New treatment opportunities in non-small cell lung cancer

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Lung Cancer, 1993; 9 (Suppl. 2): SlO9-Sl16 0 1993 Elsevier Scientific Publishers Ireland Ltd. All rights reserved. 0169~5002/93/$06.00 LUNG 00233

New treatment

opportunities in non-small cancer

cell lung

Nice van Zandwijka, Sjoerd Rodenhuis” and Wolter J. Mooib “Department

of Medical

Oncology and bDepartment of Pathology, Netherlands

Netherlands

Cancer Lstitute,

Amsterdam,

summary We have investigated the clinical importance of K-rus oncogene activation and the expression of the neural cell adhesion molecule (N-CAM) in a series of surgically resected lung carcinomas. In patients with inoperable disease we correlated pretreatment levels of serum neuron-specific enolase (NSE) and lactate dehydrogenase (LDH) with response to chemotherapy. The presence of K-rus point mutations and N-CAM expression, as measured by Mab 123C3 immunostaining, defined subgroups of patients with non-small cell lung cancer (adenocarcinoma) for whom the prognosis is poor and disease-free survival is not usually long despite radical resection. In the patients with inoperable disease high NSE and LDH levels correlated with an increased response (60%) to chemotherapy. The understanding of basic biologic characteristics of non-small cell lung cancer, i.e. K-ras point mutations and neuroendocrine differentiation, may aid in treatment selection and help to identify groups of patients that will benefit from adjuvant chemotherapy.

Key words: NSCLC; K-rus oncogene; NSE; LDH; neural cell adhesion molecule

Introduction The pathologic classification of lung cancer is largely based on morphologic and histochemical detection of specific squamous, glandular, and neuroendocrine characteristics [ 11.Important differences in clinical behavior are seen among the lung carcinoma subtypes defined in this way, with the most clinically distinctive tumor type being small cell lung cancer (SCLC). Even within each histologic subtype, however, there is marked variability Correspondence to: N. van Zandwijk, Department of Medical Oncology, Netherlands Plesmanlaan 121, 1066 CX Amsterdam, Netherlands.

Cancer Institute,

SllO

in clinical behavior of individual tumors. Elucidation of the factors responsible for differences in tumor growth rates, metastatic potential, and sensitivity to chemotherapy and radiotherapy provides important opportunities for clinicopathologic correlation studies aimed at identifying new prognostic parameters and refining lung tumor subtyping [2,3]. In the treatment of non-small cell lung cancer (NSCLC) in particular, identification of reliable predictors of survival and response to chemotherapy would be of great value, as it would facilitate identifying patients most likely to benefit from treatment with systemic chemotherapy and help to avoid exposing patients, with minimal chances to benefit, to the complications of intensive therapy. In this context, during the past 4 years we have been studying: (1) the role of K-rus oncogene activation as a prognostic marker in adenocarcinoma of the lung; (2) the prognostic value of expression of the neural-cell adhesion molecule in NSCLC; and (3) serum neuron-specific enolase (NSE) and lactate dehydrogenase (LDH) as predictors of response to chemotherapy and survival in NSCLC.

K-rus Oncogene Activation as a Prognostic Marker

The capability of activated oncogenes to induce malignant transformation of immortalized cells in vitro suggests that they have a similar role in the pathogenesis of human tumors. Having previously determined that activation of the K-rus oncogene by a point mutation in codon 12 occurs in about one third of human lung adenocarcinomas [4,5], we subsequently studied the clinical importance of this oncogene activation in 69 patients with completely resected adenocarcinomas [6].

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Fig. 1. Survival of 69 patients after radical surgery for adenocarcinoma of the lung. From Slebos et al. (61, with permission.

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The polymerase chain reaction was used to amplify ras-specific sequences of DNA isolated from frozen or paraffrnembedded tumor samples. Mutation-specific oligonucleotide probes were used to detect and classify K-ras point mutations. Tumors from 19 patients harbored a point mutation in codon 12 of the K-ras oncogene. There was no association between the K-rus point mutation and patient age at diagnosis, sex, or presence of previous or concurrent neoplasms. Tumors with K-rus point mutations tended to be smaller and less differentiated than those without mutation. The K-W point mutation at codon 12 was found to be a strong and unfavorable prognostic factor; 12 of the 19 patients with K-rus point mutation-positive tumors died during the follow-up period, compared with 16 of 50 patients with no mutation in the K-W oncogene (P = 0.002) (Fig. 1). This difference in prognosis was also reflected in the duration of disease-free survival (P = 0.038) and the number of deaths due to cancer (P < 0.001) (Fig. 2). Thus, the presence of K-rus point mutation defines a subgroup of patients with lung adenocarcinoma in whom the prognosis is poor, and disease-free survival is usually brief despite complete surgical resection and a relatively small tumor load.

Prognostic Value of Neural Cell Adhesion Molecule Expression SCLC is characterized by neuroendocrine markers and is usually regarded as a systemic disease with a rapidly fatal outcome without chemotherapy. In contrast, NSCLC responds poorly to chemotherapy and expresses neuroendocrine markers in only 10 to 20% of cases [71.

