Engl J Med,2005, 352(26):2714-2720.
[4]Laudia I, David F, Daniel M, et al. Survival of patients with stage I lung cancer detected on CT screening. N Engl J Med,2006,355(17):1763-1771.
[5]National Lung Screening Trial Research Team, Aberle DR, Adams AM, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med.2011,365(5):395-409.
[6]Scagliotti GV, Pastorino U, Vansteenkiste JF et al. Randomized phase III study of surgery alone or surgery plus preoperative cisplatin and gemcitabine in stages IB to IIIA non-small-cell lung cancer. J Clin Oncol.2012,30(2):172-178.
[7]Maeda R, Yoshida J, Ishii G, et al. Poor prognostic factors in patients with stage IB non-small cell lung cancer according to the seventh edition TNM classification. Chest.2011,139(4):855-861.
[8]Kratz JR, He J, Van Den Eeden SK, et al. A practical molecular assay to predict survival in resected non-squamous, non-small-cell lung cancer:development and international validation studies. Lancet.2012,379(9818):823-832.
[9]Zhu ZH, Sun BY, Ma Y, Shao JY, Long H, Zhang X, Fu JH, Zhang LJ, Su XD, Wu QL, Ling P, Chen M, Xie ZM, Hu Y, Rong TH.Three immunomarker support vector machines-based prognostic classifiers for stage IB non-small-cell lung cancer. J Clin Oncol.2009,27(7):1091-1099.
[10]Leng XF, Chen MW, Xian L, et al. Combined analysis of mRNA expression of ERCC1, BAG-1, BRCA1, RRM1 and TUBB3 to predict prognosis in patients with non-small cell lung cancer who received adjuvant chemotherapy. J Exp Clin Cancer Res.2012,31(1):25.
[11]Papadaki C, Sfakianaki M, Ioannidis G, et al. ERCC1 and BRAC1 mRNA expression levels in the primary tumor could predict the effectiveness of the second-line cisplatin-based chemotherapy in pretreated patients with metastatic non-small cell lung cancer. J Thorac Oncol.2012,7(4):663-671.
[12]Zheng Z, Chen T, Li X, et al. DNA synthesis and repair genes RRM1 and ERCC1 in lung cancer. N Engl J Med.2007,356(8):800-808.
[13]Vilmar A, Garcia-Foncillas J, Huarriz M, et al. RT-PCR versus immunohistochemistry for correlation and quantification of ERCC1, BRCA1, TUBB3 and RRM1 in NSCLC. Lung Cancer.2012,75(3):306-312.
[14]Britten RA, Liu D, Tessier A, Hutchison MJ, Murray D. ERCC1 expression as amolecular marker of cisplatin resistance in human cervical tumor cells. Int J Cancer,2000,89(5):453-457.
[15]Roth JA, Carlson JJ. Prognostic role of ERCC1 in advanced non-small-cell lung cancer:a systematic review and meta-analysis. Clin Lung Cancer,2011,12(6): 393-401.
[16]Chen S, J, Wang R, et al. The Platinum-based treatments for advanced non-small cell lung cancer, is low/negative ERCC1 expression better than high/positive ERCC1 expression? A meta-analysis. lung Cancer,2010,70(1): 63-70.
[17]Zheng Z, Chen T, Li X, et al. DNA synthesis and repair genes RRM1 and ERCC1 in lung cancer. N Engl J Med.2007,356(8):800-808.
[18]Simon GR, Sharma S, Cantor A, et al. ERCC1 expression is a predictor of survival in resected patients with non-small cell lung cancer. Chest,2005, 127(3):978-983.
[19]Christian C, Erica S, Morandi U. The prognostic impact of tumor size in resected stage Ⅰ non-small cell lung cancer:evidence for a two thresholds tumor diameters classification. Lung Cancer,2006,54(2):185-191.
[20]Maeda R, Yoshida J, Ishii G, et al. Prognostic impact of histology on early-stage non-small cell lung cancer. Chest.2011,40(1):135-145.
