HLA class I loss and PD-L1 expression in lung cancer: impact on T-cell infiltration and immune escape.

Immune-checkpoint inhibitors show encouraging results in cancer treatment, but the clinical benefit is limited exclusively to a subset of patients. We analyzed the density and composition of tumor T-cell infiltration in non-small-cell lung carcinoma (NSCLC) in relation to PD-L1 and HLA class I (HLA-I) expression. We found that positive HLA-I expression, independently on PD-L1 status, is the key factor determining the increased density of the immune infiltrate. When both markers were analyzed simultaneously, we identified four phenotypes of HLA-I and PD-L1 co-expression. They demonstrated different patterns of tumor infiltration and clinicopathologic characteristics, including the tumor size and lymphatic spread. All HLA-I+/PD-L1+ tumors had a high degree of intratumoral infiltration with CD8+T-lymphocytes, whereas HLA-I loss was associated with a significantly reduced number of tumor infiltrating T-lymphocytes mostly restrained in the stroma surrounding the tumor nest. HLA-I-negative/PD-L1-positive tumors had bigger size (T) and lower grade of infiltration with CD8+T-cells. It represents a cancer immune escape phenotype that combines two independent mechanisms of immune evasion: loss of HLA-I and upregulation of PD-L1. Using GCH-array analysis of human lung cancer cell lines we found that the loss of heterozygosity (LOH) with complete or partial deletion of HLA-I genes is the principal mechanism of HLA-I alterations. This irreversible defect, which could potentially decrease the clinical efficacy of lung cancer immunotherapy, appears to be underestimated. In conclusion, our results suggest that the analysis of HLA-I is very important for the selection of potential responders to cancer immunotherapy.

Predictors for 30-day readmission after pulmonary resection for lung cancer.

BACKGROUND: The purpose of this study was to assess the rate, cause, and factors associated with readmissions following pulmonary resection for lung cancer and their relationship with 90-day mortality. METHODS: A prospective cohort study was conducted of 379 patients who underwent surgery for lung cancer at the university hospitals Granada, Spain between 2012 and 2016. RESULTS: The rate of readmissions within 30 postoperative days was 6.2%. The most common reason for readmission was subcutaneous emphysema (21.7%), pneumonia (13%), and pleural empyema (8.5%). A higher probability of requiring urgent readmission was associated with a higher Charlson index (OR 2.0,95% confidence interval 1.50-2.67, P = 0.001); peripheral arterial vasculopathy (OR 4.8, 95%CI 1.27-18.85, P = 0.021); a history of stroke (OR 8.2, 95%CI 1.08-62.37, P = 0.04); postoperative atelectasis (OR 4.7, 95%CI 1.21-18.64, P = 0.026); and air leaks (OR 12.6, 95%CI 4.10-38.91, P = 0.001).The prediction multivariable model for readmission represents an area under the curve (ROC) of 0.90. Mortality at 90 postoperative days in the group of readmitted patients was 13% versus 1.5 for the group of patients who did not require readmission (P < 0.001). CONCLUSIONS: The factors predictive for readmission can help design individualized outpatient follow-up plans and programs for the reduction of readmissions.

Impact of major video-assisted thoracoscopic surgery on care quality.

BACKGROUND: The objective of this study was to investigate the impact of a program of major video-assisted surgery on care quality in a Unit of Thoracic Surgery. METHODS: A descriptive comparative study was conducted of 793 major thoracic procedures performed between 2009 and 2012. Quality indicators and hospital performance before [2009-2010] and after (2011 and 2012) the implementation of the program. RESULTS: The incidence of surgical complications decreased significantly from 6.32%/7.88% (2009/2010, respectively) to 1.87%/1.67% (2011/2012, respectively) [95% CI for 7.08% (4.20-9.96%); 95% CI for 1.76% (0.44-3.08%) P<0.001, respectively]. The mean hospital stay was reduced from 8.5/7.8 days in 2009/2010, respectively, to 6.3/5.8 days in 2011/2012, respectively. Mortality rates were 0.57%, 0.60%, 0.93% and 0.43% in 2009, 2010, 2011, and 2012, respectively (P=0.624, 95% CI: -0.6, 0.7). The percentages of emergency readmissions in 2009/2010 were 1.16%/1.23%, respectively vs. 2.80%/0.84% in 2011/2012. CONCLUSIONS: The implementation of the video-assisted thoracic surgery (VATS) program in the unit of Thoracic Surgery Care resulted in a significant improvement in care quality, with a reduction of length of hospital stay, but without any changes in mortality or the percentage of readmissions at 30 post-operative days.

