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Ann Thorac Surg 2004;77:1883-1890
© 2004 The Society of Thoracic Surgeons

Original article: general thoracic

Neuroendocrine and biologic features of primary tumors and tissue in pulmonary large cell carcinomas

Alexandre M. Ab' Saber, MDa, Ledo Mazzei Massoni Netoa, Cristina P. Bianchia, Bruno B. Ctenas, MDa, Edwin R. Parra, MDa, Esmeralda M. Ehera, João Carlos Pereira, MDb, Teresa Takagaki, MD, PhDc, Nise H. Yamaguchi, MD, PhDc, Vera L. Capelozzi, MD, PhDa*

a Department of Pathology, University of São Paulo Medical School, São Paulo, Brazil
b Department of Thoracic Surgery, University of São Paulo Medical School, São Paulo, Brazil
c Pulmonary Division, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil

Accepted for publication November 25, 2003.

* Address reprint requests to Dr Capelozzi, Department of Pathology, School of Medicine, University of São Paulo, Av. Dr. Arnaldo 455, 01246-903, São Paulo SP, Brazil
e-mail: vcapelozzi{at}lim05.fm.usp.br


   Abstract
Top
 Abstract
Introduction
 Patients and methods
 Results
 Comment
 Acknowledgments
 References
 
BACKGROUND: Because biological behavior in lung tumors with neuroendocrine differentiation is highly dependent on cell death (apoptosis) and angiogenesis, p21waf1/cip1 and microvessel density have been targeted as potentially useful tumor markers. We sought to validate the importance of p21waf1/cip1 and microvessel density and study their interrelationship, analyzing clinical factors, subclassifications, and tumor and stromal markers.

METHODS: We examined p21waf1/cip1 and other markers in tissue from 61 patients with surgically excised large cell carcinomas. The amount of tumor staining for p21waf1/cip1 and microvessel density was evaluated by immunohistochemistry and morphometry. The study outcome was survival time until death from recurrent lung cancer.

RESULTS: Multivariate Cox model analysis demonstrated that after surgical excision, histologic subtypes were significantly related to survival time (p = 0.02), but quantitative staining of the tumor for p21waf1/cip1 and microvessel density added prognostic information and these variables were more strongly prognostic than histologic subtype (p = 0.00). Cut points at the median staining of 3.5% and 3.0% for p21waf1/cip1 and microvessel density, respectively, divided patients into two groups with distinctive survival times. Patients with p21waf1/cip1 staining of more than 3.5% and microvessel density staining of more than 3.0% had a median survival time of 14 months.

CONCLUSIONS: Tumor staining for p21waf1/cip1 and microvessel density in resected large cell carcinomas and certain other types of lung tumors was strongly related to survival. Patients with more than 3.0% staining in their tumors were at high risk of death from lung cancer and may be an appropriate target for prospective studies of adjuvant chemotherapy after surgical resection.


   Introduction
Top
 Abstract
 Introduction
Patients and methods
 Results
 Comment
 Acknowledgments
 References
 
Of the major types of non–small cell lung carcinomas (NSCLC), large cell carcinomas (LCC) are more heterogeneous with respect to their biological evolution, morphologic attributes, and genetic expression [1]. In a previous work [2], we found that ultrastructural and immunohistochemical (IHC) studies have delineated neuroendocrine (NE) features in such neoplasms, suggesting that this subclassification may be useful in treatment and prognostic evaluation of patients. Since then, NE differentiation in LCC has been recognized in the literature as large cell NE carcinoma (LCNEC) [3–6]. In 1999, the World Health Organization International Association Society of Lung Carcinoma (WHO IASLC) classification of lung tumors categorized LCNEC on morphologic grounds as a type of LCC, recognizing LCNEC as tumors with both NE morphology and IHC evidence of NE differentiation. Those tumors with NE morphology that lack IHC evidence of NE differentiation are called large cell carcinomas with NE morphology (LCCNM) [6–9].

