DNA analysis and DNA ploidy in gastric cancer and gastric precancerous lesions

Use of DNA flow cytometry in the diagnosis, risk stratification, and management of gastric epithelial dysplasia

The natural history of gastric epithelial dysplasia and the consequential surveillance strategies are not well defined in the West. To date, the diagnosis relies on morphology, and no reliable adjunct methods, either immunohistochemical or molecular, have reproducibly been able to confirm the diagnosis and/or risk stratify gastric epithelial dysplasia. Yet, such a tool would be useful in confirming the diagnosis, and developing objective and rational surveillance guidelines. DNA flow cytometry was performed using formalin-fixed paraffin-embedded gastric tissue from 23 cases of high-grade dysplasia and 38 cases of low-grade dysplasia. Twenty-four benign background mucosal samples from the same cohort (20 biopsies and 4 surgical resections from 16 low- and 8 high-grade dysplasia cases) were utilized as controls. The presence of DNA content abnormality (aneuploidy or elevated 4N fraction) correlated with increasing levels of dysplasia, as DNA content abnormality was detected in 18 (78%) of 23 high-grade dysplasia, 5 (13%) of 38 low-grade dysplasia, and none of 24 non-dysplastic samples. 1 and 4-year detection rates of high-grade dysplasia or gastric adenocarcinoma in low-grade dysplasia patients with DNA content abnormality were 80% (p = 0.003) and 100% (p = 0.005), respectively, whereas patients with low-grade dysplasia but with normal DNA content had 1, 4, and 12-year detection rates of 23, 32, and 54%, respectively. The univariate hazard ratio (HR) for subsequent detection of high-grade dysplasia or gastric adenocarcinoma in low-grade dysplasia patients with DNA content abnormality was 6.9 (p = 0.001). Older patients (HR = 1.1, p = 0.005) and those with familial adenomatous polyposis (HR = 9.7, p = 0.029) also had an increased risk for developing high-grade dysplasia or gastric adenocarcinoma in the univariate analysis, but only DNA content abnormality demonstrated a significantly elevated HR of 5.9 in the multivariate analysis (p = 0.005). While older age showed a minimally elevated risk (HR = 1.1, p = 0.013), no other potential risk factors, including male gender, ethnicity, polypoid endoscopic appearance, Helicobacter pylori infection, and intestinal metaplasia, were significantly associated with subsequent detection of high-grade dysplasia or gastric adenocarcinoma in the multivariate analysis. Among the 18 high-grade dysplasia cases with DNA content abnormality, 13 cases (72%) developed gastric adenocarcinoma within a mean follow-up time of 9 months, conferring a HR of 2.5; however, this did not reach statistical significance. In conclusion, the presence of DNA content abnormality can identify a subset of low-grade dysplasia patients who are at increased risk for subsequent detection of high-grade dysplasia or gastric adenocarcinoma. It can also provide confirmatory evidence to a morphologic impression or suspicion of high-grade dysplasia. The majority of gastric epithelial dysplasia patients with DNA content abnormality developed high-grade dysplasia or gastric adenocarcinoma within a year and thus may benefit from more thorough and rigorous endoscopic surveillance.

Cell proliferation parameters and apoptosis indices in pituitary macroadenomas

BACKGROUND

Pituitary adenomas are usually well-differentiated tumors but may show locally aggressive behavior.

AIM

To investigate the relationship between proliferation and apoptosis parameters and tumor recurrence in a series of 20 radically resected pituitary macroadenomas (11 functioning, 9 non-functioning).

MATERIALS AND METHODS

Proliferative activity and DNA ploidy were analyzed by flow cytometry (FCM) on fresh surgical specimens. Immunohistochemistry for Ki-67/MIB-1 and for the anti-apoptotic protein Bcl-2 was performed on paraffin-embedded specimens from the same tumors. Tumor regrowth was evaluated by magnetic resonance imaging (MRI).