The Escape of Cancer from T Cell-Mediated Immune Surveillance: HLA Class I Loss and Tumor Tissue Architecture.

Tumor immune escape is associated with the loss of tumor HLA class I (HLA-I) expression commonly found in malignant cells. Accumulating evidence suggests that the efficacy of immunotherapy depends on the expression levels of HLA class I molecules on tumors cells. It also depends on the molecular mechanism underlying the loss of HLA expression, which could be reversible/"soft" or irreversible/"hard" due to genetic alterations in HLA, ß2-microglobulin or IFN genes. Immune selection of HLA-I negative tumor cells harboring structural/irreversible alterations has been demonstrated after immunotherapy in cancer patients and in experimental cancer models. Here, we summarize recent findings indicating that tumor HLA-I loss also correlates with a reduced intra-tumor T cell infiltration and with a specific reorganization of tumor tissue. T cell immune selection of HLA-I negative tumors results in a clear separation between the stroma and the tumor parenchyma with leucocytes, macrophages and other mononuclear cells restrained outside the tumor mass. Better understanding of the structural and functional changes taking place in the tumor microenvironment may help to overcome cancer immune escape and improve the efficacy of different immunotherapeutic strategies. We also underline the urgent need for designing strategies to enhance tumor HLA class I expression that could improve tumor rejection by cytotoxic T-lymphocytes (CTL).

The absence of HLA class I expression in non-small cell lung cancer correlates with the tumor tissue structure and the pattern of T cell infiltration.

We wanted to analyze whether tumor HLA class I (HLA-I) expression influences the pattern of the immune cell infiltration and stromal cell reaction in the tumor microenvironment. Tumor tissues obtained from 57 patients diagnosed with lung carcinomas were analyzed for HLA expression and leukocyte infiltration. 28 patients out of the 57 were completely negative for HLA-I expression (49.1%) or showed a selective HLA-A locus downregulation (three patients, 5.2%). In 26 out of 57 tumors (47.8%) we detected a positive HLA-I expression but with a percentage of HLA-I negative cells between 10 and 25%. The HLA-I negative phenotype was produced by a combination of HLA haplotype loss and a transcriptional downregulation of ß2-microglobulin (ß2-m) and LMP2 and LMP7 antigen presentation machinery genes. The analysis and localization of different immune cell populations revealed the presence of two major and reproducible patterns. One pattern, which we designated "immune-permissive tumor microenvironment (TME)," was characterized by positive tumor HLA-I expression, intratumoral infiltration with cytotoxic T-CD8+ cells, M1-inflammatory type macrophages, and a diffuse pattern of FAP+ cancer-associated fibroblasts. In contrast, another pattern defined as "non-immune-permissive TME" was found in HLA-I negative tumors with strong stromal-matrix interaction, T-CD8+ cells surrounding tumor nests, a dense layer of FAP+ fibroblasts and M2/repair-type macrophages. In conclusion, this study revealed marked differences between HLA class I-positive and negative tumors related to tissue structure, the composition of leukocyte infiltration and stromal response in the tumor microenvironment.

Progressive changes in composition of lymphocytes in lung tissues from patients with non-small-cell lung cancer.