The clinical and biological importance of this subclassification has not been fully elucidated. LCNEC and LCCNM appear to be more clinically aggressive tumors than LCC [10], with a prognosis comparable to that of small cell carcinomas [8]. Recent studies have reported the prognostic impact of several pathologic factors [7–9]. Unfortunately, knowledge regarding these pathologic prognostic factors has not identified which tumors are likely to recur and shorten the patient's life. For adjuvant treatment to be effective, these tumors must be identified shortly after surgery.

In this regard, many researchers have studied molecular or other markers in the primary tumor and the surrounding tissue milieu to discover what might relate to tumor recurrence and shortened survival [10–15]. Because the biological behavior of lung tumors with NE differentiation is highly dependent on cell death (apoptosis) and angiogenesis, p21waf1/cip1 and microvessel density (MVD) have been targeted as potentially useful tumor markers [16–25].

We studied these markers in 61 cases of localized LCC of the lung to validate the importance of p21waf1/cip1 and MVD, to explore the quantitative relationship between these factors and clinical factors and subclassification, and to investigate the relationship between p21waf1/cip1 and MVD with other tumor and stromal factors.


   Patients and methods
Top
 Abstract
 Introduction
 Patients and methods
Results
 Comment
 Acknowledgments
 References
 
Patient characteristics
This retrospective study included 61 of 476 patients with primary lung carcinomas resected surgically and previously diagnosed as LCC at the Hospital das Clinicas da Faculdade de Medicina da USP, Hospital do Cancer AC Camargo de SP, and Hospital Amaral Carvalho de Jaú from 1982 to 2002. All 61 patients had complete preoperative staging and were considered to have tumors potentially curable by surgical resection. Mediastinoscopy was performed in 30 patients whose lymph nodes had a short axis diameter of more than 1 cm. The remaining 31 patients were preoperatively staged as N0 by radiologic criteria. However, after pathologic evaluation, when more lymph nodes were sampled, 32 patients were in N1 to N3 final stage, with the remaining 29 patients classified as N0. All patients underwent postoperative chemotherapy, some with associated radiotherapy. The major criteria for adjuvant therapy were the anaplastic or the NE phenotype and the aggressive nature of the disease. No standardized adjuvant treatment protocol was followed because a long period of time occurred between the first and last cases, with a broad variation of protocols during this period. The median complete follow-up time was 18 months (range 12 to 43 months).

Pathologic criteria for specimen selection and classification
Tumor tissue samples were obtained at surgical treatment of LCC and fixed in 10% formalin. For each case, one or two slides of the principal tumor were selected by light microscopy. Acceptable sections were those that represented the predominant histologic pattern of LCC identified on the majority of slides, with at least 10 microscopic fields at a magnification of x 250. Their respective paraffin-embedded blocks were sectioned at 3 µm and stained with hematoxylin and eosin. Two pathologists (A.M.A. and V.L.C.) reviewed these slides separately, in an independent and blind fashion, and agreed on the diagnosis of LCC. To minimize discrepancies, the criteria that were evaluated for tumor classification were agreed on in a series of preliminary discussions between the 2 pathologists and after an informal review of the cases.

The 61 tumors were classified either as LCNEC or LCCNM if evidence existed of all of the following: (1) NE morphology, such as organoid nesting, palisading rosettes, and trabeculae; (2) a high mitotic rate of at least 11 per 2 mm2 (10 high-power fields); (3) necrosis (often large zone); and (4) cytologic features of an NSCLC, ie, large cell size, low nuclear-to-cytoplasmic ratio, vesicular or fine chromatin, or frequent nucleoli (Fig 1A–C). Large cell carcinomas without NE morphology were classified as classic LCC. Thus, we compared and examined clinicopathologic and biological differences of classic LCC, LCNEC, and LCCNM.



