Hypoxia-associated biomarkers in rectal cancer treated by preoperative radiotherapy or chemoradiotherapy

Hypoksiaan liittyvät biologiset merkkiaineet leikkausta edeltävällä sädehoidolla tai kemosädehoidolla hoidetussa peräsuolisyövässä Peräsuolensyöpä on yleinen pahanlaatuinen kasvain. Leikkausta edeltävä sädehoito annetaan yleensä T3-T4-kasvaimille. Tutkimuksella pyrittiin selvittämään, voidaanko kasvaimen hapenpuutteeseen liittyvillä biologisilla merkkiaineilla arvioida peräsuolisyövän ennustetta leikkausta edeltävän sädehoidon tai kemosädehoidon jälkeen. Tällaisia merkkiaineita ovat hapenpuutteen vaikutuksesta aktivoituva HIF-1alfa hiilihappoanhydraasi IX (CA IX), sokerin kuljetukseen solussa osallistuva GLUT-1 sekä solun tukirankaproteiini ezrin. Tutkimukseen otettiin 178 potilasta, jotka olivat saaneet ennen leikkausta lyhyen (n=77) tai pitkän sädehoidon (n=10), pitkän sädehoidon ja solunsalpaajahoidon (n=37) tai ei mitään hoitoa (n=54). Lisäksi osalta leikkausta edeltävää sädehoitoa saaneelta potilaalta tutkittiin hoitoja edeltävät, diagnostiset näytteet (n=80). Tutkimuksessa käytettiin immunehistokemiallisia värjäysmenetelmiä. Kasvaimen regressiota (TRG) arvioitiin pitkän sädehoidon jälkeisistä näytteistä. Leikkausnäytteissä negatiivinen/heikko CA IX intensiteetti liittyi sekä pidempään tautispesifiseen (p=0.034) että tautivapaaseen elinaikaan (p=0.003) ja pitkän sädehoidon jälkeen HIF-1alfa-negatiivisuus pidempään tautispesifiseen (p=0.001) sekä negatiivinen/heikko GLUT-1 pidempään tautivapaaseen elinaikaan (p=0.066). Voimakas ezrin-ilmentymä diagnostisissa näytteissä liittyi lyhyempään tautivapaaseen ja tautispesifiseen (p=0.027 ja p=0.002) ennusteeseen. Monimuuttuja-analyysissä vahva CA IX intensiteetti leikkausnäytteissä ennusti itsenäisesti huonompaa tautivapaata ja tautispesifistä selviytymistä. Erinomainen TRG liittyi negatiiviseen/heikkoon CA IX- (p=0.057), ezrin- (p=0.012) ja GLUT-1 -ilmentymään (p=0.013) leikkausnäytteissä. Kun kaikki neljä merkkiainetta analysoitiin yhdessä monimuuttuja-analyysissä, CA IX intensiteetti leikkausnäytteissä ennusti itsenäisesti tautispesifistä elinaikaa. Voimakas CA IX-ilmentymä leikkausnäytteissä ja positiivinen HIF-1alfa- ja vahva GLUT-1-ilmentymä pitkän sädehoidon jälkeisissä leikkausnäytteissä sekä vahva ezrin-ilmentymä diagnostisissa näytteissä liittyivät epäsuotuisaan ennusteeseen. Monimuuttujaanalyysissä kohtalainen/voimakas CA IX intensiteetti leikkausnäytteissä ennusti itsenäisesti huonompaa tautivapaata ja tautispesifistä elinaikaa. CA IX on vahva biologinen merkkiaine peräsuolisyövässä.Rectal cancer (RC) is a common malignancy. Preoperative radiotherapy (RT) is usually given to patients with T3-T4 tumours. The aim of the study was to assess hypoxiainducible factor-1alpha (HIF-1alpha), carbonic anhydrase IX (CA IX), ezrin and glucose transporter-1 (GLUT-1) expression as predictors of disease-free survival (DFS) and disease-specific survival (DSS) in RC treated by preoperative radiotherapy (RT) or chemoradiotherapy. Diagnostic biopsies (n=80) and corresponding operative samples from 178 consecutive RC patients, treated by short- (n= 77) or long-course RT with (n=37) or without (n=10) chemotherapy or no treatment preoperatively (n=54), were analysed for HIF-1alpha, CA IX, ezrin and GLUT-1 using immunohistochemistry (IHC). Tumour regression grade (TRG) was analysed after long-course RT. In operative samples, negative/weak (N/W) CA IX staining intensity was associated with favourable DFS (p=0.003) and DSS (p=0.034). After long-course RT, negative HIF- 1α expression was linked to longer DSS (p= 0.001) and N/W GLUT-1 (0.066) with longer DFS than with positive or strong expression of these markers. Moderate/strong (M/S) ezrin expression in biopsies was associated with unfavourable DFS (p=0.027) and DSS (p= 0.002). In multivariate analysis, M/S CA IX intensity in operative samples was an independent predictor of poor DFS and DSS. Excellent TRG was linked to N/W CA IX (p=0.057), ezrin(p=0.012) and GLUT-1(p=0.013) in operative samples. In multivariate model with all four markers, CA IX intensity in operative samples independently predicted DSS. In conclusion, positive HIF-1alpha expression and M/S expression of CA IX and GLUT-1 in operative samples as well as M/S ezrin in biopsies were related to unfavourable disease outcome. CA IX intensity in operative samples independently predicted DFS and DSS in multivariate analysis. Moderate/strong CA IX intensity is a powerful predictor of poor disease outcome in RC.Siirretty Doriast