[21]刘树库,许绍发,骆宝剑,等.1380例手术后的非小细胞肺癌的多因素预后分析.中国肺癌杂志,2006,9(5)：465-468.
[22]Huhti E, Saloheimo M, Sutinen S, et al. Does the location of lung cancer affect its prognosis? Eur J Respir Dis.1983,64(6):460-465.
[23]Joachim PF, Thomas MU, Herinrich BU, et al. Prognostic assessment after surgical resection for non-small cell lung cancer:Experiences in 2083 patients. Lung Cancer,2006,2608:7.
[24]Hirsch FR, Spreafico A, Novello S, et al. The prognostic and predictive role of histology in advanced non-small cell lung cancer:a literature review. J Thorac Oncol.2008,3(12):1468-1481.
[25]Warth A, Muley T, Meister M, et al. The Novel Histologic International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society Classification System of Lung Adenocarcinoma Is a Stage-Independent Predictor of Survival. J Clin Oncol.2012,30(13):1438-1446.
[26]Port JL, Kent MS, Korst RJ, et al. Tumor size predicts survival within stage IA non-small cell lung cancer. Chest,2003,124(5):1828-1833
[27]Ishida T, Yano T, Maeda K, Strategy for lymphadenectomy in lung cancer 3 cm or less in diameter. Ann Thorac Surg,1990,50:708-713.
[28]28.刘树库,许绍发,刘志东,等.IA期非小细胞肺癌的肿瘤大小对其预后的影响.中国肺癌杂志,2006,9(1)：68-70.
[29]Wooddg JH. Unusual radiograph manifestations of lung cancer. Radiol Clin North Am,1990.28(3):601-602.
[30]肖湘生,洪应中,荣独山.空泡征的病理基础及其对肺癌早期诊断的价值.中华放射学杂志,1988.22(1)：31-33.
[31]Cangir AK, Kutlay H, Akal M, et al. Prognostic value of tumor size in non-small cell lung cancer larger than five centimeters in diameter. Lung Cancer,2004, 46(3):325-331
[32]Onn A, Choe DH, Herbst RS, et al.Tumor cavitation in stage I non-small cell lung cancer:epidermal growth factor receptor expression and prediction of poor outcome. Radiology,2005,237(1):342-347.
[33]Ohtsuka T, Nomori H, Hodo H, et al. Radiological examination for peripheral lung cancers and benign nodules less than 10 mm. Lung Cancer,2003,42(3): 291-296.
[34]Maeda R, Yoshida J, Ishii G, et al.Prognostic impact of intratumoral vascular invasion in non-small cell lung cancer patients.Thorax,2010,65(12):1092-1098.
[35]Harpole DH Jr, Healey EA, DeCamp MM Jr,et al. Chest wall invasive non-small cell lung cancer:patterns of failure and implications for a revised staging system. Ann Surg Oncol.1996,3(3):261-9.
[36]Li M, Ito H, Wada H, et al. Pit-fall sign on computed tomography predicts pleural involvement and poor prognosis in non-small cell lung cancer. Lung Cancer,2004,46(3):349-355.
[37]Meniga IN, Tiljak MK, Ivankovic D,et al.Prognostic value of computed tomography morphologic characteristics in stage I non-small-cell lung cancer.Clin Lung Cancer.2010,11(2):98-104.
[38]Cedres S, Quispe I, Martinez P, et al.Computed tomography (CT) predicts accurately the pathologic tumour size in stage I non-small-cell lung cancer (NSCLC).Clin Transl Oncol.2010,12(12):829-835.
[1]Leng XF, Chen MW, Xian L, et al. Combined analysis of mRNA expression of ERCC1, BAG-1, BRCA1, RRM1 and TUBB3 to predict prognosis in patients with non-small cell lung cancer who received adjuvant chemotherapy. J Exp Clin Cancer Res.2012,31(1):25.