RESULTS

Six adenomas recurred after surgery, regardless of hormonal hypersecretion. Pre-surgical tumor size was significantly higher in recurrent than in non-recurrent adenomas (p=0.003). Pre-surgical MRI demonstrated cavernous sinus (CS) invasiveness in all recurrent tumors, while none of the non-invasive adenomas recurred (p=0.042, by Fisher's exact test). The DNA content was aneuploid in 5/20 adenomas, one of which recurred. Cell percentages in the S (%SPF) and G2+M (%G2-M) phases and proliferative index (PI) (PI=%SPF+%G2-M) were significantly higher in aneuploid than in diploid adenomas (p<0.05), but no significant differences concerning all FCM parameters were observed between recurrent and non-recurrent adenomas. Similarly, MIB-1 did not show a significant difference of expression between recurrent and non-recurrent adenomas (p=0.33). Bcl-2 immunoreactivity was detected in 12/15 pituitary adenomas, involving 63±35% of tumor cells, regardless of tumor recurrence.

CONCLUSIONS

In this group of radically resected pituitary macroadenomas, neuroradiological finding of CS invasiveness--but not FCM parameters nor MIB-1 and Bcl-2 expression--is useful for predicting tumor recurrence.

Clinical aspect and molecular mechanism of DNA aneuploidy in gastric cancers

The biological characteristics of cancers depend mostly on genetic alterations in the cancer cells of individuals. Gastric cancers show a high frequency of DNA aneuploidy, a phenotype of chromosomal instability. Compared to diploid tumors, gastric carcinomas with aneuploidy have been shown to have high proliferative activity and high metastatic or invasive potential; these characteristics lead to a poor prognosis. It has been suggested that an abnormal spindle assembly checkpoint is involved in DNA aneuploidy, but the underlying mechanism is still unclear. This review, in order to determine whether gastric carcinomas that display aneuploidy are associated with a poorer prognosis than diploid tumors, and to discuss the biological mechanisms that induce aneuploidy, summarizes the results of studies on DNA ploidy in gastric cancer published in the English literature. Analysis of DNA ploidy in gastric cancer may provide clinically useful information from diagnostic, therapeutic, and prognostic standpoints. Further investigations may be needed to clarify the relationship between chromosome instability and DNA ploidy.

The effect of age and Helicobacter pylori infection on gastric epithelial cell kinetics

BACKGROUND

Helicobacter pylori infection is a known risk factor for gastric cancer. The aim of the study was to determine the effect of H. pylori and age on gastric epithelial cell kinetics.

METHODS

One hundred and fifty-seven patients (92 men, median age: 58.5 years, range: 18-85) who had undergone upper gastrointestinal endoscopy due to dyspeptic symptoms were enrolled into the study. Six antral biopsy samples were obtained for flow cytometric DNA analysis (expressed as proliferative index [PI], S+G2/M phase), presence of H. pylori (CLO-test, culture and histology), and histopathologic examination.

RESULTS

Eighty-four (53.5%) patients were H. pylori positive and 93.3% of patients had diploid pattern and 6.7% expressed aneuploid pattern. The mean PI was 4.8 ± 0.2 for the whole group studied. PI were 5.14 ± 0.33 and 4.26 ± 0.36 for H. pylori (+) and H. pylori (-) patients respectively (P = 0.017). When age groups were taken into account, PI was found higher in patients over 75 years of age (n = 14, PI = 6.66 ± 1.3) compared to patients under 35 years of age (n = 25, PI = 3.83 ± 0.41, P = 0.014). There was no correlation between histological changes and PI. H. pylori (P = 0.045) and age (P = 0.082) were independent factors for PI.

CONCLUSION

PI of gastric antral mucosa increases in patients with H. pylori infection. Although PI increases by age, H. pylori is the only factor that significantly and independently influences the rate of epithelial cell proliferation.

Cytometry and DNA ploidy: clinical uses and molecular perspective in gastric and lung cancer

Flow cytometry is one of the most powerful and specific methods used for the integrated study of the molecular and morphological events occurring during cell proliferation. Many methods have been described for investigating this process. Several cell cycle regulators controlling the correct entry and progression through the cell cycle are altered in tumors. In fact, in most, if not all, human cancers there is a deregulated control of G1 phase progression, the period when cells decide if they will start proliferation or stay quiescent. Cytometry (flow and image) is able to analyze DNA content thanks to the use of the same "molecule" conjugates with a fluorochrome that permits to identify DNA content of single cell in a sample. Most important results of studies on DNA ploidy have been reviewed during the last years and as a result the analyses of DNA ploidy in cancer may provide clinically useful information on diagnostic, therapeutic and prognostic aspects. In fact, aneuploid cancer has a high proliferative activity and a metastatic or invasive potential, markers of a poor prognosis. Multiparametric flow cytometry should allow the simultaneous determination of morphology, phenotype, intracellular protein expression, and status of chromatin and DNA. Evaluating if a particular protein is responsible for the aggressiveness of cancer, or the alteration of DNA content, or if the activation of its state is the cause of rapid growth of cancer cells, is very important and it can facilitate the clinical treatment of patients.

