Preliminary Investigation of the Clinical Significance of Detecting Circulating Tumor Cells Enriched from Lung Cancer Patients Chi Wu, MD, Huaijie Hao,

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Preliminary Investigation of the Clinical Significance of Detecting Circulating Tumor Cells Enriched from Lung Cancer Patients Chi Wu, MD, Huaijie Hao, MS, Longyun Li, MD, Xiaoyun Zhou, MD, Zijian Guo, MD, Li Zhang, MD, Xiaotong Zhang, MD, Wei Zhong, MD, Huiqin Guo, MD, PhD, Ross Macrae Bremner, MD, PhD, Ping Lin, MD, PhD Journal of Thoracic Oncology Volume 4, Issue 1, Pages 30-36 (January 2009) DOI: 10.1097/JTO.0b013e3181914125 Copyright © 2009 International Association for the Study of Lung Cancer Terms and Conditions

FIGURE 1 Blinded validation of the new enrichment strategy by spiking study. Live human lung cancer cells A549 were labeled with 4′-6-diamidino-2-phenylindole (DAPI), followed by trypsinization and washed. The desired number of cells ranging from 5, 10, 20, 50, to 100 (determined under microscope or from series dilution) were spiked into 7.5 ml blood, followed by enrichment procedure. Obtained cells were enumerated under microscope. The plot was obtained from an average of four separate triplicate experiments. The doted line represents initial spiked cell number, and solid line represents the recovered number of cells. Result shows the number of recovered cells is almost identical to cells spiked in the blood. Journal of Thoracic Oncology 2009 4, 30-36DOI: (10.1097/JTO.0b013e3181914125) Copyright © 2009 International Association for the Study of Lung Cancer Terms and Conditions

FIGURE 2 Distribution of circulating tumor cell (CTC) enriched from nontreated lung cancer patients. The new enrichment strategy was applied to isolate CTC from 47 lung cancer patients, including 41 newly diagnosed and 6 recurrent patients before subjected to chemotherapy. The gray dash line indicates 1 cell per 7.5 ml blood as the cutoff point. A cutoff of ≥2 cancer cells per 7.5 ml blood was classified as positive. In 18 healthy donors (HD), only 1 had a positive cell. In 13 of tuberculosis patients (TB), 1 patient had 1 and another had 2 positive cells. In the group of 41 newly diagnosed patients 2 of 3 patients with stage II/II were positive for CTC. Among 18 stage III patients, 13 subjects (including 7 adenocarcinoma [ADC], 3 squamous cell carcinoma [SCC] and 3 small cell lung cancer [SCLC]) were found to be positive, All of the 20 stage IV patients were positive. In the group of 6 recurrent patients, 2 stage III plus 2 stage IV ADC as well as 1 of SCLC (stage III) were positive for CTC detection. Journal of Thoracic Oncology 2009 4, 30-36DOI: (10.1097/JTO.0b013e3181914125) Copyright © 2009 International Association for the Study of Lung Cancer Terms and Conditions

FIGURE 3 Circulating tumor cell (CTC) detection rate of pooled nontreated lung cancer patients. All of nontreated patients including both newly diagnosed and recurrent are classified into stage I–II, III, and IV on each adenocarcinoma (ADC), squamous cell carcinoma (SCC) and small cell lung cancer (SCLC) pathologic types. Sixty-seven percent of ADC I–II (2 of 3), 82% ADC III (9 of 11) and 54% of ADC IV (7 of 13) were positive for CTC (CTC ≥2 cells/7.5 ml blood). The percentage of CTC ≥5 among those CTC ≥2 patients are 50, 56, and 43%, respectively. Among SCC patients, 60% of stage III (3 of 5) were CTC positive with 67% (2 of 3 positive patients) of CTC ≥5. No CTC was detected in 2 of SCC IV patients. In the category of SCLC, 67% (4 of 6) and 71% (5 of 7) patients were CTC positive for stage III and IV, and their CTC ≥5 rate is 50 (2 of 4) and 40% (2 of 5), respectively. Journal of Thoracic Oncology 2009 4, 30-36DOI: (10.1097/JTO.0b013e3181914125) Copyright © 2009 International Association for the Study of Lung Cancer Terms and Conditions

FIGURE 4 Statistical analysis of circulating tumor cell (CTC) counting. A, Newly diagnosed and recurrent patients (all pathologic types): statistical analysis indicates the variation of the number of CTC enriched from different pathologic types at different stages. ADC stages I–II, III and IV have an average counting (Mean, CTCave) of 5, 8.5, and 2.5 cells in 7.5 ml blood, respectively. Squamous cell carcinoma (SCC) III has an CTCave value of 6.5. No detectable CTC is observed in 2 of SCC IV patients. Regarding small cell lung cancer (SCLC) patients, CTCave 3.5 and 10.5 are found on SCLC III and IV, respectively. The recurrent group of patients has highest CTCave value of 11. The significance of difference between health donors (HD) and each of pathologic types is denoted by (*p < 0.05) and (**p < 0.01). B, Pooled newly diagnosed patients: statistical analysis on stage I–II, III and IV patients from pooled various pathologic types of newly diagnosed patients shows that CTCave of stage I–II (n = 2), stage III (n = 13) and stage IV (n = 10) is 5 (*p < 0.05), 7 (***p < 0.0001), and 7 (***p = 0.0005), respectively. Journal of Thoracic Oncology 2009 4, 30-36DOI: (10.1097/JTO.0b013e3181914125) Copyright © 2009 International Association for the Study of Lung Cancer Terms and Conditions

FIGURE 5 Correlation of circulating tumor cell (CTC) counting and computed tomography (CT) scanning with a follow-up study. Correlation of CT scanning and CTC counting was evaluated on a small scale of follow-up study. CTC was enumerated from each patient before chemotherapy started. After two courses of first line chemotherapy, patient CTC was measured, followed by CT examination. Eight of 12 patients (patient 1–8) including 5 adenocarcinoma (ADC), 2 squamous cell carcinoma (SCC) and 1 small cell lung cancer (SCLC) were classified by CT as stable disease. Among those 8 patients, 5 patients dropped their CTC to 0, 1 patient dropped from 21 to 3, 2 patients remained 0, and in 1 patient the count increased from 2 to 3. Three patients had a partial radiologic response: For partial response (PR) patients (patients 9–11), one was noted to have a CTC drop from 52 to 0, while the CTC in the other 2 patients remained below 2. Only one patient was noted to have an increasing CTC, from 2 to 12 after treatment, and this patient was confirmed to have progressive disease (PD). Clinical responses are classified by CT scanning according to the Response Evaluation Criteria in Solid Tumors (RECIST). Journal of Thoracic Oncology 2009 4, 30-36DOI: (10.1097/JTO.0b013e3181914125) Copyright © 2009 International Association for the Study of Lung Cancer Terms and Conditions

FIGURE 6 Visualization of lung cancer circulating tumor cell (CTC). CTC enriched from lung cancer patient was subjected to immunofluorescent (IF) staining (A) for identification of CTC and immunohistochemical (IHC) staining (B) for counter staining. A, Showed that CTC was specifically immunostained with both anti-Cytokeratin (CK) 8/18 and anti-CK 19, but not with anti-CD45 IHC staining as revealed in (B). Nucleus of cells were stained with 4′-6-diamidino-2-phenylindole (DAPI) (A). Only white blood cells (WBCs) were found CD45 positive but CK negative as demonstrated in B. Journal of Thoracic Oncology 2009 4, 30-36DOI: (10.1097/JTO.0b013e3181914125) Copyright © 2009 International Association for the Study of Lung Cancer Terms and Conditions