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Aldilaijan AF, Kim YI, Kim CW, Yoon YS, Park IJ, Lim SB, Kim J, Ro JS, Kim JC. Clinical implication of tissue carcinoembryonic antigen expression in association with serum carcinoembryonic antigen in colorectal cancer. Sci Rep 2023; 13:7616. [PMID: 37165043 PMCID: PMC10172318 DOI: 10.1038/s41598-023-34855-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 05/09/2023] [Indexed: 05/12/2023] Open
Abstract
This study aimed to evaluate the prognostic significance of carcinoembryonic antigen (CEA) expression in tumor tissues of patients with colorectal cancer (CRC). The cohort included 7,412 patients with CRC from January 2010 to December 2015. Survival outcomes were assessed based on tissue CEA (t-CEA) patterns and intensities. Three-year (76.7% versus 81.3%) and 5-year (71.7% versus 77.6%, p < 0.001) disease-free survival (DFS) rates were significantly (p < 0.001) poorer in patients with a diffuse-cytoplasmic pattern than an apicoluminal pattern. Three-year (79% versus 86.6%) and 5-year (74.6% versus 84.7%) DFS rates were also significantly (p < 0.001) poorer in patients with high than low t-CEA intensity. Three-year (84.6% versus 88.4%) and 5-year (77.3% versus 82.6%) overall survival (OS) rates were significantly (p < 0.001) poorer in patients with diffuse-cytoplasmic than apicoluminal pattern of CEA expression, and both 3-year (86.7% versus 91.2%) and 5-year (80.1% versus 87.7%) OS rates were significantly (p < 0.001) poorer in patients with high than low t-CEA intensity. Multivariate analyses showed that high-intensity t-CEA was independently associated with DFS (p = 0.02; hazard ratio [HR] = 1.233) and OS (p = 0.032; HR = 1.228). Therefore, high-intensity t-CEA is a significant prognostic factor in CRC, independent of serum CEA (s-CEA), and can complement s-CEA in predicting survival outcomes after CRC resection.
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Affiliation(s)
- Abdulmohsin Fawzi Aldilaijan
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Young Il Kim
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Chan Wook Kim
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea.
| | - Yong Sik Yoon
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - In Ja Park
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Seok-Byung Lim
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Jihun Kim
- Department of Pathology, Institute of Innovative Cancer Research, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jun-Soo Ro
- Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jin Cheon Kim
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea
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Shi J, Jiang D, Yang S, Sun Y, Wang J, Zhang X, Liu Y, Lu Y, Yang K. Molecular profile reveals immune-associated markers of lymphatic invasion in human colon adenocarcinoma. Int Immunopharmacol 2020; 83:106402. [PMID: 32200154 DOI: 10.1016/j.intimp.2020.106402] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 02/23/2020] [Accepted: 03/11/2020] [Indexed: 12/14/2022]
Abstract
Lymphatic invasion (LI) is an early event of metastasis and closely associated with overall survival in colon adenocarcinoma (COAD). Our aim was to gain deeper insight into the mechanism of lymphatic invasion in COAD. Subtype-specific somatic mutations and differentially expressed genes (DEGs) screening were based on The Cancer Genome Atlas (TCGA). Gene Ontology (GO) enrichment analysis was utilized to explore the biological function. The condition of tumor-infiltrating lymphocytes was performed by TIMER online database. Survival analysis was based on Kaplan-Meier curve method. Lymphatic invasion was associated with poor prognosis of patients with COAD. Nine mutations were enriched in lymphatic invasion-negative group. A total of 50 were differentially expressed between LI-positive tissues and LI-negative tissues. The DEGs were enriched in lipoprotein-related functions. MUC4 in-frame deletion at A4166-S4181 was associated with favorable prognosis of COAD patients. BMPR2 frameshift mutation g.chr2:202555407delA played cis and trans functions in downregulation of itself and CTLA4 upregulation. And it was associated with higher mutational burden. LAMP5, CUBN and TCHH were DEGs associated with prognosis and abundance of tumor-infiltrating lymphocytes. In conclusion, our study provides LI-associated genetic and transcriptional alterations, which helps to better understand the potential mechanisms and microenvironment in COAD.