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  		Fig 1. (A) LCC with nucleoli evident, lower nuclear-to-cytoplasmic ratio, and absence of neuroendocrine features. (Hematoxylin & eosin; x200 before reduction.) (B) LCNEC (hematoxylin & eosin; x100 before reduction) and (C) LCCNM (hematoxylin & eosin; x200 before reduction) show a neuroendocrine morphology with organoid nesting, palisading, and rosettes. Numerous mitoses are seen. Cytologic features include large cell size, fine chromatin, and nucleoli evident. (D) The tumor cells stained with anti-chromogranin A antibody; only the LCNEC tumors stained for chromogranin. (x200 before reduction.) (LCC = large cell carcinoma; LCNEC = large cell neuroendocrine carcinoma; LCCNM = large cell carcinoma with neuroendocrine morphology.)

 
To detect NE differentiation, we used a polyclonal anti-chromogranin antibody (Dako, Glostrup, Denmark) at a 1:1,600 dilution and a monoclonal anti-synaptophysin antibody (Dako) at a 1:100 dilution. The same IHC procedure described below was used for matrix metalloproteinase 9 (MMP-9), the tumor suppressor gene p53, p21waf1/cip1, and cyclooxygenase-2 (COX-2). Examples of tumor staining for chromogranin and synaptophysin appear in Figure 1D.

Histologic tumor variables
The presence of p53, p21waf1/cip1, MMP-9, and COX-2 were analyzed by IHC staining using the avidin-biotin immunoperoxidase complex technique, pressure cooking antigen retrieval, biotinylated rabbit anti-mouse IgG (Dako; dilution, 1:400) streptavidin combined in vitro with biotinylated horseradish peroxidase (Dako; dilution, 1:1,000), diaminobenzidine tetrahydrochloride, and counterstaining with hematoxylin. The antibodies used were monoclonal mouse anti-human p53 protein (DO7; Dako; dilution 1:40), p21waf1/cip1 monoclonal antibody (Dako; dilution 1:100), MMP-9 mouse monoclonal clone 56 to 2A4, which recognizes both latent and active MMP-9 at a dilution of 1:100 (Biogen) and COX-2 monoclonal antibody (Dako; dilution 1:50). Brownish nuclear staining was considered evidence of the p53 and p21waf1/cip1 antigen expression by cells, whereas membranous and cytoplasmic staining characterized MMP-9 and COX-2. In addition, we quantified the staining as follows. First, at low magnification, we selected the region of highest expression. Then, at x400, we used an eyepiece systematic point-sampling grid with 100 points and 50 lines to count the fraction of points overlaying positively stained structures. We averaged this over more than 10 microscopic fields to obtain a percentage of stained structures [26, 27].

Tissue environment variables
We evaluated MVD using the anti-CD34 monoclonal antibody (Novocastra Laboratory, Newcastle, United Kingdom) at a 1:25 dilution and the same IHC procedure as used for MMP-9, p53, p21waf1/cip1, and COX-2. For each slide, the 10 most vascular areas within the tumor mass were chosen, and at x200 magnification, we counted the number of CD34-positive staining vascular structures (single cells or cell clusters) by conventional area sampling [26, 27] and then recorded the average counts of the 10 fields. We did not count larger vessels with muscular walls or with lumens greater than 50 µm, and we carefully avoided other cells that might stain for CD34, such as transformed lymphocytes.

Statistical analysis
The clinical and pathologic variables considered were the following: sex, age, pathologic TNM, nodal metastasis (N stage), and histologic subtypes. The unpaired t test was used to detect significant differences in patient's age and tumor mitotic rates. Biological variables considered were p53, p21waf1/cip1, CD34, MMP-9, and COX-2. Associations between biological variables and clinical/pathologic variables were assessed using the {chi}2 or Spearman tests. Overall survival curves were calculated from the date of surgery, using death from any cause as the end point. Kaplan–Meier estimates were calculated for each clinical and biological variable and were compared using the log-rank test. Multivariate assessment of overall survival was performed with the Cox proportional hazard model. Clinical-pathologic features with a univariate p value less than 0.05 were initially included in the multivariate model. Variables not significantly associated with overall survival were removed from the model by means of a stepwise procedure based on the likelihood ratio test. The significance level for removing a variable from the model was set at 0.05. For association and survival analysis, cut points in variables were obtained by dichotomization at the median. All the procedures used for statistical evaluation were analyzed with SPSS 10.0 software (SPSS Inc, Chicago, IL). The threshold for statistical significance was taken as p = 0.05.


