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Galon J, Kawakami Y, Torigoe T, Wang Y, Patel P, Vora H, Mlecnik B, Marliot F, Bifulco C, Lugli A, Nagtegaal I, Hartmann A, van den Eynde M, Roehrl M, Ohashi P, Zavadova E, Marincola F, Ascierto P, Fox B, Pagès F. 79O Clinical performance of Immunoscore® in early colon cancer in the Asian population. Ann Oncol 2020. [DOI: 10.1016/j.annonc.2020.10.099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Mlecnik B, Bifulco C, Marliot F, Lugli A, Nagtegaal I, Hartmann A, Eynde MVD, Roehrl M, Ohashi P, Zavadova E, Torigoe T, Patel P, Wang Y, Kawakami Y, Hermitte F, Marincola F, Ascierto P, Fox B, Pagès F, Galon J. O-17 A TNM-Immune (TNM-I) classification staging system for predicting survival in colon cancer in a multicenter international SITC study. Ann Oncol 2020. [DOI: 10.1016/j.annonc.2020.04.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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3
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Bokhorst JM, Blank A, Lugli A, Zlobec I, Dawson H, Vieth M, Rijstenberg LL, Brockmoeller S, Urbanowicz M, Flejou JF, Kirsch R, Ciompi F, van der Laak JAWM, Nagtegaal ID. Assessment of individual tumor buds using keratin immunohistochemistry: moderate interobserver agreement suggests a role for machine learning. Mod Pathol 2020; 33:825-833. [PMID: 31844269 PMCID: PMC7190566 DOI: 10.1038/s41379-019-0434-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 11/07/2019] [Accepted: 11/23/2019] [Indexed: 02/07/2023]
Abstract
Tumor budding is a promising and cost-effective biomarker with strong prognostic value in colorectal cancer. However, challenges related to interobserver variability persist. Such variability may be reduced by immunohistochemistry and computer-aided tumor bud selection. Development of computer algorithms for this purpose requires unequivocal examples of individual tumor buds. As such, we undertook a large-scale, international, and digital observer study on individual tumor bud assessment. From a pool of 46 colorectal cancer cases with tumor budding, 3000 tumor bud candidates were selected, largely based on digital image analysis algorithms. For each candidate bud, an image patch (size 256 × 256 µm) was extracted from a pan cytokeratin-stained whole-slide image. Members of an International Tumor Budding Consortium (n = 7) were asked to categorize each candidate as either (1) tumor bud, (2) poorly differentiated cluster, or (3) neither, based on current definitions. Agreement was assessed with Cohen's and Fleiss Kappa statistics. Fleiss Kappa showed moderate overall agreement between observers (0.42 and 0.51), while Cohen's Kappas ranged from 0.25 to 0.63. Complete agreement by all seven observers was present for only 34% of the 3000 tumor bud candidates, while 59% of the candidates were agreed on by at least five of the seven observers. Despite reports of moderate-to-substantial agreement with respect to tumor budding grade, agreement with respect to individual pan cytokeratin-stained tumor buds is moderate at most. A machine learning approach may prove especially useful for a more robust assessment of individual tumor buds.
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Affiliation(s)
- J. M. Bokhorst
- grid.10417.330000 0004 0444 9382Radboud University Medical Center, Nijmegen, Netherlands
| | - A. Blank
- grid.5734.50000 0001 0726 5157University of Bern, Bern, Switzerland
| | - A. Lugli
- grid.5734.50000 0001 0726 5157University of Bern, Bern, Switzerland
| | - I. Zlobec
- grid.5734.50000 0001 0726 5157University of Bern, Bern, Switzerland
| | - H. Dawson
- grid.5734.50000 0001 0726 5157University of Bern, Bern, Switzerland
| | - M. Vieth
- grid.7384.80000 0004 0467 6972University of Bayreuth, Bayreuth, Germany
| | - L. L. Rijstenberg
- grid.10417.330000 0004 0444 9382Radboud University Medical Center, Nijmegen, Netherlands
| | - S. Brockmoeller
- grid.9909.90000 0004 1936 8403University of Leeds, Leeds, UK
| | - M. Urbanowicz
- grid.418936.10000 0004 0610 0854EORTC Translational Research Unit, Brussels, Belgium
| | - J. F. Flejou
- grid.412370.30000 0004 1937 1100Saint-Antoine Hospital, Paris, France
| | - R. Kirsch
- grid.17063.330000 0001 2157 2938University of Toronto, Toronto, Canada
| | - F. Ciompi
- grid.10417.330000 0004 0444 9382Radboud University Medical Center, Nijmegen, Netherlands
| | - J. A. W. M. van der Laak
- grid.10417.330000 0004 0444 9382Radboud University Medical Center, Nijmegen, Netherlands ,grid.5640.70000 0001 2162 9922Center for Medical Image Science and Visualization, Linköping University, Linköping, Sweden
| | - I. D. Nagtegaal
- grid.10417.330000 0004 0444 9382Radboud University Medical Center, Nijmegen, Netherlands
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Galon J, Hermitte F, Mlecnik B, Marliot F, Bifulco C, Lugli A, Nagtegaal I, Hartmann A, van den Eynde M, Roehrl M, Ohashi P, Zavadova E, Torigoe T, Patel P, Wang Y, Kawakami Y, Marincola F, Ascierto P, Fox B, Pagès F. Immunoscore predicts significant differences in time to recurrence in stage I colon cancer patients. Ann Oncol 2019. [DOI: 10.1093/annonc/mdz421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Dawson H, Blank A, Zlobec I, Lugli A. Potential clinical scenarios of tumour budding in colorectal cancer. Acta Gastroenterol Belg 2019; 82:515-518. [PMID: 31950807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Tumour budding, defined as single tumour cells or clusters of 4 tumour cells or less detached from the main tumour body, is a wellestablished indicator of aggressive tumour biology in colorectal cancer. As a marker of tumour dissemination, evidence points towards tumour budding as a morphological correlate of epithelialmesenchymal type changes in the tumour microenvironment. Despite many studies in the literature going back decades, tumour budding has not been systematically integrated in colorectal cancer reporting protocols. The recently published proceedings of the International Tumour Budding Consensus Conference (ITBCC) have sparked the systematic implementation of tumour budding in routine reporting of colorectal cancer. Tumour budding may be particularly relevant to patient management in endoscopically resected pT1 colorectal cancer, stage II tumour and pre-operative biopsies. The present review focuses mainly on these three potential clinical scenarios with the aim to provide a concise and updated overview on tumour budding in CRC.
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Affiliation(s)
- H Dawson
- Clinical Pathology Division, Institute of Pathology, University of Bern, Bern, Switzerland
| | - A Blank
- Clinical Pathology Division, Institute of Pathology, University of Bern, Bern, Switzerland
| | - I Zlobec
- Translational Research Unit, Institute of Pathology, University of Bern, Bern, Switzerland
| | - A Lugli
- Clinical Pathology Division, Institute of Pathology, University of Bern, Bern, Switzerland
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Galon J, Hermitte F, Mlecnik B, Marliot F, Bifulco C, Lugli A, Nagtegaal I, Hartmann A, Van den Eynde M, Roehrl M, Ohashi P, Zavadova E, Torigoe T, Patel P, Wang Y, Kawakami Y, Marincola F, Ascierto P, Fox B, Pagès F. Significant differences in outcome between Immunoscore categories in stage I colon cancer patients. Ann Oncol 2019. [DOI: 10.1093/annonc/mdz154.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Koelzer VH, Glatz K, Bubendorf L, Weber A, Gaspert A, Cathomas G, Lugli A, Zippelius A, Kempf W, Mertz KD. [The pathology of adverse events with immune checkpoint inhibitors]. Pathologe 2019; 38:197-208. [PMID: 28421272 DOI: 10.1007/s00292-017-0281-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Immunotherapy has gained importance with the development of new effective cancer treatments. Immune checkpoint inhibitors (ICI) are monoclonal antibodies that promote T‑cell mediated tumor immune rejection. Checkpoint blockade also carries the risk of inducing autoimmune reactions ("immune related adverse events", irAEs). The diagnosis and classification of irAEs constitute a new and important field in pathology. AIM Practice-oriented review of the diagnosis and classification of irAEs. MATERIALS AND METHODS Structured, selective literature review based on PubMed und UpToDate ® online. RESULTS The most common irAEs affect the skin, the gastrointestinal tract, the liver, and the respiratory system. The correct diagnosis and classification of irAEs by an interdisciplinary care team is essential for appropriate therapy and the prevention of long-term sequelae. Other important irAEs affect the endocrine organs, the heart, the joints, the kidneys and the nervous system. Because of their rarity and/or limited options for bioptic diagnosis, only limited data on the morphology and pathophysiology of these irAEs are currently available. Autopsies carried out after ICI therapy constitute an important element of quality control and allow better documentation of the incidence and pathogenesis of irAEs. DISCUSSION Pathology plays a central role in the diagnosis and treatment of irAEs. Future studies may contribute to a better mechanistic understanding of irAEs for individualized knowledge-based risk assessment.
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Affiliation(s)
- V H Koelzer
- Institut für Pathologie, Kantonsspital Baselland, Mühlemattstraße 11, 4410, Liestal, Schweiz.,Translational Research Unit (TRU), Institut für Pathologie, Universität Bern, Bern, Schweiz
| | - K Glatz
- Institut für Pathologie, Universitätsspital Basel, Basel, Schweiz
| | - L Bubendorf
- Institut für Pathologie, Universitätsspital Basel, Basel, Schweiz
| | - A Weber
- Institut für Pathologie und Molekularpathologie, Universität Zürich und Universitätsspital Zürich, Zürich, Schweiz
| | - A Gaspert
- Institut für Pathologie und Molekularpathologie, Universität Zürich und Universitätsspital Zürich, Zürich, Schweiz
| | - G Cathomas
- Institut für Pathologie, Kantonsspital Baselland, Mühlemattstraße 11, 4410, Liestal, Schweiz
| | - A Lugli
- Klinische Pathologie, Institut für Pathologie, Universität Bern, Bern, Schweiz
| | - A Zippelius
- Klinik für Onkologie, Universitätsspital Basel, Basel, Schweiz
| | - W Kempf
- Kempf und Pfaltz Histologische Diagnostik, Research Unit, Zürich, Schweiz
| | - K D Mertz
- Institut für Pathologie, Kantonsspital Baselland, Mühlemattstraße 11, 4410, Liestal, Schweiz.
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Galon J, Mlecnik B, Hermitte F, Marliot F, Bifulco C, Lugli A, Nagtegaal I, Hartmann A, van den Eynde M, Roehrl M, Ohashi P, Zavadova E, Torigoe T, Patel P, Wang Y, Kawakami Y, Marincola F, Ascierto P, Fox B, Pagès F. MSI status plus immunoscore to select metastatic colorectal cancer patients for immunotherapies. Ann Oncol 2018. [DOI: 10.1093/annonc/mdy493.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Affiliation(s)
- A Blank
- Institut für Pathologie, Universität Bern, Murtenstraße 31, 3008, Bern, Schweiz.
| | - H Dawson
- Institut für Pathologie, Universität Bern, Murtenstraße 31, 3008, Bern, Schweiz
| | - C Hammer
- Institut für Pathologie, Universität Bern, Murtenstraße 31, 3008, Bern, Schweiz
| | - A Perren
- Institut für Pathologie, Universität Bern, Murtenstraße 31, 3008, Bern, Schweiz
| | - A Lugli
- Institut für Pathologie, Universität Bern, Murtenstraße 31, 3008, Bern, Schweiz
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Amicarella F, Muraro MG, Hirt C, Cremonesi E, Padovan E, Mele V, Governa V, Han J, Huber X, Droeser RA, Zuber M, Adamina M, Bolli M, Rosso R, Lugli A, Zlobec I, Terracciano L, Tornillo L, Zajac P, Eppenberger-Castori S, Trapani F, Oertli D, Iezzi G. Dual role of tumour-infiltrating T helper 17 cells in human colorectal cancer. Gut 2017; 66:692-704. [PMID: 26719303 PMCID: PMC5529969 DOI: 10.1136/gutjnl-2015-310016] [Citation(s) in RCA: 124] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Revised: 11/11/2015] [Accepted: 11/30/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND The immune contexture predicts prognosis in human colorectal cancer (CRC). Whereas tumour-infiltrating CD8+ T cells and myeloid CD16+ myeloperoxidase (MPO)+ cells are associated with favourable clinical outcome, interleukin (IL)-17-producing cells have been reported to correlate with severe prognosis. However, their phenotypes and functions continue to be debated. OBJECTIVE To investigate clinical relevance, phenotypes and functional features of CRC-infiltrating, IL-17-producing cells. METHODS IL-17 staining was performed by immunohistochemistry on a tissue microarray including 1148 CRCs. Phenotypes of IL-17-producing cells were evaluated by flow cytometry on cell suspensions obtained by enzymatic digestion of clinical specimens. Functions of CRC-isolated, IL-17-producing cells were assessed by in vitro and in vivo experiments. RESULTS IL-17+ infiltrates were not themselves predictive of an unfavourable clinical outcome, but correlated with infiltration by CD8+ T cells and CD16+ MPO+ neutrophils. Ex vivo analysis showed that tumour-infiltrating IL-17+ cells mostly consist of CD4+ T helper 17 (Th17) cells with multifaceted properties. Indeed, owing to IL-17 secretion, CRC-derived Th17 triggered the release of protumorigenic factors by tumour and tumour-associated stroma. However, on the other hand, they favoured recruitment of beneficial neutrophils through IL-8 secretion and, most importantly, they drove highly cytotoxic CCR5+CCR6+CD8+ T cells into tumour tissue, through CCL5 and CCL20 release. Consistent with these findings, the presence of intraepithelial, but not of stromal Th17 cells, positively correlated with improved survival. CONCLUSIONS Our study shows the dual role played by tumour-infiltrating Th17 in CRC, thus advising caution when developing new IL-17/Th17 targeted treatments.
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Affiliation(s)
- F Amicarella
- Department of Biomedicine, Institute of Surgical Research, University of Basel, Basel, Switzerland
| | - M G Muraro
- Department of Biomedicine, Institute of Surgical Research, University of Basel, Basel, Switzerland
| | - C Hirt
- Department of Biomedicine, Institute of Surgical Research, University of Basel, Basel, Switzerland
| | - E Cremonesi
- Department of Biomedicine, Institute of Surgical Research, University of Basel, Basel, Switzerland
| | - E Padovan
- Department of Biomedicine, Institute of Surgical Research, University of Basel, Basel, Switzerland
| | - V Mele
- Department of Biomedicine, Institute of Surgical Research, University of Basel, Basel, Switzerland
| | - V Governa
- Department of Biomedicine, Institute of Surgical Research, University of Basel, Basel, Switzerland,Institute of Pathology, University of Basel, Basel, Switzerland
| | - J Han
- Department of Biomedicine, Institute of Surgical Research, University of Basel, Basel, Switzerland,Department of General Surgery, Shanghai East Hospital, Tongji University, Shanghai, China
| | - X Huber
- Department of Biomedicine, Institute of Surgical Research, University of Basel, Basel, Switzerland,Department of General Surgery, University Hospital Basel, Basel, Switzerland
| | - R A Droeser
- Department of General Surgery, University Hospital Basel, Basel, Switzerland
| | - M Zuber
- Department of Visceral Surgery, Kantonsspital Olten, Olten, Switzerland
| | - M Adamina
- Department of Visceral Surgery, Kantonsspital St Gallen, St. Gallen, Switzerland
| | - M Bolli
- Department of Visceral Surgery, St Claraspital, Basel, Switzerland
| | - R Rosso
- Department of Visceral Surgery, Ospedale Civico Lugano, Lugano, Switzerland
| | - A Lugli
- Institute of Pathology, University of Bern, Bern, Switzerland
| | - I Zlobec
- Institute of Pathology, University of Bern, Bern, Switzerland
| | - L Terracciano
- Institute of Pathology, University of Basel, Basel, Switzerland
| | - L Tornillo
- Institute of Pathology, University of Basel, Basel, Switzerland
| | - P Zajac
- Department of Biomedicine, Institute of Surgical Research, University of Basel, Basel, Switzerland
| | | | - F Trapani
- Institute of Pathology, University of Basel, Basel, Switzerland
| | - D Oertli
- Department of General Surgery, University Hospital Basel, Basel, Switzerland
| | - G Iezzi
- Department of Biomedicine, Institute of Surgical Research, University of Basel, Basel, Switzerland
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Seeber A, Spizzo G, Terracciano L, Lugli A, Steiner N, Mazzoleni G, Gastl G, Fong D. Truncated Epcam is Associated with a More Aggressive Phenotype and Predicts Poor Overall Survival in Colorectal Cancer. Ann Oncol 2014. [DOI: 10.1093/annonc/mdu326.52] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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12
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Zlobec I, Hädrich M, Dawson H, Koelzer VH, Borner M, Mallaev M, Schnüriger B, Inderbitzin D, Lugli A. Intratumoural budding (ITB) in preoperative biopsies predicts the presence of lymph node and distant metastases in colon and rectal cancer patients. Br J Cancer 2013; 110:1008-13. [PMID: 24366305 PMCID: PMC3929877 DOI: 10.1038/bjc.2013.797] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Revised: 11/29/2013] [Accepted: 12/02/2013] [Indexed: 02/08/2023] Open
Abstract
Background: In colorectal cancer (CRC), tumour budding at the invasion front is associated with lymph node (LN) and distant metastasis. Interestingly, tumour budding can also be detected in biopsies (intratumoural budding; ITB) and may have similar clinical importance. Here we investigate whether ITB in preoperative CRC biopsies can be translated into daily diagnostic practice. Methods: Preoperative biopsies from 133 CRC patients (no neoadjuvant therapy) underwent immunohistochemistry for pan-cytokeratin marker AE1/AE3. Across all biopsies for each patient, the densest region of buds at × 40 (high-power field; HPF) was identified and buds were counted. Results: A greater number of tumour buds in the biopsy was associated with pT stage (P=0.0143), LN metastasis (P=0.0007), lymphatic (P=0.0065) and venous vessel invasion (P=0.0318) and distant metastasis (cM1) (P=0.0013). Using logistic regression, a ‘scale' was developed to estimate the probability of LN and distant metastasis using the number of tumour buds (e.g. 10 buds per HPF: 64% chance of LN metastasis; 30 buds per HPF: 86% chance). Inter-observer agreement for ITB was excellent (intraclass correlation coefficient: 0.813). Conclusion: Tumour budding can be assessed in the preoperative biopsy of CRC patients. It is practical, reproducible and predictive of LN and distant metastasis. Intratumoural budding qualifies for further investigation in the prospective setting.
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Affiliation(s)
- I Zlobec
- Translational Research Unit (TRU), Institute of Pathology, University of Bern, Bern, Switzerland
| | - M Hädrich
- Department of Visceral Surgery and Medicine, Bern University Hospital, Bern, Switzerland
| | - H Dawson
- 1] Translational Research Unit (TRU), Institute of Pathology, University of Bern, Bern, Switzerland [2] