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Improving Lung Cancer Survival Time to Move On . Heuvers E arlies arlies M Time to move on NG LUNG CANCER CANCER LUNG NG I VAL I IMPROV SURV Marlies E. Heuvers IMPROVING LUNG CANCER SURVIVAL Time to move on Improving lung cancer survival; Time to move on Marlies E. Heuvers ISBN: 978-94-6169-388-4 Improving lung cancer survival; time to move on Thesis, Erasmus University Copyright © M.E. Heuvers All rights reserved. No part of this thesis may be reproduced, stored in a retrieval system of any nature, or transmitted in any form or by any means without permission of the author. Cover design: Lay-out and printing: Optima Grafische Communicatie, Rotterdam, The Netherlands Printing of this thesis was kindly supported by the the Department of Respiratory Medicine, GlaxoSmithKline, J.E. Jurriaanse Stichting, Boehringer Ingelheim bv, Roche, TEVA, Chiesi, Pfizer, Doppio Rotterdam. Improving Lung Cancer Survival; Time to move on Verbetering van de overleving van longkanker; tijd om verder te gaan Proefschrift ter verkrijging van de graad van doctor aan de Erasmus Universiteit Rotterdam op gezag van de rector magnificus Prof. dr. H.G. Schmidt en volgens besluit van het College van Promoties. De openbare verdediging zal plaatsvinden op 11 juni 2013 om 13.30 uur door Marlies Esther Heuvers geboren te Hoorn Promotiecommissie Promotor: Prof. dr. H.C. Hoogsteden Copromotoren: dr. J.G.J.V. Aerts dr. J.P.J.J. Hegmans Overige leden: Prof. dr. R.W. Hendriks Prof. dr. B.H.Ch. Stricker Prof. dr. S. Sleijfer Ingenuas didicisse fideliter artes emollit mores, nec sinit esse feros. Ovidius, Epistulae ex Ponto 2.9.47 CONTENTS PART I GENERAL INTRODUCTION AND OUTLINE OF THE THESIS Chapter 1 General introduction lung cancer 11 Chapter 2 Aims and outline of the thesis 27 Chapter 3 Improving lung cancer survival; time to move on 31 PART II EVALUATING THE ROLE OF LUNG CANCER SCREENING Chapter 4 Generalizing lung cancer screening results 43 Chapter 5 Generalizability of results from the National Lung Screening Trial 47 PART III THE CONTRIBUTION OF THE IMMUNE SYSTEM IN LUNG CANCER Chapter 6 Patient-tailored modulation of the immune system may 57 revolutionize future lung cancer treatment Chapter 7 Elevated ILT3 expression on myeloid-derived suppressor cells in 83 peripheral blood of patients with non-small cell lung cancer Chapter 8 Arginase-1 mRNA expression correlates with myeloid-derived 99 suppressor cell levels in peripheral blood of patients with non-small cell lung cancer Chapter 9 Pre-treatment immune profile correlates to performance status 119 and stage of the disease of patients with non-small cell lung cancer Chapter 10 History of tuberculosis as an independent prognostic factor for 135 lung cancer survival PART IV GENERAL DISCUSSION AND SUMMARY Chapter 11 General discussion and summary 151 Dutch summary (Nederlandse samenvatting) 167 Acknowledgements (Dankwoord) 175 About the author 181 List of publications 185 PhD Portfolio 189 Part I General introduction and outline of the thesis Chapter 1 General introduction lung cancer Chapter 2 Aims and outline of the thesis Chapter 3 Improving lung cancer survival; time to move on Chapter 1 General introduction lung cancer General introduction lung cancer 13 GENERAL INTRODUCTION 1.1 Lung cancer In 1761, lung cancer was first described as a distinct disease based on autopsies by Giovanni Morgagni.1 In 1810, Gaspard Laurent Bayle described lung cancer in more detail in his book entitled Recherches sur la phthisie pulmonaire.2 At that time it was an extremely rare disease; in 1878, malignant lung tumors included only one percent of all cancers discovered during autopsies at the Institute of Pathology of the University of Dresden in Germany. Nowadays lung cancer is the major cause of cancer deaths worldwide.3 There are two major groups of lung cancer: non-small- cell lung cancer (NSCLC) and small-cell lung cancer, accounting for approximately 85% and 15% of lung cancer cases, respectively.3 NSCLC can be divided into four histological subtypes: squamous cell carcinoma, adenocarcinoma, large cell lung carcinoma and undifferentiated NSCLC. Squamous cell carcinoma mostly develops from bronchial epithelial cells in the central airway, while most tumors that are not related to smoking, like adenocarcinoma, develop from basal bronchial cells and type II pneumocytes and arise in the more peripheral parts of the lung.4 Although the subdivision of NSCLC has no direct treatment consequences in lim- ited disease, in advanced disease treatment choices depend on these histological differences.5 The 5-year survival of lung cancer is 73% for localized NSCLC and only 13% for metastasized disease.6 One of the reasons for this extremely poor survival is that most lung cancer cases are diagnosed at an advanced stage due to the relative lack of clinical symptoms during early stages. Metastatic NSCLC is currently an incurable disease for which standard chemotherapy provides only minor improvement in over- all survival. Less than 30% of unselected patients with advanced-stage NSCLC have a clinical response to platinum-based chemotherapy, which is in general considered to be the most effective first line treatment at this stage of the disease.7 1.2 Prognostic factors of lung cancer 1.2.1 Stage of disease Stage of lung cancer is an important prognostic factor. The 5-year survival rates sig- nificantly differ between the different subgroups (Table 1). The stage of lung cancer is determined based on the characteristics of the 7th revised tumor, node and metastases (TNM) criteria, established by the International Associations for the Study of Lung Cancer (IASLC) (Table 2). These criteria have defined four major stages of lung cancer. The TNM classification can be subdivided in the clinical TNM stage (cTNM) and the pathological TNM stage (pTNM). The cTNM is based on the results of a chest X-ray, 14 Chapter 1 Table 1 Survival of non-small cell lung cancer according to stage of the disease70-72 Lung cancer stage Median survival (months) 5-year survival (%) IA 59 73 IB 48 58 IIA 30 46 IIB 24 36 IIIA 14 24 IIIB 9 9 IV 4 13 Table 2 Lung cancer staging according to the TNM descriptor and subgroups71,73 T/M Detailed T/M N0 N1 N2 N3 T1 (< 2 cm) T1a IA IIA IIIA IIIB T1 (> 2-3 cm) T1b IA IIA IIIA IIIB T2 (> 3-< 5 cm) T2a IB IIA IIIA IIIB T2 (> 5-7 cm) T2b IIA IIB IIIA IIIB T2 (> 7 cm) T3 IIB IIIA IIIA IIIB T3 invasion IIB IIIA IIIA IIIB T4 (same lobe nodules) IIB IIIA IIIA IIIB T4 (extension) T4 IIIA IIIA IIIB IIIB M1 (ipsilateral lung) IIIA IIIA IIIB IIIB T4 (pleural effusion) M1a IV IV IV IV M1 (contralateral lung) IV IV IV IV M1 (distant) M1b IV IV IV IV computer tomography (CT) scan of the chest and upper abdomen, a fluorodeoxyglu- cose- positron emission tomography (FDG-PET) scan, and/or a magnetic resonance imaging (MRI) of the brain, while the pTNM is based on the pathological results of a surgical resection. Because the latter is most accurate, there can be differences between cTNM and pTNM. Treatment options are determined based on the stage of the disease. 1.2.2 World Healthy Organisation (WHO) performance status WHO performance status is next to the stage of lung cancer the most pivotal inde- pendent prognostic factor.8 It runs from 0 to 5, with 0 denoting perfect health and 5 death (Table 3). The 5-year survival rates are significantly different between the five categories.9,10 From this it can be concluded that patients will benefit from a diagnosis of lung cancer in an asymptomatic stage. General introduction lung cancer 15 Table 3 WHO performance score9 WHO-score Description 0 Asymptomatic (Fully active, able to carry on all activities without restriction) 1 Symptomatic but completely ambulatory (Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature) 2 Symptomatic, <50% in bed during the day (Ambulatory and capable of all self care but unable to perform any work activities) 3 Symptomatic, >50% in bed, but not bedbound (Capable of only limited self-care) 4 Bedbound (Completely disabled. Not able to perform any self-care) 5 Death 1.3 Pathogenesis of lung cancer 1.3.1 Risk factors The most important risk factor for NSCLC is smoking, which account for approxi- mately 85% of all lung cancer cases.11 In 1929, the German physician Fritz Lickint already recognized the link between smoking and lung cancer, which led to an aggressive anti-smoking campaign. However, the first major epidemiological study about the link between lung cancer and smoking was published by sir Richard Doll and sir A. Bradford Hill in 1956.12 Smoking causes all types of lung cancer but is most strongly correlated with small-cell lung cancer and squamous-cell lung cancer. Adenocarcinoma is the most common type in never smokers.13 Environmental factors and genetic susceptibility interact to influence carcinogen- esis. Lung tissue injury, from tobacco smoke or other environmental factors, such as asbestos, initially occurs in the form of genetic and epigenetic changes, like muta- tions, loss of heterozygosity and promotor methylation. This can lead to changes in the lung tissue, such as inflammation. These changes can persist long term and can eventually lead to aberrant pathway activation and cellular function, like dysregu- lated proliferation and apoptosis. This can cause premalignant changes, including dysplasia and clonal patches and can eventually lead to angiogenesis, invasion and early-stage cancer.14,15 1.3.2 Genetic risk factors Epidemiologic studies show an association between family history and increased risk of lung cancer. Consequently, multiple studies have been performed on inherited predisposition to lung cancer including study of polymorphisms associated with lung cancer risk and familial linkage studies.
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