   Results
Top
 Abstract
 Introduction
 Patients and methods
 Results
Comment
 Acknowledgments
 References
 
Patient and tumor characteristics
Table 1 summarizes patient characteristics according to histologic subtypes. Of the 61 tumors included in the study, 24 had evidence of NE differentiation by IHC staining and 11 demonstrated NE morphology by light microscopy. Forty percent were classified as LCNEC, 18% as LCCNM, and 42% as LCC. The mean age was similar for all patients. Patients were predominantly male (66%). A substantial difference in tumor stage existed between the histologic subtypes. This difference was statistically significant (p < 0.05), although small numbers of LCC were in stage I. The extent of lymph node metastases among the three categories was not significantly different (p > 0.05), although such metastases were more frequent in LCNEC and LCC. No significant difference was present between T stage and surgical procedure. The median survival for patients with LCNEC was significantly shorter than that for those with LCC and LCCNM (p < 0.05).


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  		Table 1. Characteristics of Patients Stratified by Histologic Subtypes

 
Associations
Table 2 summarizes the morphometric results for each histologic subtype. We compared the proportion of cases with biological tumor markers among the three histologic subtypes. p53 expression of more than 9.1% in LCNEC cases was statistically significant (p < 0.05). p21waf1/cip1 indicator more than 3.4% in LCC with NE features (LCNEC + LCCNM) was also statistically significant (p < 0.05). The proportion of cases with MMP-9 expression more than 3.38% was significantly higher in LCNEC and LCC than in LCCNM (p < 0.05). LCNEC also had significant expression of COX-2 when compared with LCC and LCCNM (p < 0.05). The difference of tumors with MVD expression less than 3.01% in LCNEC, LCC, and LCCNM was also statistically significant (p < 0.05).


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  		Table 2. Frequency of Biological Features in Cut Pointsa,b for Each Histologic Subtype

 
Of the different biological features, MVD was positively correlated with p21waf1/cip1 (R = 0.27; p < 0.05), COX-2 (R = 0.27; p < 0.05), and MMP-9 (R = 0.90; p < 0.01) (data not shown).

Survival according to clinical and biological features
Table 3 lists the results of the univariate analysis for the prognostic significance of each factor analyzed in relation to survival, expressed as median survival time, 95% confidence intervals (CI), 3-year survival rate, and p values. The 3-year survival rate for patients with stage II disease compared with those with stage I and III was statistically significant (p > 0.05). LCCNM had a statistically significant 3-year survival rate (p < 0.01). Surgical procedure had different hazards for survival; this difference was statistically significant (p < 0.05). Adjuvant therapy had no impact on survival (data not shown).


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  		Table 3. Overall Survival Time Estimated With the Kaplan-Meier Method According to Clinical, Pathologic, and Biologic Features (Univariate Analysis)

 
Table 4 lists the results of the multivariate analysis with Cox's proportional hazard model factor, analyzed in relation to ß coefficient, standard error, Wald test, p significance level for Wald test, hazard ratio, and 95% CI. Surgery excision, histologic subtype, p21waf1/cip1, CD34, MMP-9, and COX-2 were independent prognostic factors for survival (p < 0.05) (Table 3). In the multivariate analysis, only four variables were significantly associated with survival time: surgery, histologic type, staining of the tumor for CD34, and p21waf1/cip1 (Table 4; Fig 2). Patients who underwent pneumonectomy had poor survival (8 months, p < 0.05 by log-rank test, Table 3) compared with patients with lobectomy and bilobectomy (Fig 2A). Of the histologic subtypes, LCNEC had the poorest median survival time (13 months, p < 0.05 by log-rank test, Table 3). The group with less than 3.0% MVD appears as the upper curve; the median survival time for this group was 28 months. By contrast, those with more than 3.01% MVD (lower curve) had a median survival time of only 13 months after surgery (p < 0.05 by log-rank test, Table 3) (Fig 2C).


