Cancer Res-2011-Kawada-0008-5472.CAN-10-3277

Published OnlineFirst January 6, 2011.Cancer Res Kenji Kawada and Makoto Mark Taketo Cancer ProgressionSignificance and Mechanism of Lymph Node Metastasis in

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Review

Significance and Mechanism of Lymph Node Metastasis in Cancer Progression

Kenji Kawada and Makoto Mark Taketo

Abstract

The effect of local therapy, such as surgical lymph node (LN) dissection and radiotherapy,

on the survival of cancer patients has been debated for decades. Several lines of recent

clinical evidence support that LN metastasis plays significant roles in systemic

dissemination of cancer cells, although the effects of surgical LN dissection on survival was

downplayed historically because of controversial data. Molecular studies of LN metastasis

suggest that the microenvironment within LNs, including chemokines and

lymphangiogenesis, can mediate the metastatic spread to the sentinel LNs, and beyond. It

has been demonstrated that chemokine receptor CXCR3 is involved in LN metastasis, and

its inhibition may improve patient prognosis. Although it remains to be determined whether

local therapy is best pursued through LN dissection or through a combination of resection

with radiation, prevention of regional metastases is an important goal in the treatment of

cancer patients to achieve a better survival.

Autors’ affiliation: Departments of Surgery and Pharmacology, Kyoto University Graduate

School of Medicine, Kyoto, Japan

Corresponding Author: Makoto Mark Taketo, Kyoto University Graduate School of Medicine

(Pharmacology), Yoshida-Konoé-cho, Sakyo, Kyoto 606-8501, Japan. Phone: +81-75-753-4391;

Fax, +81-75-753-4402; E-mail, [email protected]




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Patients with advanced cancers have a significant risk of local recurrence and distant metastasis

after surgical resections of the primary tumors. Systemic therapy to prevent distant metastasis

has been emphasized to improve the survival of cancer patients, but the effect of local therapy

has been debated for decades, as reviewed by Punglia et al. (1) and summarized below. The most

frequently used strategy to control local recurrence includes radical resection combined with LN

dissection (lymphadenectomy) and local radiation therapy. Regarding local therapy, three clinical

viewpoints have been proposed. In the early last century, William Halsted proposed that breast

cancer is a local disease that spreads primarily in a predictable, stepwise manner from the

primary tumor to the regional lymphatics and then systemically to distant organs (2). Local

regional LNs are the commonest and earliest site of metastasis of solid tumors, and his idea

provided the justification for radical breast-cancer surgery with extended LN dissection (2). In

reaction to the “Halstedian” theory, the “systemic” theory arose. Bernard Fisher and others

proposed the view that breast cancer is a systemic disease from the beginning and that LN

dissection is merely useful for prognostic information, but does not affect overall survival,

suggesting more important role of hematogenous dissemination to vital organs (liver, lungs etc.)

in metastasis (3). Thus, effective systemic therapies were emphasized in breast-cancer treatment,

which indeed helped to improve the overall survival. As a third hypothesis, the “spectrum”

theory balanced these two opposing strategies (4). Cancer cells develop metastatic potential as

tumors grow through their clinical evolution. Accordingly, the LN involvement is of prognostic

importance not only because it indicates a more malignant tumor biology, but also because

persistent disease in LNs can be the source of subsequent fatal metastases. In fact, results of

some recent clinical trials support this notion. Namely, improved local therapy is causally

associated with better overall survival in several types of cancer as exemplified below.

1) Evidence from clinical trials a) Breast cancer: Two (i.e., Canadian and Danish) prospective randomized trials demonstrated

that, after mastectomy, the addition of radiation therapy and adjuvant chemotherapy not only

decreased local recurrence but also improved overall survival, indicating that local treatment

prevents recurrence from generating fatal metastases (5, 6). A recent meta-analyses also

presented the findings from 78 randomized clinical trials that improved local control during first




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5 years resulted in a statistically significant improvement in the overall survival at 15 years, and

that the survival benefit was similar either by extensive surgery or by radiation therapy (7).

With the widespread introduction of the sentinel LN biopsy procedure, the question was

raised about how to deal with potential and additional LN metastases in case of a positive

sentinel LN. Micrometastases in regional LNs were associated with a reduced disease-free

survival with early-stage breast cancer (8). To investigate differences in regional control, survival,

and long-term morbidity between axillary LN dissection and radiation therapy, an international

multicenter phase III trial was initiated in 2001, and is still ongoing (9).

b) Gastric cancer: The need for radical LN dissection for curative treatment of gastric cancer

continues to be debated. Two large randomized trials from the Netherlands and UK that

compared the less extended D1 dissection (lymphadenectomy limited to the perigastric LNs)

with the D2 dissection (lymphadenectomy extended to hepatic, gastric, cardiac and splenic LNs )

failed to show a survival benefit for the D2 procedure (10, 11). In these studies, however, lack of

experience with the surgical skills and postoperative care appeared responsible for the high

morbidity (~45%) and mortality (~12%) of the patients who underwent D2 dissection (Table 1).