[2]Papadaki C, Sfakianaki M, Ioannidis G, et al. ERCC1 and BRAC1 mRNA expression levels in the primary tumor could predict the effectiveness of the second-line cisplatin-based chemotherapy in pretreated patients with metastatic non-small cell lung cancer. J Thorac Oncol.2012,7(4):663-671.
[3]Zheng Z, Chen T, Li X, et al. DNA synthesis and repair genes RRM1 and ERCC1 in lung cancer. N Engl J Med.2007,356(8):800-808.
[4]Vilmar A, Garcia-Foncillas J, Huarriz M, et al. RT-PCR versus immunohistochemistry for correlation and quantification of ERCC1, BRCA1, TUBB3 and RRM1 in NSCLC.Lung Cancer.2012,75(3):306-312.
[5]Bepler G, Gautam A. Simon G, et al. PTEN, RRM1 and ERCC1 are coexpressed in non-small cell lung cancer (NSCLC) and are predictive of survival. Lung cancer,2003.41(S2):76.
[6]Bepler G, Sharma S, Cantor A, et al. RRM1 and PTEN as prognostic parameters for overall and disease free survival in patients with non—small cell lung cancer. J Clin oncol,2004,22(10):1878-1885.
[7]Jiang J, Liang X, Zhou X, et al. ERCC1 expression as a prognostic and predictive factor in patients with non-small cell lung cancer:a meta-analysis. Mol Biol Rep,2012 Feb 3. [Epub ahead of print]
[8]Hubner RA, Riley RD, Billingham LJ, et al. Excision repair cross-complementation group 1 (ERCC1) status and lung cancer outcomes:a meta-analysis of published studies and recommendations. PLoS One,2011, 6(10):e25164.
[9]Olaussen KA, Dunant A, Fouret P, et al. DNA repair by ERCC1 in non-small-cell lung cancer and cisplatin-based adjuvant chemotherapy. N Engl J Med,2006,355:983-991.
[10]Britten RA, Liu D, Tessier A, Hutchison MJ, Murray D. ERCC1 expression as amolecular marker of cisplatin resistance in human cervical tumor cells. Int J Cancer,2000,89(5):453-7.
[11]Roth JA, Carlson JJ. Prognostic role of ERCC1 in advanced non-small-cell lung cancer:a systematic review and meta-analysis. Clin Lung Cancer,2011,12(6): 393-401.
[12]Chen S, J, Wang R, et al. The Platinum-based treatments for advanced non-small cell lung cancer, is low/negative ERCC1 expression better than high/positive ERCC1 expression? A meta-analysis. lung Cancer,2010,70(1): 63-70.
[13]魏淑珍,施毅,宋勇.非小细胞肺癌患者ERCC1蛋白表达与铂类化疗敏感性的Meta分析.循证医学,2010,10(6)：355-358.
[14]Ding Z, Zhang J, Shao J. et al. ERCC1 expression as a predictor of survival after operation in stage I non-small cell lung cancer patients. Zhong guo Fei Ai Za Zhi.2010,13(5):522-525.
[15]Simon GR, Sharma S, Cantor A, et al. ERCC1 expression is a predictor of survival in resected patients with non-small cell lung cancer. Chest,2005, 127(3):978-83.
[16]Rosell R, Danenberg K, Sanchez JJ, et al.0-43 Ribonucleotide reductase M1 (RRM1) mRNA expression and survival in advanced non-small cell lung cancer patients treated with Gemcitabine plus Cisplatin. Lung Cancer,2003,41:S16.
[17]Rosell R, Felip E, Taron M, et al. Gene expression as a predictive marker of outcome in stage Ⅱ B-ⅢA—ⅢB non-small cell lung cancer after induction Gemcitabine-based chemotherapy followed by resectional surgery. Clin Cancer Res,2004,10:4215-4219.
[18]Friboulet L, Barrios-Gonzales D, Commo F, et al. Molecular Characteristics of ERCC1-Negative versus ERCC1-Positive Tumors in Resected NSCLC. Clin Cancer Res.2011,17(17):5562-72.
[19]Valsecchi ME, Holdbrook T, Leiby BE, et al. Is there a role for the quantification of RRM1 and ERCC1 expression in pancreatic ductal adenocarcinoma? BMC Cancer.2012,12(1):104.
[20]Scagliotti GV, Pastorino U, Vansteenkiste JF et al. Randomized phase Ⅲ study of surgery alone or surgery plus preoperative cisplatin and gemcitabine in stages IB to IIIA non-small-cell lung cancer. J Clin Oncol.2012;30(2):172-178.
[21]Maeda R, Yoshida J, Ishii G, et al. Poor prognostic factors in patients with stage IB non-small cell lung cancer according to the seventh edition TNM classification. Chest.2011,139(4):855-861.
[22]Zhu ZH, Sun BY, Ma Y, Shao JY, Long H, Zhang X, Fu JH, Zhang LJ, Su XD, Wu QL, Ling P, Chen M, Xie ZM, Hu Y, Rong TH.Three immunomarker support vector machines-based prognostic classifiers for stage IB non-small-cell lung cancer. J Clin Oncol.2009,27(7):1091-1099.
[23]Marcel Th, van Rens, Aart Brutel de la Riviere, et al. Prognostic Assessment of 2,361 Patients Who Underwent Pulmonary Resection for Non-small Cell Lung Cancer, Stage Ⅰ,ⅡI, and ⅢA. Chest,2000,117(2):374-379.
[24]Maeda R, Yoshida J, Ishii G, et al.Prognostic impact of intratumoral vascular invasion in non-small cell lung cancer patients.Thorax,2010,65(12):1092-1098.
[2]Goldstraw P, Crowley J, Chansky K, et al.International Association for the Study of Lung Cancer International Staging Committee, Participating Institutions. The IASLC Lung Cancer Staging Project:proposals for the revision of the TNM stage groupings in the forthcoming (seventh) edition of the TNM Classification of malignant tumours. J Thorac Oncol.2007,2(8):706-714
[3]J. L. Mulshine, D. C. Sulliran. Lung cancer screening. N Engl J Med,2005, 352(26):2714-2720.
[4]Laudia I, David F, Daniel M, et al. Survival of patients with stage I lung cancer detected on CT screening. N Engl J Med,2006,355(17):1763-1771.
[5]National Lung Screening Trial Research Team, Aberle DR, Adams AM, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med.2011,365(5):395-409.
[6]Scagliotti GV, Pastorino U, Vansteenkiste JF et al. Randomized phase III study of surgery alone or surgery plus preoperative cisplatin and gemcitabine in stages IB to IIIA non-small-cell lung cancer. J Clin Oncol.2012,30(2):172-178.
[7]Maeda R, Yoshida J, Ishii G, et al. Poor prognostic factors in patients with stage IB non-small cell lung cancer according to the seventh edition TNM classification. Chest.2011,139(4):855-861.
[8]Kratz JR, He J, Van Den Eeden SK, et al. A practical molecular assay to predict survival in resected non-squamous, non-small-cell lung cancer:development and international validation studies. Lancet.2012,379(9818):823-832.
[9]Zhu ZH, Sun BY, Ma Y, Shao JY, Long H, Zhang X, Fu JH, Zhang LJ, Su XD, Wu QL, Ling P, Chen M, Xie ZM, Hu Y, Rong TH.Three immunomarker support vector machines-based prognostic classifiers for stage IB non-small-cell lung cancer. J Clin Oncol.2009,27(7):1091-1099.
[10]Leng XF, Chen MW, Xian L, et al. Combined analysis of mRNA expression of ERCC1, BAG-1, BRCA1, RRM1 and TUBB3 to predict prognosis in patients with non-small cell lung cancer who received adjuvant chemotherapy. J Exp Clin Cancer Res.2012,31(1):25.
