Significance of microsatellite instability in different types of early-stage nonfamilial colorectal carcinomas

Tracking the molecular features of nonpolypoid colorectal neoplasms: a systematic review and meta-analysis

OBJECTIVES

Nonpolypoid colorectal neoplasms (NP-CRNs) are proposed as a major contributor to the occurrence of interval cancers, but their underlying biology remains controversial. We conducted a systematic review and meta-analysis to clarify the major biological events in NP-CRNs.

METHODS

We systematically searched for studies examining molecular characteristics of NP-CRNs. We performed random effect meta-analyses. We measured the heterogeneity among studies using I(2) and possible publication bias using funnel plots.

RESULTS

Fifty-three studies on KRAS, APC, or BRAF mutations, microsatellite instability (MSI), CpG island methylator phenotype (CIMP), or DNA promoter hypermethylation were included. We observed less KRAS mutations (summary odds ratio (OR) 0.30, confidence interval (CI)=0.19-0.46, I(2)=77.4%, CI=70.1-82.9) and APC mutations (summary OR 0.42, CI=0.24-0.72, I(2)=22.6%, CI=0.0-66.7) in NP-CRNs vs. protruded CRNs, whereas BRAF mutations were more frequent (summary OR 2.20, CI=1.01-4.81, I(2)=0%, CI=0-70.8), albeit all with large heterogeneity. Less KRAS mutations were especially found in NP-CRNs subtypes: depressed CRNs (summary OR 0.12, CI=0.05-0.29, I(2)=0%, CI=0-67.6), non-granular lateral spreading tumors (LSTs-NG) (summary OR 0.61, CI=0.37-1.0, I(2)=0%, CI=0-74.6), and early nonpolypoid carcinomas (summary OR 0.11, CI=0.06-0.19, I(2)=0%, CI=0-58.3). MSI frequency was similar in NP-CRNs and protruded CRNs (summary OR 0.99, CI=0.21-4.71, I(2)=70.3%, CI=38.4-85.7). Data for promoter hypermethylation and CIMP were inconsistent, precluding meaningful conclusions.

CONCLUSIONS

This meta-analysis provides indications that NP-CRNs are molecularly different from protruded CRNs. In particular, some subtypes of NP-CRNs, the depressed and LST-NG, are featured by less KRAS mutations than polypoid CRNs. Prospective, multicenter studies are needed to clarify the molecular pathways underlying nonpolypoid colorectal carcinogenesis and potential implications for surveillance intervals.

Flat adenomas

This article was presented at the conjoint CSSA and RACS (colorectal section) spring meeting Queensland, Australia, September 2004. The adenoma-carcinoma sequence describes a succession of events from polypoid adenoma to colorectal cancer. However, this model only accounts for up to two-thirds of colorectal cancers. There is growing evidence that flat adenomas are precursor lesions to a flat type of colorectal cancer and certain subtypes of these polyps are at greater risk of malignant transformation. If confirmed, the implications for screening, endoscopic recognition and management will become of increasing importance if we are to decrease the incidence of colorectal cancer.

Chronological trend of calorie intake and the incidence of epithelial neoplasms of the large intestine during the past 30 years in Japan

OBJECTIVES

The authors tried to elucidate the effects of food intake on the incidences of colorectal cancer and adenoma.

MATERIALS AND METHODS

Large intestines obtained from a series of consecutive autopsies performed at the Tokyo Metropolitan Geriatric Hospital were scrutinized to detect colorectal neoplasms. Chronological trends and age-dependent incidences of adenoma and overt lethal cancer were checked, while cancer in adenoma were included in the category of adenoma. Data on food consumption were obtained from the 'The National Nutrition Survey in Japan' (Ministry of Health, Labor and Welfare of Japan).

RESULTS

There were 405 cancers and 12,883 adenomas in the 7,091 large intestines examined. The incidences of cancer and adenoma increased with age; overt lethal cancer was found in 5.79% and adenoma in 56.79% of the general population > or =60 years in Tokyo. Calorie intake steeply increased since 1964, the year of the Olympic Games in Tokyo, until the early 1970s. Subsequently, it has continuously declined down to the level of the late 1940s, although the ingredients have changed tremendously. Chronological trends of the incidences of colorectal cancer and adenoma showed similar patterns as calorie intake, but, the influence of calorie intake on the incidences of cancer or adenoma was manifested 18 and 24 years later, respectively.

