Annals of Oncology 9: 247-250, 1998.
© 1998 Kluwer Academic Publishers. Printed in the Netherlands.
Review
Does bone marrow involvement affect prognosis in small-cell lung cancer?
F. Pasini,1 G. L. Cetto1 & G. Pelosi2
l
Cattedra di Oncologia Medica, Universila di Verona; 2Servnio di Analomia Patoiogica, Ospedale Civile Maggiore, Verona. Italy
Key words: bone marrow involvement, monoclonal antibodies, prognosis, small-cell lung cancer
Small-cell lung cancer (SCLC) is a highly aggressive
tumor and most patients have disseminated disease at
the time of diagnosis. Responses to both standard and
high-dose chemotherapy are of only brief duration, and
the long-term survival rate is disappointing. One probable cause of treatment failure is the frequent involvement of bone marrow by tumor cells. In fact, with the
advent of monoclonal antibodies (MoAbs) it has become clear that tumor cells are far more often present
than was previously shown by cyto-histomorphological
methods, and recent reports have also suggested that
bone marrow involvement has clinical relevance.
This article reviews the principal studies of the prognostic value of bone marrow involvement in SCLC.
poor outcome. This finding, however, probably reflects
the presence of advanced disease with heavy marrow
involvement. Other studies failed to find relevant correlations with the hematologic values [10, 11, 14] or with
the ability to deliver chemotherapy [8, 11, 17]. The poor
prognosis of patients with bone marrow metastases was
also confirmed by some studies [12-16], but not by
others [3, 7-9, 11]. Moreover, when patients with extensive disease were analyzed separately according to the
positivity or negativity of the biopsy [2, 7-9, 10-12, 16,
17], in only some of the studies [2, 8, 12, 16, 17] were
bone marrow metastases predictive of poorer outcome.
Conventional morphological methods were therefore
of no great help in improving the staging system in order
to identify subsets of patients with different prognoses.
Conventional histological and cytological methods
Immunostaining
Retrospective studies have demonstrated that conventional histological and cytological methods can identify
bone marrow localization in 6%-30% of cases [1-18].
Most of these patients presented widespread disease [712, 14], since bone marrow infiltration was rarely the only
site of metastasis outside the lung, with 2% to 9% of the
patients being staged as having extensive disease on the
basis of bone marrow findings only [5, 8, 9-12, 14, 18-20].
Tumor cell detection is likely to be linked to the yield
of the material, which in turn depends on the technical
procedure used. Some studies supported the bilaterality
of the specimens [19], in contrast to others which maintained that unilateral examination is adequate [3, 4].
The role of aspiration was also a matter of debate [4, 11,
14, 17, 19, 20], but only two reports [17, 19] found the
aspirate superior to conventional biopsy. The differences
in aspiration technique (clots or smears) and in the
length/volume of the biopsy specimens, mainly due to
the type of needle used, probably explain these contradictory findings.
Hirsch et al. [2] demonstrated that prognosis and
response were significantly worse in the subgroup with
positive bone marrow biopsy and that thrombocytopenia
(< 135,000/mm3) at onset, although rare, heralded very
Since the advent of MoAbs made it possible to detect a
small number of tumor cells otherwise not identifiable,
numerous studies, conducted on cytospins of bone marrow aspirate, have demonstrated a percentage of involvement higher than that previously found with morphological methods. Generally the detection of bone marrow involvement depends on the characteristics of the
individual MoAb, the cross reactions with normal haemopoietic cells and the methods of investigation (i.e.,
immunocytochemistry or immunofluorescence). Three
international workshops grouped many of these MoAbs
into clusters on the basis of their pattern of reactivity on
normal and cancer tissues [21-23]. To date, however,
only some of these MoAbs have been studied in relation
to clinical outcome.
The antigen recognized by the cluster 1 MoAbs is the
neural cell adhesion molecule (NCAM/CD56) which is
expressed on a variety of tissues at an early stage of
embriogenesis and, as development proceeds, on neuro.ectodermal tissues. NCAM is a family of cell-surface
glycoproteins and the molecule, which is mainly represented by three isoforms of 180, 140 and 129 kDa, is
believed to be involved in cell-cell interaction [24].
248
The serum levels of the molecule were [25, 26] found
to be raised in SCLC patients with advanced or relapsing disease, and may therefore be associated with prognosis. However, the finding can be interpreted in different ways: we described that NCAM serum levels were
higher in patients with immunocytochemical bone marrow involvement than in those with negative aspirate,
whereas the percentage of extensive disease was similar
in the two groups. We suggested that this subset of
patients might have peculiar biological characteristics
such as a greater tendency for infiltration of bone marrow [27]. Whether the presence of immunocytochemicalpositive cells is simply part of a disseminated disease or
reflects the behavior of a particular biological subgroup is
unknown; the topic was addressed in a previous report
[28]. Using a panel of seven MoAbs against clusters 1 and
2, cytokeratins and epithelial antigens, it was reported
that the presence of residual marrow disease at clinical
remission predicts early metastatic relapse. Tumor cells
were in fact detected in the marrow of eight of the 12
patients found free of disease by conventional staging
procedures, and six of these eight relapsed within very
few months.
Using MoAbs directed against NCAM on bone marrow aspirate of SCLC patients, the positivity rate in
general ranges between 30% and 50%.
In three series, tumor cells were identified with a panel
of MoAbs [29, 30], or with a single MoAb (MOC-1) [31],
in the aspirate of 43%-75% of the patients and in 55% of
the patients with limited disease. One of these studies
showed that early systemic relapse was more likely to
occur in patients with immunocytologically-positive
bone marrow at restaging after chemotherapy [30].
Trillet et al. [32] found a positivity rate of 36% (12 of
33 patients) with the MoAbs UJ13A and 11.14; adding
this percentage to the results obtained with magnetic
resonance imaging, the detection rate of bone marrow
involvement was raised to 54%.
Recently Beiske et al. [6] reported that bone marrow involvement was present in 32% of the cases (26
of 81 patients), with one-third of the positive cases detected only by immunocytochemistry; however, these
two studies do not report clinical data on survival or
response to treatment.
We have described [33, 34], with two anti-NCAM
MoAbs (NCC-LU-243 and NCC LU-246) in immunocytochemistry, the presence of positive cells in the aspirate of 40%-53% of patients and in about 45% of those
with limited disease. Moreover, these data seem to have
prognostic value, since these patients with 'untrue'
limited disease had shorter survival. We showed that
patients with limited disease and an absence of tumor
cells in the aspirate had a considerable survival advantage over those with positive apirate (16 vs. 7 months).
Similar data were reported by Bucher et al. [35] who
examined 98 patients; of the 53 with limited disease, 45%
had positive aspirate. Among patients with limited disease, median survival of those with no tumor cells in the
aspirate was 703 vs. 303 days for those with positive cells.
In other words, the immunocytochemistry of the
aspirate appears to be useful in selecting a subset of
patients with a better prognosis.
To our knowledge, cluster 2 MoAbs have been used
only inside panels [29, 30], and the cluster 4 antigen has
been unsuccessfully targeted in an imaging study [36];
thus these groups of MoAbs do not seem at present to be
potentially useful in a clinical setting.
The antigen recognized by cluster 6 MoAbs is present
on a variety of glycoproteins and glycolipids carried on
the cell membrane of SCLC as well as on other tumors.
The MoAb MLuCl, previously known as MOvl5, recognizes the Ley blood group antigen which is present in
higher amounts on SCLC cells than on other tumor and
normal lung cells. This difference may explain both the
higher sensitivity of SCLC cell lines to immunotoxins
with this MoAb than with normal cell lines bearing the
Y apten [37], and why this MoAb was deemed suitable
for the identification of SCLC cells in bone marrow.
Moreover, the cross-reactivity of MLuCl with normal
haemopoietic cells was reported to be negligible [38].
Menard et al. [39], using this MoAb with immunofluorescence, found positive cells in 10 of 30 patients
(33%) and six of these 10 positive patients were negative at conventional histology. Although the issue of
prognosis was not specifically addressed, the study reported that of seven patients with positive pre-treatment
aspirate, six became negative after induction chemotherapy.
With the same antibody in immunocytochemistry, we
confirmed a similar percentage of positivity [40]. Later,
in a larger series of 60 unselected patients, we demonstrated that the presence of clusters or more than 10
cells was associated with an extremely poor prognosis
(median survival about six months), statistically shorter
than that of negative patients. However, it was not
possible to determine the outcome of the patients with
few (< 10) contaminating cells because of the small
cohort. It remains unclear whether the few cells were
simply in-transit cells or had some clinical role, although
many of these cells co-expressed the associated proliferation antigen Ki-67, suggesting clonogenic potentiality
(unpublished).
Two studies with immunofluorescence [41, 42] reported a positivity rate of 38% and 69%, and in 26% and
50%, respectively, of the patients with limited disease.
The prognostic significance of bone marrow positivity
was not examined by the authors, who, however, speculated about the use of MoAbs for selecting negative
patients for new therapeutic strategies such as highdose chemotherapy with the support of bone marrow
transplantation.
A panel of seven MoAbs against epithelial antigens
and cytokeratins was utilized by Skov et al. [43] on clots
obtained from bone marrow aspirate. Although immunocytochemistry did not improve the detection of tumor
cells over conventional morphological examination, it
was found that patients with negative bone marrow had
statistically significantly longer survival. On the other
249
hand, the positivity rate has probably been underestimated by the use of paraffin embedded clots.
As previously reported [31, 33-35, 40, 42], by acceptance of the immunocytochemical positivity of bone marrow as one of the staging criteria, the percentage of
extensive disease would sharply increase by a factor of
50% (from 40%-50% to about 75%).
It has also been shown that the leukapheresis product,
after mobilization of peripheral blood progenitor cells
with chemotherapy and G-CSF, was contaminated in
patients presenting bone marrow involvement, as detected by the presence of cells reactive to MoAbs anticytokeratins and/or to HEA 125 [44]. The clinical value
of this contamination is unclear, but it certainly raises
concerns.
Contributing further proof of the clinical relevance
ascribed to bone marrow involvement with respect to
treatment response or prognosis are the numerous studies
attempting to achieve an effective purging, both in vitro
and in vivo, of bone marrow. Besides the others, we cite
the experiences of Myklebust et al. who in vitro, with a
panel of MoAbs and immunomagnetic beads [45] or
immunotoxins [46], achieved a six-log separation. Regarding the purging in vivo, there is a growing consensus
about the use of standard chemotherapy for both tumor
debulking and purging before high-dose chemotherapy
[47, 48]; in fact tumor cells were no longer detectable in
bone marrows, previously defined as positive, after a
couple of cycles of conventional chemotherapy [47].
In conclusion: i) in SCLC with the use of MoAbs it
has been shown that a relevant proportion of patients
has bone marrow involvement which seems to be associated with poorer survival; ii) this finding is of particular interest in patients with limited disease iii) in order
to confirm these preliminary results it would be auspicious to include tumor cell detection by means of immunocytochemistry of the aspirate in large prospective therapeutical trials, as recently planned by the EBMT phase
III study comparing standard vs. high-dose chemotherapy i.v.) for this purpose it seems reasonable to suggest
the use of a panel of MoAbs against cluster 1 (NCAM),
cluster 6 and low-molecular-weight cytokeratins.
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Received 17 July 1997, accepted 29 October 1997.
Correspondence to •
Dr. Felice Pasini
Cattedra di Oncologia Medica
Universita di Verona
Piazzale Stefani, 1
37126 Verona
Italy