[11]Papadaki C, Sfakianaki M, Ioannidis G, et al. ERCC1 and BRAC1 mRNA expression levels in the primary tumor could predict the effectiveness of the second-line cisplatin-based chemotherapy in pretreated patients with metastatic non-small cell lung cancer. J Thorac Oncol.2012,7(4):663-671.
[12]Zheng Z, Chen T, Li X, et al. DNA synthesis and repair genes RRM1 and ERCC1 in lung cancer. N Engl J Med.2007,356(8):800-808.
[13]Vilmar A, Garcia-Foncillas J, Huarriz M, et al. RT-PCR versus immunohistochemistry for correlation and quantification of ERCC1, BRCA1, TUBB3 and RRM1 in NSCLC. Lung Cancer.2012,75(3):306-312.
[14]Britten RA, Liu D, Tessier A, Hutchison MJ, Murray D. ERCC1 expression as amolecular marker of cisplatin resistance in human cervical tumor cells. Int J Cancer,2000,89(5):453-457.
[15]Roth JA, Carlson JJ. Prognostic role of ERCC1 in advanced non-small-cell lung cancer:a systematic review and meta-analysis. Clin Lung Cancer,2011,12(6): 393-401.
[16]Chen S, J, Wang R, et al. The Platinum-based treatments for advanced non-small cell lung cancer, is low/negative ERCC1 expression better than high/positive ERCC1 expression? A meta-analysis. lung Cancer,2010,70(1): 63-70.
[17]Zheng Z, Chen T, Li X, et al. DNA synthesis and repair genes RRM1 and ERCC1 in lung cancer. N Engl J Med.2007,356(8):800-808.
[18]Simon GR, Sharma S, Cantor A, et al. ERCC1 expression is a predictor of survival in resected patients with non-small cell lung cancer. Chest,2005, 127(3):978-983.
[19]Christian C, Erica S, Morandi U. The prognostic impact of tumor size in resected stage Ⅰ non-small cell lung cancer:evidence for a two thresholds tumor diameters classification. Lung Cancer,2006,54(2):185-191.
[20]Maeda R, Yoshida J, Ishii G, et al. Prognostic impact of histology on early-stage non-small cell lung cancer. Chest.2011,40(1):135-145.
[21]刘树库,许绍发,骆宝剑,等.1380例手术后的非小细胞肺癌的多因素预后分析.中国肺癌杂志,2006,9(5)：465-468.
[22]Huhti E, Saloheimo M, Sutinen S, et al. Does the location of lung cancer affect its prognosis? Eur J Respir Dis.1983,64(6):460-465.
[23]Joachim PF, Thomas MU, Herinrich BU, et al. Prognostic assessment after surgical resection for non-small cell lung cancer:Experiences in 2083 patients. Lung Cancer,2006,2608:7.
[24]Hirsch FR, Spreafico A, Novello S, et al. The prognostic and predictive role of histology in advanced non-small cell lung cancer:a literature review. J Thorac Oncol.2008,3(12):1468-1481.
[25]Warth A, Muley T, Meister M, et al. The Novel Histologic International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society Classification System of Lung Adenocarcinoma Is a Stage-Independent Predictor of Survival. J Clin Oncol.2012,30(13):1438-1446.
[26]Port JL, Kent MS, Korst RJ, et al. Tumor size predicts survival within stage IA non-small cell lung cancer. Chest,2003,124(5):1828-1833
[27]Ishida T, Yano T, Maeda K, Strategy for lymphadenectomy in lung cancer 3 cm or less in diameter. Ann Thorac Surg,1990,50:708-713.
[28]28.刘树库,许绍发,刘志东,等.IA期非小细胞肺癌的肿瘤大小对其预后的影响.中国肺癌杂志,2006,9(1)：68-70.
[29]Wooddg JH. Unusual radiograph manifestations of lung cancer. Radiol Clin North Am,1990.28(3):601-602.