Ezrin expression combined with MSI status in prognostication of stage II colorectal cancer

Currently used factors predicting disease recurrence in stage II colorectal cancer patients are not optimal for risk stratification. Thus, new biomarkers are needed. In this study the applicability of ezrin protein expression together with MSI status and BRAF mutation status were tested in predicting disease outcome in stage II colorectal cancer. The study population consisted of 173 stage II colorectal cancer patients. Paraffin-embedded cancer tissue material from surgical specimens was used to construct tissue microarrays (TMAs) with next-generation technique. The TMA-slides were subjected to following immunohistochemical stainings: MLH1, MSH2, MSH6, PMS2, ezrin and anti-BRAF V600E antibody. The staining results were correlated with clinicopathological variables and survival. In categorical analysis, high ezrin protein expression correlated with poor disease-specific survival (p = 0.038). In univariate analysis patients having microsatellite instabile / low ezrin expression tumors had a significantly longer disease-specific survival than patients having microsatellite stable / high ezrin expression tumors (p = 0.007). In multivariate survival analysis, the presence of BRAF mutation was associated to poor overall survival (p = 0.028, HR 3.29, 95% CI1.14-9.54). High ezrin protein expression in patients with microsatellite stable tumors was linked to poor disease-specific survival (p = 0.01, HR 5.68, 95% CI 1.53-21.12). Ezrin protein expression is a promising biomarker in estimating the outcome of stage II colorectal cancer patients. When combined with microsatellite status its ability in predicting disease outcome is further improved.Peer reviewe

Haimasyövän nykyhoito

VertaisarvioituToteamishetkellä vain 10–20 % haimasyövistä voidaan hoitaa radikaalileikkauksella. Ennustetta pyritään parantamaan kehittämällä varhaisdiagnostiikkaa ja keskittämällä leikkaushoitoa. Jopa puolet leikkauspotilaista saa komplikaatioita, mutta suuri osa on hoidettavissa ilman uusintaleikkausta. Leikkauskuolleisuus on alle 4 %. Leikkausta edeltävän solunsalpaajahoidon käyttö on lisääntynyt. Prospektiivisten tutkimusten tuloksia odotetaan.Peer reviewe

Lymfoomahoitojen jälkeiset pitkäaikaishaitat, niiden ehkäisy ja seuranta

Myöhäishaitat ovat edelleen tavallisia lymfoomahoitojen jälkeen, ja niiden riski jatkuu koko elämän. Vaikka hoitojen kehittyminen on vähentänyt haittoja, varsinkin sekundaarisyövät sekä sydän- ja verisuonitaudit aiheuttavat ylikuolleisuutta. Perusterveydenhuollon tuleekin olla tietoinen mahdollisista ongelmista ja hoitaa riskitekijöitä tehokkaasti. Psykososiaalisten haittojen ehkäisemiseksi tarvitaan lisää tukea potilaille. Suomen Lymfoomaryhmä on tehnyt suosituksen myöhäishaittojen ehkäisemiseksi ja seuraamiseksi. </p

CDX2 Loss With Microsatellite Stable Phenotype Predicts Poor Clinical Outcome in Stage II Colorectal Carcinoma