Immune cell infiltration is a common feature of many human solid tumors. Innate and adaptative immune systems contribute to tumor immunosurveillance. We investigated whether tumors evade immune surveillance by inducing states of tolerance and/or through the inability of some immune subpopulations to effectively penetrate tumor nests. Immunohistochemistry and flow cytometry analysis were used to study the composition and distribution of immune subpopulations in samples of peripheral blood, tumor tissue (TT), adjacent tumor tissue (ATT), distant non-tumor tissue (DNTT), cancer nests, cancer stroma, and invasive margin in 61 non-small-cell lung cancer (NSCLC) patients. A significantly higher percentage of T and B cells and significantly lower percentage of NK cells were detected in TT than in DNTT. Memory T cells (CD4+CD45RO+, CD8+CD45RO+) and activated T cells (CD8+DR+) were more prevalent in TT. Alongside this immune activation, the percentage of T cells with immunosuppressive activity was higher in TT than in DNTT. B- cells were practically non-existent in tumor nests and were preferentially located in the invasive margin. The dominant NK cell phenotype in peripheral blood and DNTT was the cytotoxic phenotype (CD56+ CD16+), while the presence of these cells was significantly decreased in ATT and further decreased in TT. Finally, the immunologic response differed between adenocarcinoma and squamous cell carcinoma and according to the tumor differentiation grade. These findings on the infiltration of innate and adaptative immune cells into tumors contribute to a more complete picture of the immune reaction in NSCLC.

Survival, classifications, and desmosomal plaque genes in non-small cell lung cancer.

Novel biomarkers are required to improve prognostic predictions obtained with lung cancer staging systems. This study of 62 surgically-treated Non-Small Cell Lung Cancer (NSCLC) patients had two objectives: i) to compare the predictive value of T-stage classifications between the 6(th) and 7(th) editions of the Tumor, Node, and Metastasis staging system (TNM); and ii) to examine the association of Pkp1 and/or Krt15 gene expression with survival and outcomes. Multivariate and Kaplan-Meier survival analyses were performed, examining the relationship of survival with T-stage, recurrence, and TNM-stage (by each TNM edition) and with the single/combined expression of Pkp1 and/or Krt15 genes. Five-year survival rates only significantly differed as a function of T-stage in patients without recurrence when estimated using the 6(th) edition of the TNM classification and only in patients in pathologic TNM-stage IA using the 7(th). Overall survival for patients with elevated expression of both genes was 13.5 months in those with adenocarcinoma and 34.6 months in those with squamous cell carcinoma. Overall survival was 30.4 months in patients with Pkp1 gene upregulation and 30.9 months in those with Krt15 gene upregulation. In conclusion, survival estimations as a function of T-staging differed between the 6(th) and 7(th) editions of TNM. Overall survival differed according to the expression of Pkp1 and/or Krt15 genes, although this relationship did not reach statistical significance.

Differential immunohistochemical localization of desmosomal plaque-related proteins in non-small-cell lung cancer.

AIMS: Immunohistochemistry is a highly valuable and widely used tool in the subtyping of lung carcinomas. The aim of this study was to identify markers for the differential diagnosis of non-small-cell carcinomas. METHODS AND RESULTS: We report on the immunohistochemical localization of plakophilin-1 (PKP1), keratin-15 (KRT15) and desmoglein-3 (DSG3) intercellular adhesion proteins in samples from 75 primary non-small-cell lung cancers in non-treated patients. The staining pattern of these proteins differed between squamous cell carcinomas and adenocarcinomas, with no membrane staining in the latter. Membrane staining for all three proteins was characteristic of squamous cell carcinomas. We observed a relationship between the presence/absence of these proteins in the membranes of squamous cell carcinomas and the differentiation grade, with more intense staining in better differentiated areas. CONCLUSIONS: Staining for these proteins marked intercellular junctions that are characteristic of stratified squamous epithelium and of neoplasias with this type of differentiation, and can be useful in the diagnosis of patients with squamous cell carcinoma of the lung. The high specificity of membrane staining for PKP1 and DSG3 and high sensitivity of cytoplasmic and membrane staining for KRT15 for the diagnosis of squamous cell carcinoma may be useful for the differential diagnosis of non-small-cell carcinomas.

Surgical adhesive may cause false positives in integrated positron emission tomography and computed tomography after lung cancer resection.

Surgical adhesives are frequently used after pulmonary resection to prevent or reduce pulmonary air leakages, since leakages may cause complications delaying the removal of chest drainage tubes and prolonging in-hospital stay. In this paper, we present 2 patients who underwent curative-intent pulmonary resection for non-small-cell lung carcinoma, in which the biological adhesive BioGlue(®) was used. Follow-up fluoro-2-deoxy-D-glucose positron emission tomography/computed tomographic (FDG-PET/CT) imaging revealed hypermetabolic pulmonary nodular lesions. Subsequent surgical exploration showed that the lesions were foreign body reactions to the bioadhesive. To our knowledge, this is the first study to examine false-positive follow-up FDG-PET/CT scans caused by the use of BioGlue(®) in pulmonary resection procedures.