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after radical surgery for adenocarcinoma et al. [6], with permission.

of the lung. From Slebos

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We recently found that monoclonal antibody (Mab) 123C3, one of our own SCLCcluster I antibodies [8], recognizes the polypeptide backbone of the neural cell adhesion molecule [9]. Based on this finding, we retrospectively analyzed the prognostic value of the presence of Mab 123C3 in tumor specimens of 226 radically resected NSCLC patients

WI. Overall survival, relapse-free survival, and relapse-free interval were assessed for the whole group of tumors, differentiated according to stage, histologic type, and presence of Mab 123C3. The strongest factor was stage. Tumors positive for Mab 123C3 were associated with a significantly shorter overall survival time and disease-free survival time, despite correction for differences in tumor stage (overall survival, P = 0.046, disease-free log rank test, Figs. 3 and 4). survival, P = 0.044; The prognostic significance of Mab 123C3 reactivity, which in contrast to K-ras point mutations is not specific for a particular differentiation subtype, support of the idea that markers directly involved in one of the aspects of malignant behavior might be used to identify subgroups of patients that could benefit from adjuvant therapies. Serum NSE and LDH as Predictors of Response to Chemotherapy and Survival Elevated serum levels of NSE, a glycolytic enzyme produced mainly by neural and neuroendocrine cells, have been detected in most patients with SCLC. Elevated levels have been reported in 1l-41% of NSCLC patients [ 1 l- 131.

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Months Fig. 3. Overall survival of 226 patients with NSCLC according to 123C3 immunoreactivity. From Kibbelaar et al. [IO], with permission.

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Based on the suggestion by others that lung cancers of non-small cell histology are characterized by biologic features resembling those of SCLC, i.e. shortened survival but increased sensitivity to chemotherapy [ 14- 171, we have correlated pretreatment levels of NSE and LDH (another prognostic serum marker in SCLC) with subsequent response to chemotherapy and survival in 42 patients with locally advanced or metastatic NSCLC treated in one of two chemotherapy trials [18]. Pretreatment NSE levels ranged from 4.6 to 34.5 rig/ml (median value, 7.5 &ml) and were above 10 ng/ml in 10 patients (23.8%). LDH levels varied between 85 and 2484 U/l (median value, 220 U/l and were above 250 U/l in 12 patients (29.3%). Elevated levels of both enzymes were significantly more common in patients with metastatic disease than in those with locoregional disease (40% vs. 9% for NSE and 40% vs. 18% for LDH, respectively). A strong positive correlation (correlation factor, 0.693) was found between NSE and LDH serum levels. Levels of neither markers were found to correlate with age, sex, previous therapy, performance status, or histology. Responses to chemotherapy were seen more frequently among patients with elevated NSE levels (six of 10, 60%) than in those with normal values (seven of 32, 22%; P < 0.02) (Table 1). In a logistic regression analysis, both markers considered individually remained signiticant when adjusted for sex, age, performance status, prior therapy, histology, and extent of disease. High levels of NSE and LDH and metastatic disease were the three pretreatment characteristics found to be associated with shorter survival; with adjustment for extent of disease, however, elevated marker levels were no longer correlated with shorter survival.

s114 TABLE 1 Response to chemotherapy according to pretreatment parameters.

Age (years) s55 >55

No. patients

Response (%)

P-value

17 25

23.5 36.0

NS

31 11

29.0 36.5

NS

36 6

33.3 16.7

NS

7 23 12

42.8 21.7 41.6

22 20

27.3 35.0

NS

34 8

32.3 25.0

NS

29

21.0

Sex

Male Female Performance status O-l 2 Histology Squamous cell carcinoma Adenocarcinoma Large cell carcinoma Extent of disease Limited Extensive Previous therapy No Yes LDH (U/l) s 250 >250 NSE (@ml) $10

12

58.1

32

21.8

> 10 Total

10 42

60.0 30.9

<0.02

< 0.02

NS, not significant.

The rapid accumulation of information pertaining to the basic biology of lung carcinomas is leading to a better understanding of the clinical characteristics of these tumors. Our findings of a significantly shorter overall and disease-free survival in adenocarcinoma patients with activated K-ru+~oncogenes or in NSCLC patients expressing the neural cell adhesion molecule as recognized by Mab 123C3 may have clinical consequences. One could contemplate possible benefits from adjuvant chemotherapy in these patients. While recent reports suggest that tumor cells acquiring rus oncogene point mutations in vitro may become resistant to radiation and several drugs [19,20], such resistance to radiation or chemotherapy could not be detected in vivo (Rodenhuis S et al. November 1991. Unpublished data). On the other hand, it is likely that tumors exhibiting neuroendocrine characteristics are more likely to respond to chemotherapy. Thus, clinical studies are now indicated to prospectively compare the role of adjuvant chemotherapy in mutationpositive lung adenocarcinomas and 123C3-positive NSCLC.

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In contrast to sophisticated methods used previously to determine probable response of NSCLC to chemotherapy, the simple determination of serum NSE and LDH appears to be a potential predictor. Despite the relatively small number of patients in this last study, our data suggest that the evaluation of serum NSE and LDH may aid in treatment selection. In view of the limited value of standard pretreatment characteristics for predicting response in NSCLC, these assays also may be of help in the stratification of patients for future clinical trials. Finally, it should be kept in mind that the majority of NSCLC patients present with disease too extensive to control with locoregional therapy alone. Clearly, if we are to improve the survival rates for these patients, we need an effective treatment program for both local and metastatic disease. Even a partially effective systemic therapy like chemotherapy, which adds only a small number to the long-term survival rate. would save thousands of lives annually.

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