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Affiliation(s)
- Jingqi Shi
- Department of Immunology, The Fourth Military Medical University, Xi'an 710032 Shaanxi, People's Republic of China
| | - Dongbo Jiang
- Department of Immunology, The Fourth Military Medical University, Xi'an 710032 Shaanxi, People's Republic of China
| | - Shuya Yang
- Department of Immunology, The Fourth Military Medical University, Xi'an 710032 Shaanxi, People's Republic of China
| | - Yuanjie Sun
- Department of Immunology, The Fourth Military Medical University, Xi'an 710032 Shaanxi, People's Republic of China
| | - Jing Wang
- Department of Immunology, The Fourth Military Medical University, Xi'an 710032 Shaanxi, People's Republic of China
| | - Xiyang Zhang
- Department of Immunology, The Fourth Military Medical University, Xi'an 710032 Shaanxi, People's Republic of China
| | - Yang Liu
- Department of Immunology, The Fourth Military Medical University, Xi'an 710032 Shaanxi, People's Republic of China
| | - Yuchen Lu
- School of Basic Medicine, The Fourth Military Medical University, Xi'an 710032 Shaanxi, People's Republic of China
| | - Kun Yang
- Department of Immunology, The Fourth Military Medical University, Xi'an 710032 Shaanxi, People's Republic of China.
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Preoperative evaluation of lymphovascular invasion using high-resolution pelvic magnetic resonance in patients with rectal cancer: a 2-year follow-up study. J Comput Assist Tomogr 2013; 37:583-8. [PMID: 23863536 DOI: 10.1097/rct.0b013e31828d616a] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVES The objectives of this study were to preoperatively evaluate lymphovascular invasion (LVI) using pelvic magnetic resonance (MR) in patients with rectal cancer and to determine the correlation with distant metastasis rate. METHODS If the mesorectal perivascular infiltrative signal was visible on pelvic MR imaging, the possibility of LVI was recorded. Distant metastatic lesions were also recorded at the time of the initial diagnostic workup and over a 2-year follow-up period. RESULTS Fifteen (68.2%) of the 22 LVI patients showed mesorectal perivascular infiltrative signals on pelvic MRI. For the prediction of LVI in rectal cancer, MR had a sensitivity of 68.2% and a specificity of 93.2. The initial distant metastasis rate was significantly higher in patients with MR LVI (52%) than in patients without MR LVI (5.7%) (P < 0.0001). CONCLUSIONS On pelvic MR, the presence of mesorectal perivascular infiltration by nodes is a specific sign of LVI in rectal cancer, and the presence of LVI is a predictor of distant metastasis.
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Xiao H, Yoon YS, Hong SM, Roh SA, Cho DH, Yu CS, Kim JC. Poorly differentiated colorectal cancers: correlation of microsatellite instability with clinicopathologic features and survival. Am J Clin Pathol 2013; 140:341-7. [PMID: 23955452 DOI: 10.1309/ajcp8p2dynkgrbvi] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES To evaluate the association of microsatellite instability (MSI) with clinicopathologic features and oncologic outcomes in patients with poorly differentiated colorectal cancer (PD). METHODS Study patients were divided into well-differentiated colorectal cancer (WD) and PD, which were compared according to histologic differentiation and MSI status. RESULTS Among 1,941 patients, PD was more frequent among microsatellite-unstable tumors (23.6%) than among microsatellite-stable (MSS) tumors (4.2%, P < .001). Patients with PD had worse 4-year overall survival rates than patients with WD (78.6% vs 88.2%, P = 0.010). Compared with MSS-PD tumors, MSI-PD tumors were characterized by right-colon predilection, larger size, and infrequent lymph node metastasis (P < .001 to P = .007). CONCLUSIONS The clinicopathologic characteristics of PD were closely associated with those of MSI. The outcomes of MSI-PD tumors were better than those of MSS-PD tumors, but this finding did not reach statistical significance.
