The Blood-perfusion System Derived Factors For Prognosis Prediction Of Non-small Cell Lung Cancer Patients

ObjectiveThe blood-perfusion system plays a key role in the development and metastasis of non-small cell lung cancer(NSCLC).However,the clinical value of prognostic factors associated with vascular perfusion characteristics iscontroversial.Considering of impaired perfusion-behavior in tumor,especially induced by tumor microenvironment,a comprehensive factor derived from microvessels and stromal profile maybe proposed as a preferable prognositic marker.In this thesis,we evaluated the role of comprehensive factors of blood-perfusion system and microenvironment in prognosis of NSCLC patients.MethodsThe intratumor microvessels of NSCLC patients were visualized by immunohistochemistry-staining against CD31-antigen.The blood-perfusion distances were evaluated as the distance from each vessel to its nearest cancer cell(Dmv-cc).Apart from total microvesseldensity(tMVD),modified microvessel density(mMVD)which defined as the density of microvessels neared to cancer cells within cutoff value of Dmv-cc,stroma-normalized microvessel-area(SnMVA),tumor microvessels aspect ratio(TMAR)and collapse-microvessel fraction were determined.The correlation of them with the survival was evaluated by univariate and multivariate analysis,respectirely.The role of aforementioned factors in prognostic prediction was evaluated by sensitivity and specificity analysis using the receiver operator characteristic curve(ROC)and significant test,then their optimal cutoff-values for survival prediction was determined using Cutoff Finder software.Ultimately,the correlation of those factors with the survival was evaluated by univariate analysis using log-rank test and multivariate analysis using COX regression.ResultsA total of 100 patients(74 males and 26 females)were included with a median age of 59 years(range,40-79 years).About 71%of patients were of early-stage(stage I or II),and the remained patients were of advanced-stage(stage Ⅲ or Ⅳ).Differentiation status was classified into three categories,poorly-(n=49),moderately-(n=47),and well differentiated(n=1).Fifty-four cases were adenocarcinoma and 43 cases were squamous carcinoma.The median follow-up time was 51.1 months(range,45.5-60.0).The median-and optimal cutoff-value of Dmv-cc was 15.93 μm(range,1.74-269.74 μm)and 18.80 μm,respectively.A long Dmv-cc significantly predicted high risk of both death(HR= 6.90,95%CI:3.22-15.80,p<0.0001)and recurrence(HR=2.17,95%CI:1.14-4.12,p=0.014).And it was proven as an independent prognosis factor of both cancer-related death(HR=16.67,95%CI:4.39-63.29,p<0.001)and recurrence(HR=3,66,95%CI:1.52-8.813,p=0.004)by COX regression.The mMVD(range,2 to 70;median,23)was counted from tMVD according to the cutoff-Dmv-cc(～20 μm).Compared with tMVD,larger fraction of mMVD(80%vs 2.9%)was with significant role for overall survival(OS)with improved AUC of ROC curve(0.74 vs 0.56).High mMVD was an independently positive indicator of OS and progression-free survival(PFS).In contrast,tMVD was only related to PFS at its optimal cutoff.The SnMVA(range,0.00393 × 10-6 to 0.259 × 10-6;median 0.0441 × 10-6)and MVA(range,0.00393 to 0.172;median,0.0228)were evaluated.Higher fraction of SnMVA(58.0%for OS and 31.9%for PFS)was significantly related to survival compared with MVA(11.1%for OS and 4.1%for PFS).Despite of cutoff setting,SnMVA was a positive indicator for OS(p≤0.046)and PFS(p≤0.057),with independence being tested in OS(p≤0.036)and PFS(p≤0.002)multivariate analysis.By contrast,MVA was only significant to OS at optimal cutoff in univariate analysis(p= 0.011).Most of intratumor microvessels were flattened with a median TMAR of 3.65(range,2.43-6.28).Patients were stratified into high TMAR group(TMAR ≥3.6)and low TMAR group(TMAR<3.6).Kaplan-Meier survival analysis showed that the high TMAR group had significantly shortened OS than the low TMAR group(p<0.001).A shorter median PFS was observed in high TMAR group compared with low TMAR group(HR=2.06,95%CI:1.51-2.62).In multivariate analysis including various clinicopathologic factors,high TMAR independently predicted poor OS and PFS(OS:HR = 4.53,95%CI:1.70-12.06;PFS:HR-1.95,95%CI:1.04-3.68).A wide-range of collapse-microvessel fraction was observed in 96 patients(1.4-70%)with a median value of 12.8%.The collapse-microvessel ratio was related to the histology and tumor differentiation of patients.The optimal cutoff-value of collapsed ratio to predict survival was 6.5%,and high collapse ratio(≥6.5%)indicated remarkably high risk of death compared with low collapse ratio eithor in univarate analysis(HR = 4.11,95%CI:1.74-9.71,p = 0.036)or multivariate analysis(HR＝7.13,95%CI:1.60-31.82,p=0.010).ConclusionWe conclude that various extent of Dmv-cc,mMVD,SnMVA,TMAR,and collapse-microvessel fraction were all strongly associated with poor survival of NSCLC patients.