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  		Table 4. Results of the Multivariate Analysis by Means of the Cox's Proportional Hazard Model

 


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  		Fig 2. (A) Kaplan–Meier curve demonstrating the impact of surgery on survival. Surgery type: - {diamond} - = pneumonectomy; — {blacksquare} — = bilobectomy; –{triangleup}– = lobectomy. (B) Effect of histologic subtype on survival. Group: — {blacksquare} — = LCNM; - {diamond} - = LCNEC; –{triangleup}– = LCC. (LCC = large cell carcinoma; LCNM = large cell carcinoma with neuroendocrine morphology; LCNEC = large cell neuroendocrine carcinoma.) (C) Kaplan–Meier curve demonstrating the effect of MVD on survival. Upper curve < 30% of MVD in tumor; lower curve < 30% of MVD in tumor. Cut points in MVD: - - - = 3.01–12.8%; —— = 0.0–3.0%. (MVD = microvessel density.) (D) Kaplan–Meier curve demonstrating the effect of p21 on survival. Upper curve < 35% of tumor staining; lower curve < 37% of tumor staining. Cut points in p21: - - - = 3.7–46.6%; —— = 0.0–3.7%.

 
p21waf1/cip1 expression was equally important in predicting poor survival. In this context, groups with a maximum of 3.5% staining of p21waf1/cip1 (upper curve) had a statistically significant median survival time of 26 months (p < 0.05 by log-rank test, Table 3) compared with 13 months in groups with more than 3.5% p21waf1/cip1 (lower curve) (Fig 2D). The multivariate model shows the relative risks for cancer-related death in patients (Table 4), which was high for pneumonectomy (6.41-fold greater; 95% CI, 1.60 to 25.56), but was approximately the same in LCNEC cases (2.43-fold greater; 95% CI, 1.03 to 5.72) with p21waf1/cip1 overexpression (2.33-fold greater; 95% CI, 1.26 to 4.29) and high MVD (2.21-fold greater; 95% CI, 1.19 to 4.11).


   Comment
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
Acknowledgments
 References
 
Our results support the findings of Iyoda and colleagues [7, 8] who found a difference in the clinical behavior of LCNEC, LCC, and LCCNM. In the present study patients with LCCNM and LCC had similar overall survivals, significantly better than that for LCNEC patients. However, a substantial difference existed in tumor stage between these histologic subtypes. For example, only 34% of LCC were stage I, but 73% of LCCNM were stage I. Thus, the fact that many more LCCNM patients were stage I yet had similar survival to LCC suggests that, stage for stage, LCCNM has a poorer prognosis. Even considering these limitations, the poor survival (13 months) with a 3-year survival of 8% found for stage I LCNEC patients contrasts with survival reported by others (eg, Zacharias and coworkers [9] showed that accurately staged patients in stage I LCNEC had a 3-year survival of 88%, which was maintained at 5 years). The markedly poorer survival in our series may be caused by several factors. First, it is possible that the extent of complete anatomical resection determined by the T stage, such as pneumonectomy, accounted for the markedly poor survival results in our series. As shown in Table 4 and Figure 2A, the relative risk for cancer-related death in patients was high for pneumonectomy (6.41-fold greater; 95% CI, 1.60 to 25.56). Second, our series had a high percentage of patients with lymph node metastasis (52%) compared with the group analyzed by Zacharias and colleagues [9]. In their study, only 18% of patients were in stage III, which would have improved the prognosis. In addition, adjuvant therapy in our study, as in several trials [4, 5], did not extend an advantage in survival, probably because no standardized treatment protocol was followed.