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Affiliation(s)
- Haitao Xiao
- Department of Surgery, University of Ulsan College of Medicine, Seoul, Korea
- Beijing United Family Hospital, Beijing, China
| | - Yong Sik Yoon
- Department of Surgery, University of Ulsan College of Medicine, Seoul, Korea
- Institute of Innovative Cancer Research and Asan Institute for Life Sciences, Asan Medical Center, Seoul
| | - Seung-Mo Hong
- Department of Pathology, University of Ulsan College of Medicine, Seoul
| | - Seon Ae Roh
- Department of Surgery, University of Ulsan College of Medicine, Seoul, Korea
- Institute of Innovative Cancer Research and Asan Institute for Life Sciences, Asan Medical Center, Seoul
| | - Dong-Hyung Cho
- Institute of Innovative Cancer Research and Asan Institute for Life Sciences, Asan Medical Center, Seoul
- Graduate School of East-West Medical Science, Kyung Hee University, Gyeoggi-do, Korea
| | - Chang Sik Yu
- Department of Surgery, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Cheon Kim
- Department of Surgery, University of Ulsan College of Medicine, Seoul, Korea
- Institute of Innovative Cancer Research and Asan Institute for Life Sciences, Asan Medical Center, Seoul
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Kim JC, Lee HC, Cho DH, Choi EY, Cho YK, Ha YJ, Choi PW, Roh SA, Kim SY, Kim YS. Genome-wide identification of possible methylation markers chemosensitive to targeted regimens in colorectal cancers. J Cancer Res Clin Oncol 2011; 137:1571-80. [PMID: 21850381 DOI: 10.1007/s00432-011-1036-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2011] [Accepted: 08/04/2011] [Indexed: 01/07/2023]
Abstract
PURPOSE Few efficient methylation markers of chemosensitivity have been discovered. The genome-wide analysis of methylation markers is needed to identify chemosensitive candidates to targeted therapy. METHODS This study describes a two-step process to select chemosensitive candidates of methylation genes. A genome-wide screening of methylation genes was performed using a Beadarray and an in vitro chemosensitivity assay of 119 colorectal cancers (CRCs). Ten candidate genes identified during the initial screening were verified by biological utility assessment using cell viability assays of transfected CRC cells. RESULTS Five methylation genes related to sensitivity to bevacizumab regimens (RASSF1, MMP25, KCNQ1, ESR1, and GALR2) or cetuximab regimens (SCL18A2, GPX7, NID2, IGFBP3, and ALX4) were chosen during the first step. A viability assay revealed that GALR2-overexpressing HCT116 cells were significantly more chemosensitive to bevacizumab regimens than control cells (P = 0.022 and 0.019 for bevacizumab with FOLFIRI and FOLFOX, respectively), concurrently verified on a caspase-3 activity assay. GPX7- or ALX4-overexpressed RKO cells were significantly less viable to cetuximab regimens compared to control cells (GPX7: P = 0.027 each for cetuximab with FOLFIRI and FOLFOX; ALX4: P = 0.049 and 0.003 for cetuximab with FOLFIRI and FOLFOX, respectively), but caspase-3 activity was not prominent in GPX7-overexpressed RKO cells. CONCLUSIONS Two novel genes, GALR2 and ALX4, have been identified as chemosensitive methylation candidates to bevacizumab and cetuximab regimens, respectively. As our study did not include a clinical association study, the two candidates should be validated in large clinical cohorts, hopefully predicting responsive patients to targeted regimens.
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Affiliation(s)
- Jin C Kim
- Department of Surgery, University of Ulsan College of Medicine, Seoul, Korea.
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Lim SB, Yu CS, Jang SJ, Kim TW, Kim JH, Kim JC. Prognostic significance of lymphovascular invasion in sporadic colorectal cancer. Dis Colon Rectum 2010; 53:377-84. [PMID: 20305435 DOI: 10.1007/dcr.0b013e3181cf8ae5] [Citation(s) in RCA: 120] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE It remains unclear whether lymphovascular invasion marks a poor prognosis for patients with sporadic colorectal cancers. Here, we analyzed the association between lymphovascular invasion and the clinicopathological features and prognosis of sporadic colorectal cancer patients. METHODS The clinicopathological features and prognosis of 2417 patients with sporadic primary colorectal cancer who underwent an operation at the Asan Medical Center between January 1998 and December 2002 were examined. The patients' clinicopathological parameters and follow-up and survival data were obtained from a prospectively collected database. RESULTS Of the 2417 patients, a lymphovascular invasion-positive tumor was detected in 610 (25.2%). Compared with patients with lymphovascular invasion-negative tumors those with lymphovascular invasion-positive tumors were older (P < .001) and had higher preoperative serum carcinoembryonic antigen levels (P = .011). Their tumors were also more likely to be poorly differentiated (P < .001) and more advanced in terms of T and N categories (P < .001 and P < .001, respectively). The lymphovascular invasion-positive tumors were also more likely to have metastasized systemically (P < .001). Although lymphovascular invasion-positive and lymphovascular invasion-negative tumors metastasized equally frequently to the liver, lung, peritoneum, and bone, lymphovascular invasion-positive tumors metastasized to systemic lymph nodes more often (P < .001). These tumors also recurred at systemic lymph nodes after curative intent surgery more often (P = .007). Lymphovascular invasion-positive status was an independent unfavorable prognostic factor for the 5-year overall and 5-year disease-free survival of patients with sporadic colorectal cancer (P < .001 and P < .001, respectively). CONCLUSION Lymphovascular invasion-positive status could be used to identify patients with sporadic primary colorectal cancer with aggressive tumors and as a factor that independently indicates an unfavorable prognosis.