The American Intergroup study showed that chemoradiotherapy after no or limited

lymphadenectomy (D0 or D1 dissection) decreased the local recurrence rate and increased

overall survival, suggesting that chemoradiotherapy eliminated the residual LN metastases that

could be removed by D2 dissection (12). In 2006, a prospective randomized trial in Taiwan

showed a significant benefit in overall survival for a D2 dissection over D1 alone, without

increased operative mortality (13). In this trial, all the surgeons had already performed at least 80

D2 operations, and there were no deaths in either group (Table 1). In a surgical trial to compare

two different operative methods, participating surgeons should be experienced equally in both

techniques. These results suggest that adequate local treatment is essential for effective treatment

of gastric cancer.

In 2008, a prospective randomized trial in Japan showed no improvement in overall

survival with D2 dissection plus para-aortic nodal dissection (PAND) as compared with D2 alone.

This trial was performed by experienced surgeons in 24 specialized hospitals with a high volume

of cases, and resulted in very low mortality rates (0.8%) and good long-term survival in both




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groups (14). The result may suggest that para-aortic LN metastasis is a systemic, not local,

disease, and that PAND is an unworthy and excessive procedure against advanced gastric

cancers.

c) Rectal cancer: In the United States, extended LN dissection in rectal cancer was performed in

the 1950s, but the effectiveness of lateral pelvic LN dissection was not accepted because it led to

an increase in blood loss, and urinary and sexual dysfunctions without further survival benefit

(15). Preoperative radiotherapy reduced the relative risk of local recurrence, although without

significant survival improvement (16, 17). Although a recent meta-analysis comparing extended

and non-extended lymphadenectomy of the lateral pelvic LN showed no overall difference in

cancer-specific outcome (18), this study has limitations such as varying protocols, different

levels of surgical expertise, different patient populations and different time periods. In many

Western countries, current standard therapy for lower rectal cancer is total mesorectal excision

(TME) with preoperative radiotherapy.

In Japan, on the other hand, lateral pelvic LN dissection has been performed extensively

along with TME in advanced rectal cancer, which contributed to the reduced local recurrence and

improved survival in retrospective multicentre studies (19). A retrospective analysis suggests that

lateral pelvic LN dissection can be equivalent to the preoperative radiotherapy in terms of the

curative effect for patients with lower rectal cancers (20). It is worth noting that a phase III

prospective randomized trial is ongoing, assessing the effectiveness of lateral pelvic LN

dissection (JCOG 0212).

Similar situations have been reported for lung cancer (21), endometrial cancer (22) and

esophageal cancer (23, 24). In stage I-IIIA non-small cell lung cancer, a meta-analysis of

randomized controlled trials suggests that complete mediastinal LN dissection is associated with

improved survival (21). In endometrial cancer, comparative cohort study reports that para-aortic

LN dissection (PAND) has survival benefits, and that pelvic LN dissection alone might be an

insufficient surgical procedure for patients at intermediate or high risk of recurrence (22). In

adenocarcinoma of the esophagus, one randomized controlled trial suggests that in patients with

1 to 8 metastatic LNs, extended transthoracic esophagectomy with en bloc LN dissection results




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in improved 5-year survival compared with limited transhiatal resection (23). On the other hand,

in pancreatic cancer, 3 randomized controlled trials suggest that extended LN dissection does not

result in survival benefit (25-27). Although there is no doubt that the presence of LN metastases

worsens prognosis of a patient, unambiguous evidence to support LN dissection is still lacking.

For many solid tumors, the role of LN dissection is yet controversial, and may depend on the

tumor type and the stage of patient presentation for diagnosis. Namely, cancers of the breast,

colon and stomach are often diagnosed as local diseases, whereas pancreatic cancer is found after

they have progressed to the systemic diseases. Accordingly, well-designed randomized controlled

trials are required to evaluate the systemic vs. local therapy in a scientific manner.

2) Molecular mechanisms of LN metastasis Cancer metastasis appears to form through a chain of events where organ selectivity by the tumor

cells is largely determined by physical factors (blood and lymph flows) and biological molecules

that are expressed in the tumor microenvironment. As described above, several lines of evidence

are beginning to show that LN metastasis not only provides the prognostic information, but also

plays active roles in developing distant metastases to the vital organs, causing eventual lethality.

However, little is known about its molecular mechanisms. Questions remain whether tumor cells

are trapped by LNs, causing a lag phase in tumor dissemination, whether LN metastases just

serve as evidence of tumor cell transit through the LNs, or whether the LNs promote spreading

of the tumor cells by amplifying them and serving as a launch pad for further systemic metastasis

(28, 29). As the lymph flows into the systemic circulation through the thoracic duct or

lymphovascular shunts, LN metastasis can be regarded as a side loop of the hematogenous

metastasis circuit.

Recent studies suggest that the least efficient steps in metastasis are the survival and

growth of the micrometastatic foci and their persistence that affect colonization, indicating the

importance of interactions between the ‘seed’ (cancer cell) and ‘soil’ (microenvironment). Of the

different components that affect the organ selectivity, instrumental roles have been attributed to

interactions between chemokine receptors on cancer cells and their ligands in the target organs

(30). To date, several sets of chemokines and their receptors have been suggested to play

important roles in the matastatic organ selectivity, and one of the best-studied examples is the




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CXCL12-CXCR4 axis in breast cancer metastasis to the bone. Regarding the direct role of

chemokines in LN metastasis, recent reports suggest critical roles for CXCR3, CXCR4 and

CCR7 (31-34). Importantly, these three receptors are involved in the recruitment and patterning

of several types of immune cells to LNs, suggesting that cancer cells often acquire these

receptors and are controlled by their ligands in a manner analogous to the immune cell

interactions.

Although early studies to describe chemokine receptors and melanoma or breast cancer

did not detect receptor CXCR3, it has been demonstrated recently that CXCR3 plays the critical

role in LN metastasis of melanoma and colon cancer cells, but not in their hematogenous

metastasis (31, 32). Upon construction of B16F10 mouse melanoma cell derivatives with

reduced CXCR3 expression by antisense RNAs, their metastatic activities have been investigated

after subcutaneous inoculations into mouse footpads. The metastatic frequency of these cells to

popliteal LNs was markedly reduced compared with control B16F10 cells, without affecting

hematogenous metastasis to the lung or liver. In addition, human colon cancer cells were

constructed that expressed CXCR3 cDNA (DLD-1-CXCR3), and compared with controls by

rectal transplantation in nude mice. In 6 weeks, 59% of mice inoculated with DLD-1-CXCR3

showed macroscopic metastases in para-aortic LNs, whereas only 14% of those did with the

control. Metastasis to the liver or lung was rare, and unaffected by CXCR3 expression.

In 92 human colon cancer specimens, expression of CXCR3 was found in 31 (33.7%)

cases, most of which had LN metastasis (32). Importantly, the patients with CXCR3-positive

colon cancer showed significantly shorter survivals than those without CXCR3. The patients

with CXCR4-positive tumors also had a significant poorer prognosis, but its effect was less than

that of CXCR3. In addition, the patients with tumors double positive for CXCR3 and CXCR4

had a significantly poorer prognosis than those with tumors positive only for CXCR4 or the

double negatives (Figure 1). In breast cancer, high CXCR3 expression has also been reported to

be associated with poorer prognosis (35). These results demonstrate that activation of CXCR3

stimulates cancer metastasis preferentially to the draining LNs with poorer prognosis,

implicating a critical role of LN metastasis in overall patient survival (32).

More results have emerged recently in support of the role for CXCR3 in the metastasis

of melanoma and neuroblastoma, and cancers of colon, breast, ovaries, and prostate. Namely,




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several laboratories have provided data that CXCR3 strengthens the invasion-related properties

of cancer (36) and that CXCR3 facilitates lung metastasis of breast and colon cancers (37, 38). In

addition, lymphangiogenesis within the sentinel LNs is also associated with tumor metastasis to

distant sites (39). These results indicate that the microenviornment in LNs, including chemokines

and lymphangiogenesis, can mediate the metastatic spread of tumor cells to the sentinel LNs, and

beyond.

For decades, the oncology community has focused on adjuvant therapies in an effort to

prevent distant metastasis. Although the effects of local recurrence on patient survival was

downplayed, or even denied, prevention of local recurrence is getting to be appreciated as a key

goal for many types of cancer. In the meantime, it is yet to be determined whether regional

treatment of cancer is best pursued through LN dissection or a combination of resection with

radiation. It is also worth noting that economic factors on the health insurance system need to be

evaluated carefully in establishing the therapeutic strategy on metastasis. We should be able to

overcome tumor metastasis with a better understanding of the interplay between the cancer cells

and their microenvironment not only in hematogenous but also LN metastasis.

Acknowledgment. Authors thank Masahiro Aoki for comments on the manuscript. The results

quoted from the authors papers were supported by grants from MEXT, Japan, and by

Littlefield-AACR colon cancer metastasis research grant (to MMT).




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Table 1. Four randomized controlled trials of gastric cancer

No. of 5-year perioperative perioperative participating patients survival rate morbidity mortality surgeons/hospitals

Taiwan trial (13) single hospital 3 experienced surgeons

D2 /D3 111 59.5 %* 17 %** 0 %

D1 110 53.6 % 7 % 0 %

Dutch trial (10) 80 hospitals

D2 331 47 % 43 % ** 10 % **

D1 380 45 % 25 % 4 %

UK trial (11) 33 surgeons

D2 200 33 % 46 % ** 13 % ***

D1 200 35 % 28 % 6.5 %

Japan trial (14) 24 hospitals

D3 (D2+PAND) 259 70 % 28.1 % 0.8 %

D2 263 69 % 20.9 % 0.8 %

* P < 0.05 compared with D1 (log-rank test)

** P < 0.01 compared with D1 (Fisher’s exact test)

*** P < 0.05 compared with D1 (Fisher’s exact test)




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Legend to Figure 1. Survival curve (Kaplan and Meier estimates) by expression of CXCR3 and

CXCR4 in colon cancer (27).







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Cancer Res-2011-Kawada-0008-5472.CAN-10-3277