Gene expression profiling reveals novel biomarkers in nonsmall cell lung cancer.

The development of reliable gene expression profiling technology is having an increasing impact on our understanding of lung cancer biology. Our study aimed to determine any correlation between the phenotypic heterogeneity and genetic diversity of lung cancer. Microarray analysis was performed on a set of 46 tumor samples and 45 paired nontumor samples of nonsmall cell lung cancer (NSCLC) samples to establish gene signatures in primary adenocarcinomas and squamous-cell carcinomas, determine differentially expressed gene sequences at different stages of the disease and identify sequences with biological significance for tumor progression. After the microarray analysis, the expression level of 92 selected genes was validated by qPCR and the robust Bonferroni test in an independent set of 70 samples composed of 48 tumor samples and 22 nontumor samples. Gene sequences were differentially expressed as a function of tumor type, stage and differentiation grade. High upregulation was observed for KRT15 and PKP1, which may be good markers to distinguish squamous-cell carcinoma samples. High downregulation was observed for DSG3 in stage IA adenocarcinomas.

Preoperative chemotherapy plus surgery versus surgery plus adjuvant chemotherapy versus surgery alone in early-stage non-small-cell lung cancer.

PURPOSE: To address whether preoperative chemotherapy plus surgery or surgery plus adjuvant chemotherapy prolongs disease-free survival compared with surgery alone among patients with resectable non-small-cell lung cancer. PATIENTS AND METHODS: In this phase III trial, 624 patients with stage IA (tumor size > 2 cm), IB, II, or T3N1 were randomly assigned to surgery alone (212 patients), three cycles of preoperative paclitaxel-carboplatin followed by surgery (201 patients), or surgery followed by three cycles of adjuvant paclitaxel-carboplatin (211 patients). The primary end point was disease-free survival. RESULTS: In the preoperative arm, 97% of patients started the planned chemotherapy, and radiologic response rate was 53.3%. In the adjuvant arm, 66.2% started the planned chemotherapy. Ninety-four percent of patients underwent surgery; surgical procedures and postoperative mortality were similar across the three arms. Patients in the preoperative arm had a nonsignificant trend toward longer disease-free survival than those assigned to surgery alone (5-year disease-free survival 38.3% v 34.1%; hazard ratio [HR] for progression or death, 0.92; P = .176). Five-year disease-free survival rates were 36.6% in the adjuvant arm versus 34.1% in the surgery arm (HR 0.96; P = .74). CONCLUSION: In early-stage patients, no statistically significant differences in disease-free survival were found with the addition of preoperative or adjuvant chemotherapy to surgery. In this trial, in which the treatment decision was made before surgery, more patients were able to receive preoperative than adjuvant treatment.

Prognostic value of chronic obstructive pulmonary disease in 2994 cases of lung cancer.

OBJECTIVE: Given the frequent association between chronic obstructive pulmonary disease (COPD) and lung cancer (LC), the objective of this paper is to analyse the prognosis of this comorbidity. METHODS: Multicenter prospective study compiling 2994 consecutive cases of surgically treated LC (1993-1997), the population with non-small cell lung cancer and complete resection was selected for the prognostic study of COPD. COPD is defined when the FEV1/FVC is <0.7 (n=1370; 46%). Overall and conditional survivals (survival likelihood when alive at 2, 3 or 5 years after treatment) as well as the degree of severity (FEV1% percentiles) were calculated to establish prognosis. RESULTS: Although the overall survival is similar whether or not COPD is present (Log-rank: 0.34), the conditional survival analysis is different in every stage at 60 months (Log-rank: 0.02) and different in stage pI at 24-36 months (Log-rank: 0.04). In LC (stage pI) with COPD, the presence of a worst pulmonary function (last FEV1% percentile vs first FEV1% percentile) is a bad prognostic factor (Log-rank: 0.002). CONCLUSIONS: The analysis of conditional survival at 24 months shows that COPD can be considered as a prognostic factor and that there is a clear relationship between the severity of the condition (FEV1%) and survival.