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Affiliation(s)
- Seok-Byung Lim
- Department of Surgery, University of Ulsan College of Medicine, Seoul. Korea
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Intratumoral as well as peritumoral lymphatic vessel invasion correlates with lymph node metastasis and unfavourable outcome in colorectal cancer. Clin Exp Metastasis 2010; 27:123-32. [PMID: 20195706 DOI: 10.1007/s10585-010-9309-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2009] [Accepted: 02/08/2010] [Indexed: 12/11/2022]
Abstract
The aim of this study was to assess the intratumoral and peritumoral distribution of lymphatic vessel density (LVD) and lymphatic vessel invasion (LVI) in colorectal cancer and their relationships with patients' clinicopathological characteristics and survival. Paraffin sections of 81 primary colorectal cancers were examined by immunohistochemical staining using monoclonal antibody D2-40. Peritumoral LVD was significantly higher than intratumoral LVD (P = 0.000). Both intratumoral LVD and peritumoral LVD were correlated with the presence of LVI (P = 0.006 and P = 0.003, respectively). LVI, intratumoral LVI and peritumoral LVI were identified, respectively in 38, 28 and 32% of the samples investigated. Both intratumoral LVI and peritumoral LVI were correlated with lymph node metastasis (P = 0.030 and P = 0.014, respectively). Lymph node metastasis, the presence of intratumoral LVI and peritumoral LVI were adversely associated with the 5-year overall survival in a univariate analysis (P = 0.001, P = 0.011 and P = 0.017, respectively). Multivariate analysis using Cox proportional hazard model showed that neither intratumoral LVI nor peritumoral LVI was an independent prognostic factor of overall survival. The results of this study demonstrated that intratumoral as well as peritumoral LVI was associated with lymph node metastasis and adverse outcome in colorectal cancer.
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Identification of Rho GTPase Activating Protein 6 Isoform 1 Variant as a New Molecular Marker in Human Colorectal Tumors. Pathol Oncol Res 2009; 16:319-26. [DOI: 10.1007/s12253-009-9226-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2009] [Accepted: 11/09/2009] [Indexed: 01/16/2023]
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Abstract
Most cancerous lesions metastasize through the lymphatic system and the status of regional lymph nodes is the most important indicator of a patient's prognosis. The extent of lymph node involvement with cancer is also an important parameter used for determining treatment options. Although the importance of the lymphatic system for metastasis has been well recognized, traditionally, the lymphatic vessels have not been considered actively involved in the metastatic process. Recent evidence, however, indicates that the activation of the lymphatic system is an important factor in tumor progression to metastasis. Tumor lymphangiogenesis has been associated with increased propensity for metastasis, and lymphatic vessel density has emerged as another promising prognostic indicator. More recently, lymphangiogenesis in the sentinel lymph nodes has been shown to contribute to malignant progression. In addition to its role as a transport system for tumor cells, the lymphatic system may also be more actively involved in metastases by directly facilitating tumor cell recruitment into the lymphatic vessels. This review highlights recent advances in our understanding of the mechanisms by which lymphatic vessels participate in metastasis.
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Affiliation(s)
- Suvendu Das
- Department of Oncological Sciences, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1130, New York, NY 10029, USA
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Kim JC, Cho YK, Roh SA, Yu CS, Gong G, Jang SJ, Kim SY, Kim YS. Individual tumorigenesis pathways of sporadic colorectal adenocarcinomas are associated with the biological behavior of tumors. Cancer Sci 2008; 99:1348-54. [PMID: 18422752 PMCID: PMC11159463 DOI: 10.1111/j.1349-7006.2008.00819.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Clinicopathologic features of sporadic colorectal adenocarcinomas were compared using integrated data from 224 [corrected] patients subjected to curative resection. Individual steps in the tumorigenesis pathway, that is, adenomatosis polyposis coli (APC), Wnt-activated, base excision repair mutations, mismatch repair defects, RAF-mediated, transforming growth factor (TGF)-beta-suppressed, bone morphogenic protein (BMP)-suppressed, and p53 alterations, were examined in terms of genetic and epigenetic changes, as well as protein expression. Genetic and molecular alterations of right colon cancers were distinct from those of left colon and rectal cancers. Rectal cancers showed the attenuated phenotype of left colon cancers. Tumors most frequently displayed either TGF-beta- or BMP-suppressed alterations (81.2%), followed by RAF-mediated alterations (78.6%), and mismatch repair defects (38.4%), constituting a total of 24 integrated pathways. Tumors lacking APC mutations or carrying the RAF alteration (V600E) were frequently associated with lymphovascular invasion and lymph node metastasis (P < 0.05). Poorly differentiated or mucinous adenocarcinomas were generally associated with high level microsatellite instability, Axin2 suppression, TGF-beta1 or BMPR1A suppression, loss of heterozygosity of D18S46 or D18S474, and absence of base excision repair mutations (P < 0.0001-0.05). Early tumor recurrence was significantly correlated with lack of APC mutations (P = 0.036). Moreover, tumors that concurrently displayed APC/Wnt-activated, TGF-beta/BMP-suppressed, and p53 alterations were significantly predisposed to early recurrence (P = 0.026). Our data clearly indicate that particular steps or pathways of colorectal tumorigenesis are closely associated with characteristic clinicopathologic features that, in turn, determine biological behavior, such as tumor growth, invasion, and recurrence.
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Affiliation(s)
- Jin C Kim
- Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 388-1 Poongnap-2-Dong Songpa-Ku, Seoul 138-736, Republic of Korea.
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Liang P, Nakada I, Hong JW, Tabuchi T, Motohashi G, Takemura A, Nakachi T, Kasuga T, Tabuchi T. Prognostic significance of immunohistochemically detected blood and lymphatic vessel invasion in colorectal carcinoma: its impact on prognosis. Ann Surg Oncol 2006; 14:470-7. [PMID: 17103258 DOI: 10.1245/s10434-006-9189-3] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2006] [Revised: 08/10/2006] [Accepted: 08/10/2006] [Indexed: 12/21/2022]
Abstract
BACKGROUND The prognostic significance of blood vessel invasion (BVI) and lymphatic vessel invasion (LVI) is unclear. Because of the absence of specific markers for venous and lymphatic vessels, earlier studies could not reliably distinguish between BVI and LVI. METHODS By immunostaining for podoplanin and CD34 antigen, we retrospectively investigated LVI and BVI in 419 tissue specimens of colorectal carcinoma. We performed univariate and multivariate analysis of the clinicopathologic features, frequency of recurrence, and outcome of patients with or without LVI and BVI. RESULTS The use of hematoxylin and eosin (H&E) staining to identify BVI and LVI yielded a false positive rate of 9.1% and false negative rate of 12.6%. The incidence of BVI was significantly higher among tumors with LVI than tumors without LVI (P <.001). In logistic multivariate analysis, only LVI (P < .001) was associated with lymph node metastasis and BVI (P = .015) was associated with distant recurrence. Calculating the prognostic relevance, both two invasion types correlated with decreased survival in univariate analysis (both P <.001). In multivariate analysis, BVI (P =.024), lymph node status (P =.003) and tumor stage (P <.001) remained statistically significant factors for survival. CONCLUSIONS Our results suggest that immunohistologic evaluation of BVI and LVI could be useful in colorectal carcinoma indicating the risk of lymph node metastasis and recurrence, thereby contributing to prognostic evaluation.
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Affiliation(s)
- Pin Liang
- Fourth Department of Surgery, Tokyo Medical University Kasumigaura Hospital, 3-20-1 Chuo, Ami, Inashiki, Ibaraki, 300-0395, Japan.
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