COX-2 is associated with proliferation and apoptosis markers and serves as an independent prognostic factor in gastric cancer

Cyclooxygenase-2 (COX-2) is an important factor in gastric carcinogenesis, and COX-2 expression in gastric cancer patients correlates with prognosis. We have now studied the impact of COX-2 in comparison to six other tissue tumor markers, DNA index, and S-phase fraction (SPF) in a large series of gastric cancer specimens. From 342 consecutive patients, 337 archival tissue specimens were available for immunohistochemistry of COX-2, HuR, cyclin A, MMP-2, p53, p21, and Ki-67 and 313 for analysis of DNA index and S-phase fraction by flow cytometry. Associations between factors were assessed by chi-square test and survival analysis by the Kaplan-Meier method and Cox model. A significant association emerged between of COX-2 and p53 (p < 0.0001), Ki-67 (p = 0.013), DNA ploidy (p < 0.0001), and SPF (p < 0.0001). In an extended multivariate analysis, COX-2 and p53 expression were independent prognostic factors for poor survival, in addition to high stage and non-curative surgery. In gastric cancer, COX-2 expression associated with markers for apoptosis and proliferation, and furthermore, it was confirmed that COX-2 and p53 are strong prognostic indicators.

Gross genomic damage measured by DNA image cytometry independently predicts gastric cancer patient survival

Background:

DNA aneuploidy reflects gross genomic changes. It can be measured by flow cytometry (FCM-DNA) or image cytometry (ICM-DNA). In gastric cancer, the prevalence of DNA aneuploidy has been reported to range from 27 to 100%, with conflicting associations with clinicopathological variables. The aim of our study was to compare the DNA ploidy status measured using FCM-DNA and ICM-DNA in gastric cancer and to evaluate its association with clinicopathological variables.

Methods:

Cell nuclei were isolated from 221 formalin-fixed, paraffin-embedded gastric cancer samples. DNA ploidy was assessed using FCM-DNA and ICM-DNA.

Results:

A total of 178 (80.5%) gastric cancer samples were classified as DNA aneuploid using FCM-DNA, compared with 172 (77.8%) gastric cancer samples when using ICM-DNA. Results obtained from both methods were concordant in 183 (82.8%) cases (κ=0.48). Patients with ICM-DNA diploid gastric cancer survived significantly longer than those with ICM-DNA aneuploid gastric cancer (log rank 10.1, P=0.001). For FCM-DNA data, this difference did not reach statistical significance. The multivariate Cox model showed that ICM-DNA ploidy status predicted patient survival independently of tumour-node-metastasis status.

Conclusion:

ICM-DNA ploidy status is an independent predictor of survival in gastric cancer patients and may therefore be a more clinically relevant read out of gross genomic damage than FCM-DNA.

Aneuploidy involving chromosome 1 may be an early predictive marker of intestinal type gastric cancer

Intestinal type gastric cancer is a significant cause of mortality, therefore a better understanding of its molecular basis is required. We assessed if either aneuploidy or activity of the oncogenic transcription factor nuclear factor kappa B (NF-kappaB), increased incrementally during pre-malignant gastric histological progression and also if they correlated with each other in patient samples, as they are both induced by oxygen free radicals. In a prospective study of 54 (aneuploidy) and 59 (NF-kappaB) consecutive patients, aneuploidy was assessed by interphase fluorescent in situ hybridisation (FISH) for chromosome 1. NF-kappaB was assessed by expression of interleukin-8 (IL-8), and in a subset, by immunohistochemistry (IHC) for active p65. Aneuploidy levels increased incrementally across the histological series. 2.76% of cells with normal histology (95% CI, 2.14-3.38%) showed background levels of aneuploidy, this increased to averages of 3.78% (95% CI, 3.21-4.35%), 5.89% (95% CI, 3.72-8.06%) and 7.29% (95% CI, 4.73-9.85%) of cells from patients with gastritis, Helicobacter pylori positive gastritis and atrophy/intestinal metaplasia (IM) respectively. IL-8 expression was only increased in patients with current H. pylori infection. NF-kappaB analysis showed some increased p65 activity in inflamed tissues. IL-8 expression and aneuploidy level were not linked in individual patients. Aneuploidy levels increased incrementally during histological progression; were significantly elevated at very early stages of neoplastic progression and could well be linked to cancer development and used to assess cancer risk. Reactive oxygen species (ROS) induced in early gastric cancer are presumably responsible for the stepwise accumulation of this particular mutation, i.e. aneuploidy. Hence, aneuploidy measured by fluorescent in situ hybridisation (FISH) coupled to brush cytology, would be worthy of consideration as a predictive marker in gastric cancer and could be clinically useful in pre-malignant disease to stratify patients by their cancer risk.