Clearly, the likely reason that surgical excision fails to cure some patients with LCC is because of the high potential for invasion and metastases that have not yet been detected by either routine imaging or routine pathologic analysis. The question of interest is whether additional, more technological information gathered from either the tumor tissue or its milieu can help us identify tumors likely to have high potential for invasion and metastases. Tumor markers associated with apoptosis (p53, p21waf1/cip1, COX-2), angiogenesis (MVD and COX-2), and extracellular matrix degradation (MMP-9) were analyzed in the current study to determine whether they may be useful in distinguishing NE subtypes from LCC. Significant differences were found to exist in tumor p53, p21waf1/cip1, and COX-2 expression, as well as in MMP-9 and MVD quantitation.

Of these, immunohistochemistry staining for p21waf1/cip1 provided the most important prognostic information about LCC, LCCNM, and LCNEC. p21waf1/cip1 encodes a cyclin-dependent kinase inhibitor that is transcriptionally activated by the p53 tumor suppressor gene. p21waf1/cip1 is involved in the regulation of apoptosis and the cell cycle. High p21waf1/cip1 protein expression predicts p53 mutation status, poor survival, and correlates with tumor grade [16]. Abnormal expression of p21waf1/cip1 has been found in NSCLC including the vast majority of LCC and high-grade pulmonary NE tumors [16–20]. Thus, for all these reasons, we should not be surprised to learn that IHC staining for p21waf1/cip1 provides important prognostic information about NSCLC, and our results now confirm the prognostic importance of p21waf1/cip1 in LCC of the lung.

Our results suggest that staining for p21waf1/cip1 provides more prognostic information than does histologic subtypes. We also identified a binary cut point in p21waf1/cip1. A natural dividing point for these tumors was the median of 3.5% of cells staining for p21waf1/cip1, and this point provided a practical way to separate patients into two groups: patients with an expected short survival versus an expected long survival. Thus, IHC staining of the primary tumor for p21waf1/cip1 offers the potential to guide the use of adjuvant chemotherapy in patients likely to fail after surgical excision of LCC. To finalize this conclusion will require greater study in a randomized and prospective trial. We also believe it important to validate our quantitative assessment of p21waf1/cip1 as well as to extend it to other histologic types of NSCLC by studying p21waf1/cip1 in additional patients.

We also found that IHC staining for p21waf1/cip1 was associated with other prognostic factors. For example, we found that staining for p21waf1/cip1 was significantly related to tumor expression of MMP-9, but again p21waf1/cip1 provided information that was more prognostic. More interesting was the strong quantitative relationship we found between p21waf1/cip1 and MVD. p21waf1/cip1 was positively associated with MVD, even after controlling for other related variables. Microvessel density has been repeatedly found to be a strong prognostic variable in resectable NSCLC [21–25]; we found that its relationship with survival was as strong as that for p21waf1/cip1. Using MVD as a covariate with surgical excision and histologic subtypes in the Cox model produced a relative risk of cancer-related death 2.21-fold greater, whereas using p21waf1/cip1 resulted in a relative risk of 2.33-fold greater. Because the relative risk for cancer-related death was similar when using p21waf1/cip1, we concluded that both provided prognostic information for our patients.

We have demonstrated that in LCC, LCNEC, and LCCNM a strong correlation exists between MVD and the tumor level of p21waf1/cip1. The strong association between tumor staining for p21waf1/cip1 and angiogenesis suggests that tumors manufacturing and producing higher levels of p21waf1/cip1 facilitate growth by apoptosis inhibition and penetration of capillaries into the tumor tissue milieu. Thus, increased tumor expression of p21waf1/cip1 may be more of a primary event, and increased angiogenesis may be more of a secondary event. Regardless of the mechanism, staining of the primary tumor for p21waf1/cip1 and MVD for surrounding tissue milieu provides important prognostic information in LCC and its subtypes after surgical resection.


   Acknowledgments
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
 Acknowledgments
References
 
We are very grateful to Dr Venancio Avancini Ferreira Alves for technical assistance and to Dr William Travis for useful comments. This study was supported by the following Brazilian agencies: the National Council for Scientific and Technological Development (CNPq); the Foundation for the Support of Research of the State of São Paulo (FAPESP); and the Laboratories for Medical Research (LIMs), Clinicas Hospital, School of Medicine, University of São Paulo.


   References
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
 Acknowledgments
 References
 

  1. Wick M.R., Berg L.C., Usak M., Hertz M.I. Large cell carcinoma of the lung with neuroendocrine differentiation. A comparison with large cell "undifferentiated" pulmonary tumors. Am J Clin Pathol 1992;97:796-805.[Medline]
  2. Delmonte Capelozzi V., Alberti O., Saldiva P.H.N. Large cell carcinoma of the lung: ultrastructural and immunohistochemical features. Chest 1986;90:524-526.[Abstract/Free Full Text]
  3. Travis W.D., Linnoila R.I., Tsokos M.G., et al. Neuroendocrine tumors of the lung with proposed criteria for large cell neuroendocrine carcinoma. An ultrastructural, immunohistochemical, and flow cytometric study of 35 cases. Am J Surg Pathol 1991;15:529-553.[Medline]
  4. Dressler C.M., Ritter J.H., Patterson G.A., Ross E., Bailey M.S., Wick M.R. Clinicopathologic analysis of 40 patients with large cell neuroendocrine carcinoma of the lung. Ann Thorac Surg 1997;63:180-185.[Abstract/Free Full Text]
  5. Garcia-Yuste M., Matilla J.M., Alvarez-Gago T., Duque J.L., Cerezal L.J., Ramos G. Prognostic factors in neuroendocrine lung tumors: a Spanish multicentre study. Ann Thorac Surg 2000;70:258-263.[Abstract/Free Full Text]
  6. Travis W.D., Corrin B., Shimosato Y., Brambilla E. The histological typing of lung and pleural tumors. WHO/IASLC classification of lung and pleural tumours, 3rd ed Berlin: Springer Verlag, 1999.
  7. Iyoda A., Hiroshima K., Toyozaki T., Haga Y., Fujisawa T., Ohwada H. Clinical characterization of pulmonary large cell neuroendocrine carcinoma and large cell carcinoma with neuroendocrine morphology. Cancer 2001;91:1992-2000.[Medline]
  8. Iyoda A., Hiroshima K., Masayuki B., Saitoh Y., Ohwada H., Fujisawa T. Pulmonary large cell carcinomas with neuroendocrine features are high-grade neuroendocrine tumors. Ann Thorac Surg 2002;73:1049-1054.[Abstract/Free Full Text]
  9. Zacharias J., Nicholson A.G., Ladas G.P., Goldstraw P. Large cell neuroendocrine carcinoma and large cell carcinomas with neuroendocrine morphology of the lung: prognosis after complete resection and systematic nodal dissection. Ann Thorac Surg 2003;75:348-352.[Abstract/Free Full Text]
  10. Przygodzki R.M., Finkelstein S.D., Langer J.C., et al. Analysis of p53, K-ras-2, and C-ralf-1 in pulmonary neuroendocrine tumors: correlation with histological subtype and clinical outcome. Am J Pathol 1996;148:1531-1541.[Abstract]
  11. Battlehner C.N., Saldiva P.H.N., Carvalho C.R.R., et al. Nuclear/cytoplasmic ratio correlates strongly with survival in non-disseminated neuroendocrine carcinoma of the lung. Histopathology 1993;22:31-34.[Medline]
  12. Caporrino C., Saldiva P.H.N., Farhat C.A., Takagaki T.Y., Younes R.Y., Capelozzi V.L. Stereological estimates of nuclear star volume and vessels as predictors of chemotherapy response in small cell carcinoma of the lung. Histopathology 1997;31:420-429.[Medline]
