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Cellular and Molecular Biology

Extranodal extension in lung adenocarcinoma: pathological insights and its implication as a histological marker of clinical aggressiveness

British Journal of Cancer (2025)Cite this article

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Abstract

Background

Extranodal extension (ENE) is a recognized adverse prognostic factor in several malignancies, but its pathological basis and clinical significance in lung adenocarcinoma (LUAD) remain poorly understood.

Methods

We retrospectively analyzed 105 patients with N1/N2 LUAD who underwent anatomical resection between 2016 and 2020. AI-assisted image analysis quantified tumor-infiltrating lymphocytes (CD8 + , FoxP3 + ), tumor-associated macrophages (CD204 + ), and cancer-associated fibroblasts (CAFs; podoplanin + ) and measured areas of cancer cells and fibrous stroma. In vitro, the effect of CAF quantity on A549 cell invasion was evaluated. Prognostic relevance of ENE was assessed using multivariate and cumulative incidence analyses.

Results

While primary tumors showed no significant differences in immune or stromal composition, ENE-positive metastatic nodes exhibited a markedly larger fibrous stroma area than ENE-negative nodes (14.2 vs. 4.0 mm², p < 0.001). In vitro, the invasion distance of A549 cells increased when cocultured with higher numbers of CAFs. Clinically, ENE independently predicted poorer overall survival (p = 0.04) and was associated with a higher incidence of distant metastasis in both multivariate (p = 0.03) and cumulative incidence analyses (p = 0.02).

Conclusions

ENE represents a pathological prognostic factor characterized by abundant fibrous stroma. It independently predicts distant metastasis and may warrant consideration as a qualitative parameter in N classification for lung adenocarcinoma.

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Fig. 1: Immunostaining and artificial intelligence (AI)-assisted quantification of the primary tumor.
Fig. 2: Area quantification and comparison of cellular and stromal components between extranodal extension (ENE)+ and ENE− groups in primary tumors and metastatic lymph nodes (MLNs).
Fig. 3: In vitro invasion assay.
Fig. 4: Survival and recurrence outcome based on extranodal extension (ENE) status.

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Data availability

The datasets generated and/or analyzed during the current study are not publicly available due to institutional and ethical restrictions, but are available from the corresponding author upon reasonable request.

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Acknowledgements

We appreciate Yuzuri Hasegawa and Mika Narikiyo for their technical support in IHC procedures. We also thank Editage (www.editage.jp) for improving the manuscript’s English clarity.

Funding

This study was supported in part by National Cancer Center Research fund (2023-J-01) and JSPS KAKENHI (Grant number: 21H02931).

Author information

Authors and Affiliations

  1. Department of Pathology and Clinical Laboratories, National Cancer Center Hospital East, Kashiwa, Chiba, Japan

    Shunta Tsuchida, Tetsuro Taki, Kazushi Suzuki, Hiroko Hashimoto, Yukiko Sasahara, Michiko Nagamine, Shingo Sakashita, Naoya Sakamoto & Genichiro Ishii

  2. Department of Thoracic Surgery, National Cancer Center Hospital East, Kashiwa, Chiba, Japan

    Shunta Tsuchida, Kotaro Nomura, Shoko Kubota, Tomohiro Miyoshi, Kenta Tane, Yuki Matsumura, Joji Samejima, Keiju Aokage & Masahiro Tsuboi

  3. Graduate School of Medicine, Juntendo University, Tokyo, Japan

    Shunta Tsuchida

  4. Department of Pathology, Yamagata University Faculty of Medicine, Yamagata, Japan

    Kazushi Suzuki

  5. Biostatistics Division, Center for Research Administration and Support, National Cancer Center Hospital East, Kashiwa, Japan

    Masashi Wakabayashi

  6. Division of Pathology, Exploratory Oncology Research and Clinical Trial Center, National Cancer Center, Kashiwa, Japan

    Shingo Sakashita & Naoya Sakamoto

  7. Department of General Thoracic Surgery, Juntendo University School of Medicine, Tokyo, Japan

    Kenji Suzuki

  8. Division of Innovative Pathology and Laboratory Medicine, Exploratory Oncology Research and Clinical Trial Center, National Cancer Center, Chiba, Japan

    Genichiro Ishii

Authors
  1. Shunta Tsuchida
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Contributions

ST: Writing—original draft, Methodology, Investigation. TT: Writing—review & editing, Investigation. KN: Writing—review & editing, Resources. KS: Writing—review & editing, Investigation. HH: Investigation. SK: Writing—review & editing, Resources. TM: Writing—review & editing. KT: Writing—review & editing. YM: Writing—review & editing. JS: Writing—review & editing. KA: Writing—review & editing. MW: Methodology, Formal analysis. YS: Writing—review & editing. M.N.: Writing—review & editing. SS: Writing- review & editing. NS: Writing—review & editing. KS: Writing—review & editing. MT: Writing—review & editing. GI: Supervision, Writing—review & editing, Funding acquisition.

Corresponding author

Correspondence to Genichiro Ishii.

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Competing interests

Dr. Nomura has received honoraria for lectures from AstraZeneca, Chugai Pharmaceutical Co., Ltd., and Takeda Pharmaceutical Co., Ltd.; honoraria for manuscript writing from Taiho Pharmaceutical Co., Ltd., Nipponrinshosha Co., Ltd., and MedPeer, Inc.; and support for attending meetings and travel from the Chugai Foundation for Innovative Drug Discovery Science. Dr. Wakabayashi has received honoraria for lectures from Nihon Medi-Physics Co., Ltd. Dr. Samejima has received honoraria for presentations from Johnson & Johnson, Osaka Chamber of Commerce and Industry, MiRXES Japan, Taiho Pharmaceutical Co., Ltd., Ziosoft, Olympus, and Japan Blood Products Organization. Dr. Aokage has received honoraria for lectures and/or manuscript writing from various pharmaceutical and medical companies, including AstraZeneca, Chugai, Daiichi Sankyo, Taiho, and others. Dr. Tsuboi has received honoraria for lectures from Johnson & Johnson, AstraZeneca, Chugai, and other pharmaceutical companies. Dr. Ishii has received honoraria for lectures from Roche Diagnostics, Chugai, Novartis, and others. All other authors declare no competing interests.

Ethics approval and consent to participate

This study was approved by the Institutional Review Board of the National Cancer Center Hospital East (approval numbers: 2020-147, 2020-226, and 2024-048), and was conducted in accordance with the Declaration of Helsinki. Comprehensive informed consent was obtained from all study participants.

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Tsuchida, S., Taki, T., Nomura, K. et al. Extranodal extension in lung adenocarcinoma: pathological insights and its implication as a histological marker of clinical aggressiveness. Br J Cancer (2025). https://doi.org/10.1038/s41416-025-03272-2

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