Current risk factors in stage II colorectal carcinoma are insufficient to guide treatment decisions. Loss of CDX2 has been shown to associate with poor clinical outcome and predict benefit for adjuvant chemotherapy in stage II and III colorectal carcinoma. The prognostic relevance of CDX2 in stage II disease has not been sufficiently validated, especially in relation to clinical risk factors, such as microsatellite instability (MSI) status, BRAF mutation status, and tumor budding. In this study, we evaluated the protein expression of CDX2 in tumor center and front areas in a tissue microarrays material of stage II colorectal carcinoma patients (n=232). CDX2 expression showed a partial or total loss in respective areas in 8.6% and 10.9% of patient cases. Patients with loss of CDX2 had shorter disease-specific survival when scored independently either in tumor center or tumor front areas (log rank P=0.012; P=0.012). Loss of CDX2 predicted survival independently of other stage II risk factors, such as MSI status and BRAF mutation status, pT class, and tumor budding (hazard ratio=5.96, 95% confidence interval=1.55-22.95; hazard ratio=3.70, 95% confidence interval=1.30-10.56). Importantly, CDX2 loss predicted inferior survival only in patients with microsatellite stable, but not with MSI-high phenotype. Interestingly, CDX2 loss associated with low E-cadherin expression, tight junction disruption, and high expression of ezrin protein. The work demonstrates that loss of CDX2 is an independent risk factor of poor disease-specific survival in stage II colorectal carcinoma. Furthermore, the study suggests that CDX2 loss is linked with epithelial-to-mesenchymal transition independently of tumor budding.Peer reviewe

Lymfoomahoitojen jälkeiset pitkäaikaishaitat, niiden ehkäisy ja seuranta

Vertaisarvioitu. English summary.Myöhäishaitat ovat edelleen tavallisia lymfoomahoitojen jälkeen, ja niiden riski jatkuu koko elämän. Vaikka hoitojen kehittyminen on vähentänyt haittoja, varsinkin sekundaarisyövät sekä sydän- ja verisuonitaudit aiheuttavat ylikuolleisuutta. Perusterveydenhuollon tuleekin olla tietoinen mahdollisista ongelmista ja hoitaa riskitekijöitä tehokkaasti. Psykososiaalisten haittojen ehkäisemiseksi tarvitaan lisää tukea potilaille. Suomen Lymfoomaryhmä on tehnyt suosituksen myöhäishaittojen ehkäisemiseksi ja seuraamiseksi.Peer reviewe

Combined epithelial marker analysis of tumour budding in stage II colorectal cancer

Tumour budding predicts survival of stage II colorectal cancer (CRC) and has been suggested to be associated with epithelial-to-mesenchymal transition (EMT). However, the underlying molecular changes of tumour budding remain poorly understood. Here, we performed multiplex immunohistochemistry (mIHC) to phenotypically profile tumours using known EMT-associated markers: E-cadherin (adherence junctions), integrin beta 4 (ITGB4; basement membrane), ZO-1 (tight junctions), and pan-cytokeratin. A subpopulation of patients showed high ITGB4 expression in tumour buds, and this coincided with a switch of ITGB4 localisation from the basal membrane of intact epithelium to the cytoplasm of budding cells. Digital image analysis demonstrated that tumour budding with high ITGB4 expression in tissue microarray (TMA) cores correlated with tumour budding assessed from haematoxylin and eosin (H&E) whole sections and independently predicted poor disease-specific survival in two independent stage II CRC cohorts (hazard ratio [HR] = 4.50 (95% confidence interval [CI] = 1.50-13.5), n = 232; HR = 3.52 (95% CI = 1.30-9.53), n = 72). Furthermore, digitally obtained ITGB4-high bud count in random TMA cores was better associated with survival outcome than visual tumour bud count in corresponding H&E-stained samples. In summary, the mIHC-based phenotypic profiling of human tumour tissue shows strong potential for the molecular characterisation of tumour biology and for the discovery of novel prognostic biomarkers.Peer reviewe

Protein phosphatase 2A (PP2A) inhibitor CIP2A indicates resistance to radiotherapy in rectal cancer