CONCLUSIONS

(1) During the last 30 years, the incidences of colorectal cancer and adenoma were 5.79 and 56.79%, respectively, in individuals aged > or =60 years in Japan. (2) The chronological trends of both lesions showed a pattern similar to that of calorie intake, but, as the trend of cancer incidence preceded the course of adenoma by 6 years, adenoma is not the sole precursor lesion of overt lethal cancer.

CT Colonography with Computer-aided Detection: Automated Recognition of Ileocecal Valve to Reduce Number of False-Positive Detections

The ileocecal valve (ICV) is a common cause of false-positive detections of polyps at computed tomographic (CT) colonography with computer-aided detection (CAD). The authors developed a CAD algorithm for differentiating the ICV from a true polyp and evaluated this algorithm by using two colonoscopy-confirmed CT colonography data sets. Data sets 1 and 2 consisted of the data obtained at CT colonographic examinations performed in 20 and 40 patients, respectively. Forty of these patients had at least one polyp 1 cm or larger. For data set 1, the proposed ICV recognition algorithm eliminated three of nine (33%; 95% confidence interval [CI]: 8%, 70%) false-positive CAD detections that were attributable to the ICV and none of the true-positive polyp detections. For data set 2, with use of identical parameters, the algorithm eliminated 11 of 18 (61%; 95% CI: 36%, 83%) false-positive detections that were attributable to the ICV and none of the true-positive detections. The thresholds used to recognize the ICV were a mean internal CT attenuation of less than -124 HU and a volume of greater than 1.5 cm(3). The proposed algorithm successfully recognized the ICV and eliminated it in some cases. This result is clinically important because, by reducing the frequency of a common cause of false-positive detections, this algorithm may improve the efficiency of physicians who use CAD.

Pathogenesis of colorectal cancer

It is frequently stated that all but a few colorectal cancers arise in adenomatous polyps, in turn initiated by APC mutation. Moderation of this view is now required. The proportion of colorectal cancers that arises in a polypoid adenoma is likely to be around 70% [39,61]. The pre-eminence of the adenoma-carcinoma model has been influenced by two factors: (1) the need to avoid overtreatment of innocent lesions, and (2) the absence of a convincing alternative mechanism. The latter position has changed in recent years. Collectively, the alternative pathways may account for the pathogenesis of up to 30% of colorectal cancers. The alternative pathways are difficult to observe in clinical practice because the precursors may be either inconspicuous or show rapid evolution following the establishment of genetic instability. As a concept, the polyp-cancer sequence is entrenched in both specialized and student texts. This is unfortunate, because progress in prevention and early cancer detection will be delayed by the failure to adopt a critical and nondogmatic approach to the pathogenesis of colorectal cancer. The advent of DNA chip technology will catalyze the development of revised paradigms. Specifically, modern genomics will allow polyps and cancers to be grouped within pathogenic pathways on the basis of shared gene expression profiles. The era of molecular medicine has dawned for colorectal cancer.

Loss of heterozygosity in the clonal evolution of flat colorectal neoplasms

In contrast to invasive colorectal carcinomas that develop in typical exophytic adenoma-carcinoma sequences, some invasive cancers may evolve from flat mucosal dysplastic lesions. Despite their relatively small size, these flat colorectal lesions are often associated with high-grade dysplasia and may show an aggressive clinical course. To delineate the genetic pathways in the clonal evolution of these tumors, multiple foci were microdissected from 13 cases and the allelic deletions of 15 chromosomal arms were analysed. Loss of heterozygosity (LOH) was detected most frequently on 17p (77%), followed by 18q (69%), and 5q (54%). In five cases with concomitant low-grade adenomas, only one case showed LOH in low-grade adenoma foci. In high-grade dysplasia with/without submucosal invasion, early and homogeneous LOH of one to several chromosomal arms was detected. Overall, homogeneous and thus early LOH were most frequently detected on 17p (seven of 10 cases with 17p LOH), followed by 3p (two of three cases with 3p LOH), and 5q (four of seven cases with 5q LOH). In addition to homogeneous LOH, the LOH patterns observed in different portions of dysplasias and invasive cancers in individual cases identified several different genetic patterns of tumour progression, either with linear or branching (divergent) trees. Positive immunostaining for p53 was detected in 10 of the 13 cases; of these, five cases were concomitant with 17p LOH in all of the microdissected foci, four cases were concomitant with 17p LOH in a majority of foci and, one case showed retention of 17p. Except for the flat configuration and early 17p LOH, genetic heterogeneity in the flat high-grade dysplastic foci was found to be similar to genetic chaos in the late dysplastic and preinvasive stages of exophytic adenoma. These findings suggest a potentially aggressive course for these neoplasms.

Molecular and cellular biology of pre-malignancy in the gastrointestinal tract

Important pathogenic alterations within established cancers are acquired during the pre-malignant stage. These genetic alterations can be grouped into specific neoplastic pathways that differ within and between anatomical sites. By understanding the mechanisms that determine the initiation and progression of each pathway, it will be possible to develop novel approaches to the diagnosis, prevention and treatment of cancer. This chapter outlines the principles underlying the molecular characterization of pre-malignant lesions, taking colorectal neoplasia as the main model.

Pathogenesis of non-familial colorectal carcinomas with high microsatellite instability

AIMS

Microsatellite instability (MSI) was first observed in hereditary non-polyposis colorectal carcinoma (HNPCC) and was subsequently seen in non-familial colorectal carcinoma. The relation between MSI and cancer associated genes in non-familial colorectal carcinomas has yet to be evaluated. To clarify this matter, changes in cancer associated genes were examined in non-familial colorectal carcinomas.

METHODS

Alterations in the adenomatous polyposis coli (APC), p53, and Ki-ras genes were analysed in 24 MSI high (alterations in four to seven of seven loci), nine MSI low (alterations in one to three of seven loci), and 31 MSI negative non-familial carcinomas. The hMSH2 and hMLH1 genes were also analysed in 24 MSI high carcinomas.

RESULTS

Both the frequencies and types of alterations in the APC and p53 genes in MSI high carcinomas were the same as those in MSI low and MSI negative carcinomas; however, they were different from those seen in HNPCC. The frequency of Ki-ras mutation was significantly lower in the MSI high cases (two of 24; 8%) than in the others (15 of 38; 39%). Somatic mutation of hMSH2 or hMLH1 was detected in six of 24 (25%) of the MSI high cases.

CONCLUSIONS

These results suggest that APC and p53 alterations occur irrespective of microsatellite instability status in non-familial colorectal carcinomas, and that Ki-ras mutation is not involved in MSI high non-familial colorectal carcinoma. The pathogenesis of these carcinomas may differ from both the usual adenoma-carcinoma sequence and HNPCC carcinogenesis.

Hyperplastic polyps and DNA microsatellite unstable cancers of the colorectum

Although the scientific and clinical rationale for classifying colorectal cancer according to mechanisms underlying genetic instability is well supported, little is known of the early morphogenesis of sporadic cancer showing high levels of DNA microsatellite instability (MSI-H). Evidence is accumulating that the traditional adenoma-carcinoma sequence may not apply to sporadic MSI-H colorectal cancer. The serrated pathway comprising hyperplastic polyps, mixed polyps and serrated adenomas may serve as the missing link. This review relates the recently described CpG island methylator phenotype (CIMP) to the serrated pathway. Two rate-limiting genetic steps may underlie the neoplastic pathway associated with CIMP. A transmembrane receptor expressed by pericryptal myofibroblasts (HPP1) may be implicated in the transition from normal to hyperplasia whereas inactivation of hMLH1 is responsible for the conversion of hyperplasia to dysplasia through loss of DNA mismatch repair. These mechanisms fit with clinical observations relating to sporadic MSI-H colorectal cancer, specifically proximal location, multiplicity, higher frequency among females and rapid evolution of early cancer.

Predictive factors for detecting colorectal carcinomas in surveillance colonoscopy after colorectal cancer surgery

PURPOSE

The aim of this study was to identify the high-risk groups for metachronous colorectal carcinoma among patients who undergo colorectal cancer surgery.

METHODS

Three hundred forty-one patients undergoing colorectal cancer surgery who had undergone surveillance colonoscopy at least twice during a period of more than three years were analyzed. A metachronous colorectal carcinoma was defined as a new colorectal carcinoma detected by surveillance colonoscopy after surgery.

RESULTS

Surveillance colonoscopy was performed 4.6 times per patient during an average of 6.2 years. Twenty-two metachronous colorectal carcinomas in 19 patients were detected, and 14 (64 percent) of 22 were detected within five years of surgery. The cumulative incidence of developing colorectal carcinomas during a five-year period was 5.3 percent. Seventeen (77 percent) of 22 carcinomas were 10 mm or less in size. Ten (71 percent) of the 14 carcinomas in early stages showed a flat appearance. Univariate analysis showed that extracolonic malignancy, coexistence of adenoma, and synchronous multiple colorectal carcinoma were significant predictive factors for detecting colorectal carcinomas in surveillance colonoscopy and that family history of colorectal carcinoma was a possible predictive factor. Multivariate analysis performed with Cox proportional hazards regression model showed that extracolonic malignancy and the coexistence of adenoma were significant predictive factors.

CONCLUSION

We recommend that patients with the above predictive factors receive surveillance colonoscopy meticulously and regularly.

Apoptosis and its regulation in flat-type early colorectal carcinoma: comparison with that in polypoid-type early colorectal carcinoma

PURPOSE

The aim of this study was to investigate the relationship among apoptotic cell death, proliferative activity, and the expression of apoptosis-regulating proteins (p53, p21 (WAF1/CIP1), and bax) in flat-type early colorectal carcinoma and to compare these factors with those in polypoid-type early colorectal carcinoma.

METHODS

Formalin-fixed, paraffin-embedded tissues of 11 flat-type early colorectal carcinomas and 17 polypoid-type early carcinomas were studied. The histologic diagnosis was either well-differentiated adenocarcinoma or carcinoma in adenoma, and the depth of invasion was limited to mucosa or submucosa. Apoptotic cells were detected by terminal deoxynucleotide transferase-mediated deoxyuridine triphosphate-biotin nick end-labeling method, and proliferative activity was determined by Ki-67 immunohistochemistry using monoclonal antibody MIB-1. Apoptosis-regulating proteins were determined by immunohistochemistry using antibody DO-7 (p53), Cip1 (p21 (WAF1/CIP1)), and Bax (bax).

RESULTS

There was no significant difference in terminal deoxynucleotide transferase-mediated deoxy-uridine triphosphate-biotin nick end-labeling index between flat-type early colorectal carcinoma and polypoid-type early carcinoma, at 1.9 vs. 1.1, respectively. In flat-type carcinoma terminal deoxynucleotide transferase-mediated deoxyuridine triphosphate-biotin nick end-labeling index in the p53 protein overexpression group was significantly smaller than that in the p53 protein-negative group (P < 0.05). The Ki-67 labeling index/terminal deoxynucleotide transferase-mediated deoxyuridine triphosphate-biotin nick end-labeling index ratio in the p53 protein overexpression group was significantly higher than that in the p53 protein-negative group (P < 0.05). In polypoid-type carcinoma, the terminal deoxynucleotide transferase-mediated deoxyuridine triphosphate-biotin nick end-labeling index and Ki67/terminal deoxynucleotide transferase-mediated deoxyuridine triphosphate-biotin nick end-labeling index ratio showed no significant difference between the p53 protein overexpression group and p53 protein-negative group.

CONCLUSION

p53-dependent apoptosis may contribute to the development of flat-type early colorectal carcinoma. Apoptosis and its regulation in flat-type early colorectal carcinoma may differ from those in polypoid-type carcinoma.

Broadsheet number 52: Molecular genetics of colorectal cancer

The molecular genetics of colorectal cancer is presented in an order that ascends from the basic to the applied: molecular mechanisms, morphogenesis, classification and diagnosis. Major consideration is given to the nature of genetic instability and the role of this mechanism in driving neoplastic progression. It is shown how the fundamental principle of genetic instability cuts across applied research, tissue diagnosis and clinical management with respect to both sporadic and inherited forms of colorectal cancer.