[30]肖湘生,洪应中,荣独山.空泡征的病理基础及其对肺癌早期诊断的价值.中华放射学杂志,1988.22(1)：31-33.
[31]Cangir AK, Kutlay H, Akal M, et al. Prognostic value of tumor size in non-small cell lung cancer larger than five centimeters in diameter. Lung Cancer,2004, 46(3):325-331
[32]Onn A, Choe DH, Herbst RS, et al.Tumor cavitation in stage I non-small cell lung cancer:epidermal growth factor receptor expression and prediction of poor outcome. Radiology,2005,237(1):342-347.
[33]Ohtsuka T, Nomori H, Hodo H, et al. Radiological examination for peripheral lung cancers and benign nodules less than 10 mm. Lung Cancer,2003,42(3): 291-296.
[34]Maeda R, Yoshida J, Ishii G, et al.Prognostic impact of intratumoral vascular invasion in non-small cell lung cancer patients.Thorax,2010,65(12):1092-1098.
[35]Harpole DH Jr, Healey EA, DeCamp MM Jr,et al. Chest wall invasive non-small cell lung cancer:patterns of failure and implications for a revised staging system. Ann Surg Oncol.1996,3(3):261-9.
[36]Li M, Ito H, Wada H, et al. Pit-fall sign on computed tomography predicts pleural involvement and poor prognosis in non-small cell lung cancer. Lung Cancer,2004,46(3):349-355.
[37]Meniga IN, Tiljak MK, Ivankovic D,et al.Prognostic value of computed tomography morphologic characteristics in stage I non-small-cell lung cancer.Clin Lung Cancer.2010,11(2):98-104.
[38]Cedres S, Quispe I, Martinez P, et al.Computed tomography (CT) predicts accurately the pathologic tumour size in stage I non-small-cell lung cancer (NSCLC).Clin Transl Oncol.2010,12(12):829-835.
[1]Leng XF, Chen MW, Xian L, et al. Combined analysis of mRNA expression of ERCC1, BAG-1, BRCA1, RRM1 and TUBB3 to predict prognosis in patients with non-small cell lung cancer who received adjuvant chemotherapy. J Exp Clin Cancer Res.2012,31(1):25.
[2]Papadaki C, Sfakianaki M, Ioannidis G, et al. ERCC1 and BRAC1 mRNA expression levels in the primary tumor could predict the effectiveness of the second-line cisplatin-based chemotherapy in pretreated patients with metastatic non-small cell lung cancer. J Thorac Oncol.2012,7(4):663-671.
[3]Zheng Z, Chen T, Li X, et al. DNA synthesis and repair genes RRM1 and ERCC1 in lung cancer. N Engl J Med.2007,356(8):800-808.
[4]Vilmar A, Garcia-Foncillas J, Huarriz M, et al. RT-PCR versus immunohistochemistry for correlation and quantification of ERCC1, BRCA1, TUBB3 and RRM1 in NSCLC.Lung Cancer.2012,75(3):306-312.
[5]Bepler G, Gautam A. Simon G, et al. PTEN, RRM1 and ERCC1 are coexpressed in non-small cell lung cancer (NSCLC) and are predictive of survival. Lung cancer,2003.41(S2):76.
[6]Bepler G, Sharma S, Cantor A, et al. RRM1 and PTEN as prognostic parameters for overall and disease free survival in patients with non—small cell lung cancer. J Clin oncol,2004,22(10):1878-1885.
[7]Jiang J, Liang X, Zhou X, et al. ERCC1 expression as a prognostic and predictive factor in patients with non-small cell lung cancer:a meta-analysis. Mol Biol Rep,2012 Feb 3. [Epub ahead of print]
[8]Hubner RA, Riley RD, Billingham LJ, et al. Excision repair cross-complementation group 1 (ERCC1) status and lung cancer outcomes:a meta-analysis of published studies and recommendations. PLoS One,2011, 6(10):e25164.