  13. Carvalho P.E.O., Antonângelo L., Bernardi F.D.C., Leão L.E.V., Rodrigues O.R.R., Capelozzi V.L. Useful prognostic panel marker to express the biological tumor status in resected lung adenocarcinomas. Jpn J Clin Oncol 2000;30:478-486.[Abstract/Free Full Text]
  14. Capelozzi V., Battlehner C.N., Montes G.S., Saldiva P.H.N. Volume fraction of dense-core granules correlates well with survival in disseminated (stage IV) neuroendocrine carcinoma of the lung. Pathol Res Pract 1993;189:1145-1148.[Medline]
  15. Demarchi L.M., Reis M.M., Palomino S.A., et al. Prognostic values of stromal density and PCNA, Ki-67, and p53 proteins in patients with resected adenocarcinoma of the lung. Mod Pathol 2000;13:511-520.[Medline]
  16. Bennett W.P., el-Deiry W.S., Rush W.L., et al. p21waf1cip1, and transforming growth factor ß1 protein expression correlate with survival in non-small cell lung cancer. Clin Cancer Res 1998;4:1499-1506.[Abstract]
  17. Khan Q.A., Dipple A., Anderson L.M. Protease inhibitor-induced stabilization of p21(waf1/cip1) and cell-cycle arrest in chemical carcinogen-exposed mammary and lung cells. Mol Carcinog 2002;33:1-8.[Medline]
  18. DiGiuseppe J.Á., Redston M.S., Veo C.J., Kern S.E., Hruban R.H. p53-independent expression of the cyclin-dependent kinase inhibitor p21 in pancreatic carcinoma. Am J Pathol 1995;147:884-888.[Abstract]
  19. Marchetti A., Doglioni C., Barbareschi M., et al. p21 RNA and protein expression in non-small cell lung carcinomas: evidence of p53-independent expression and association with tumoral differentiation. Oncogene 1996;12:1319-1324.[Medline]
  20. Barbareschi M., Caffo O., Doglioni V.C., et al. P21 immunohistochemical expression in breast carcinoma: correlations with clinicopathologic data, oestrogen receptor status, MIB1 expression, p53 gene and protein alterations and relapse-free survival. Br J Cancer 1996;74:208-215.[Medline]
  21. Fontanini G., Lucchi M., Vignati S., et al. Angiogenesis as a prognostic indicator of survival in non-small cell lung carcinoma: a prospective study. J Natl Cancer Inst 1997;89:881-886.[Abstract/Free Full Text]
  22. Eberhard A., Kahlert S., Goede V., Hemmerlein B., Plate K.H., Augustin H.G. Heterogeneity of angiogenesis and blood vessel maturation in human tumors: implications for antiangiogenic tumor therapies. Cancer Res 2000;60:1388-1393.[Abstract/Free Full Text]
  23. Brem S., Cotran R., Folkman J. Tumor angiogenesis: a quantitative method for histologic grading. J Natl Cancer Inst 1992;48:347-356.
  24. Slodkowska J., Sikora J., Androsiuk W., Rudzinski P., Radomyski A. Lung carcinoids. Tumor angiogenesis in relation to clinicopathologic characteristics. Anal Quant Cytol Histol 1999;21:267-272.[Medline]
  25. Garzetti G.G., Ciavattini A., Lucarini G., et al. Expression of vascular endothelial growth factor related to 72-kilodalton metalloproteinase immunostaining in patients with serous ovarian tumors. Cancer 1999;85:2219-2225.[Medline]
  26. Hilliard J.E. Measurements of volume in volume. In: DeHoff R.T., Rhines F.N., eds. Quantitative microscopy. New York: McGraw-Hill, 1968:48-49.
  27. Gundersen H.J., Bendtsen T.F., Korbo L., et al. Some new, simple and efficient stereological methods and their use in pathological research and diagnosis. APMIS 1988;96:379-394.[Medline]



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