Preoperative (chemo)radiotherapy, (C)RT, is an essential part of the treatment of rectal cancer patients, but tumor response to this therapy among patients is variable. Thus far, there are no clinical biomarkers that could be used to predict response to (C)RT or to stratify patients into different preoperative treatment groups according to their prognosis. Overexpression of cancerous inhibitor of protein phosphatase 2A (CIP2A) has been demonstrated in several cancers and is frequently associated with reduced survival. Recently, high CIP2A expression has also been indicated to contribute to radioresistance in head and neck squamous cell carcinoma, but few studies have examined the connection between CIP2A and radiation response regarding other malignancies. We have evaluated CIP2A protein expression levels in relation to tumor regression after preoperative (C)RT and survival of rectal adenocarcinoma patients. The effects of CIP2A knockdown by siRNA on cell survival were further investigated in colorectal cancer cells exposed to radiation. Patients with low-CIP2A-expressing tumors had more frequently moderate or excellent response to long-course (C)RT than patients with high-CIP2A-expressing tumors. They also had higher 36-month disease-specific survival (DSS) rate in categorical analysis. In the multivariate analysis, low CIP2A expression level remained as an independent predictive factor for increased DSS. Suppression of CIP2A transcription by siRNA was found to sensitize colorectal cancer cells to irradiation and decrease their survival in vitro. In conclusion, these results suggest that by contributing to radiosensitivity of cancer cells, low CIP2A protein expression level associates with a favorable response to long-course (C)RT in rectal cancer patients.</p

EGFR gene copy number decreases during anti-EGFR antibody therapy in colorectal cancer

Epidermal growth factor receptor (EGFR) gene copy number (GCN) increase is associated with a favorable anti-EGFR antibody treatment response in RAS wild-type metastatic colorectal cancer. However, there are limited and comparative data regarding the EGFR GCN in primary colorectal cancer tumors and corresponding metastases or the effect of anti-EGFR antibody treatment on EGFR GCN in recurrent disease. In addition, little is known about the potential EGFR GCN changes during anti-EGFR therapy in comparison with other treatment regimens. EGFR GCN was analyzed by EGFR immunohistochemistry-guided silver in situ hybridization in primary and corresponding recurrent local or metastatic tumors from 80 colorectal cancer patients. GCN levels were compared between KRAS wild-type patients having received anti-EGFR therapy and patients having received other forms of treatment after primary surgery. The EGFR GCN decrease between primary and recurrent tumors was more pronounced among the anti–EGFR-treated patients than among patients not treated with anti-EGFR therapy (P = .047). None of the patients experiencing an EGFR GCN increase of at least 1.0 between the primary and recurrent tumors were treated with anti-EGFR antibodies. When including only patients with distant metastases, an EGFR GCN decrease of at least 1.0 was more common among the anti–EGFR-treated patients than among patients not treated with anti-EGFR therapy (P = .028). Our results suggest that anti-EGFR antibody treatment is associated with EGFR GCN decrease between the primary and recurrent colorectal adenocarcinomas, whereas no GCN change is observed among patients receiving other forms of treatment after primary surgery.</p

Combined epithelial marker analysis of tumour budding in stage II colorectal cancer

Tumour budding predicts survival of stage II colorectal cancer (CRC) and has been suggested to be associated with epithelial‐to‐mesenchymal transition (EMT). However, the underlying molecular changes of tumour budding remain poorly understood. Here, we performed multiplex immunohistochemistry (mIHC) to phenotypically profile tumours using known EMT‐associated markers: E‐cadherin (adherence junctions), integrin β4 (ITGB4; basement membrane), ZO‐1 (tight junctions), and pan‐cytokeratin. A subpopulation of patients showed high ITGB4 expression in tumour buds, and this coincided with a switch of ITGB4 localisation from basal membrane of intact epithelium to the cytoplasm of budding cells. Digital image analysis revealed that tumour budding with high ITGB4 expression in tissue microarray (TMA) cores correlated with tumour budding assessed from H&E whole‐sections and independently predicted poor disease‐specific survival in two independent stage II CRC cohorts (hazard ratio (HR) =4 .50 (95% CI=1.50–13.5), n=232; HR=3.52 (95% CI=1.30‐9.53), n=72). Furthermore, digitally obtained ITGB4‐high bud count in random TMA cores associated better with survival outcome than visual tumour bud count in corresponding H&E stained samples. In summary, the mIHC‐based phenotypic profiling of human tumour tissue shows strong potential for the molecular characterisation of tumour biology and for the discovery of novel prognostic biomarkers.</p