[9]Olaussen KA, Dunant A, Fouret P, et al. DNA repair by ERCC1 in non-small-cell lung cancer and cisplatin-based adjuvant chemotherapy. N Engl J Med,2006,355:983-991.
[10]Britten RA, Liu D, Tessier A, Hutchison MJ, Murray D. ERCC1 expression as amolecular marker of cisplatin resistance in human cervical tumor cells. Int J Cancer,2000,89(5):453-7.
[11]Roth JA, Carlson JJ. Prognostic role of ERCC1 in advanced non-small-cell lung cancer:a systematic review and meta-analysis. Clin Lung Cancer,2011,12(6): 393-401.
[12]Chen S, J, Wang R, et al. The Platinum-based treatments for advanced non-small cell lung cancer, is low/negative ERCC1 expression better than high/positive ERCC1 expression? A meta-analysis. lung Cancer,2010,70(1): 63-70.
[13]魏淑珍,施毅,宋勇.非小细胞肺癌患者ERCC1蛋白表达与铂类化疗敏感性的Meta分析.循证医学,2010,10(6)：355-358.
[14]Ding Z, Zhang J, Shao J. et al. ERCC1 expression as a predictor of survival after operation in stage I non-small cell lung cancer patients. Zhong guo Fei Ai Za Zhi.2010,13(5):522-525.
[15]Simon GR, Sharma S, Cantor A, et al. ERCC1 expression is a predictor of survival in resected patients with non-small cell lung cancer. Chest,2005, 127(3):978-83.
[16]Rosell R, Danenberg K, Sanchez JJ, et al.0-43 Ribonucleotide reductase M1 (RRM1) mRNA expression and survival in advanced non-small cell lung cancer patients treated with Gemcitabine plus Cisplatin. Lung Cancer,2003,41:S16.
[17]Rosell R, Felip E, Taron M, et al. Gene expression as a predictive marker of outcome in stage Ⅱ B-ⅢA—ⅢB non-small cell lung cancer after induction Gemcitabine-based chemotherapy followed by resectional surgery. Clin Cancer Res,2004,10:4215-4219.
[18]Friboulet L, Barrios-Gonzales D, Commo F, et al. Molecular Characteristics of ERCC1-Negative versus ERCC1-Positive Tumors in Resected NSCLC. Clin Cancer Res.2011,17(17):5562-72.
[19]Valsecchi ME, Holdbrook T, Leiby BE, et al. Is there a role for the quantification of RRM1 and ERCC1 expression in pancreatic ductal adenocarcinoma? BMC Cancer.2012,12(1):104.
[20]Scagliotti GV, Pastorino U, Vansteenkiste JF et al. Randomized phase Ⅲ study of surgery alone or surgery plus preoperative cisplatin and gemcitabine in stages IB to IIIA non-small-cell lung cancer. J Clin Oncol.2012;30(2):172-178.
[21]Maeda R, Yoshida J, Ishii G, et al. Poor prognostic factors in patients with stage IB non-small cell lung cancer according to the seventh edition TNM classification. Chest.2011,139(4):855-861.
[22]Zhu ZH, Sun BY, Ma Y, Shao JY, Long H, Zhang X, Fu JH, Zhang LJ, Su XD, Wu QL, Ling P, Chen M, Xie ZM, Hu Y, Rong TH.Three immunomarker support vector machines-based prognostic classifiers for stage IB non-small-cell lung cancer. J Clin Oncol.2009,27(7):1091-1099.
[23]Marcel Th, van Rens, Aart Brutel de la Riviere, et al. Prognostic Assessment of 2,361 Patients Who Underwent Pulmonary Resection for Non-small Cell Lung Cancer, Stage Ⅰ,ⅡI, and ⅢA. Chest,2000,117(2):374-379.
[24]Maeda R, Yoshida J, Ishii G, et al.Prognostic impact of intratumoral vascular invasion in non-small cell lung cancer patients.Thorax,2010,65(12):1092-1098.