Alteration of sister chromatid exchange frequencies in gastric cancer and chronic atrophic gastritis patients with and without H. pylori infection

AIM

To determine, by counting sister chromatid exchange (SCE) frequencies, whether genetic impairment and DNA damage have an effect on the pathogenesis of gastric cancer (GC).

METHODS

Analysis of SCE is a cytogenetic technique used to show DNA damage as a result of an exchange of DNA fragments between sister chromatids. We analyzed SCE frequency in 24 patients with GC, 26 patients with chronic atrophic gastritis (CAG), and 15 normal controls. The presence of H. pylori was confirmed by urease test, toluidine-blue stain and hematoxylin-eosin stain.

RESULTS

SCE was significantly increased in H. pylori-negative GC patients, and in H. pylori-negative CAG patients compared with controls (7.41 +/- 1.36 and 6.92 +/- 1.20, respectively, vs 5.54 +/- 0.8, P < 0.001). There was no difference in the SCE frequency between H. pylori-negative GC patients and H. pylori-negative CAG patients (P > 0.05). On other hand, the SCE frequencies in H. pylori-positive GC patients were higher than those in H. pylori-positive CAG patients (9.20 +/- 0.94 vs 7.93 +/- 0.81, P < 0.01). Furthermore, H. pylori-positive GC patients had a higher SCE frequency than H. pylori-negative GC patients (9.20 +/- 0.94 vs 7.41 +/- 1.36, P < 0.001). Similarly, a significant difference was detected between H. pylori-positive CAG patients and H. pylori-negative CAG patients (7.93 +/- 0.81 vs 6.92 +/- 1.20, P < 0.05).

CONCLUSION

We suggest the increased SCE in patients reflects a genomic instability that may be operative in gastric carcinogenesis.

Mitotic kinases: the key to duplication, segregation, and cytokinesis errors, chromosomal instability, and oncogenesis

Chromosomal instability (CIN) and aneuploidy are commonly observed in the vast majority of human solid tumors and in many hematological malignancies. These features are considered defining characteristics of human breast, bladder and kidney cancers since they markedly exceed a 50% aneuploidy frequency. The detection of persistent mitotic kinase over-expression, particularly the Aurora family, and centrosome amplification in precursor/pre-malignant stages, strongly implicate these molecular changes in precipitating the aneuploidy seen in many human neoplasms. Mitotic spindle checkpoint defects may also lead to aneuploid tumors. However, the sustained over-expression and activity of various members of the mitotic kinase families, including Aurora (Aur) (A, B, C), Polo-like (Plk1-4), and Nek (NIMA1-11) in diverse human tumors strongly indicate that these entities are intimately involved in the development of errors in centrosome duplication, chromosome segregation, and cytokinesis. Mitotic kinases have also been implicated in regulating the centrosome cycle, spindle checkpoint and microtubule-kinetochore attachment, spindle assembly, and chromosome condensation. These mitotic kinases are modulated by de-novo synthesis, stability factors, phosphorylation, and ubiquitin-dependent proteolysis. They, in turn, phosphorylate a myriad of centrosomal/mitotic protein substrates, and have the ability to behave as oncogenes (i.e. Aur-A, Plk-1), providing a compelling link between errors in mitosis and oncogenic processes. The recent development of selective small molecule inhibitors of Aurora kinases, in particular, will provide useful tools to ascertain more precisely their role in cancer development. Potent inhibitors of mitotic kinases, when fully developed, have the promise to be effective agents against tumor growth, and possibly, tumor prevention as well.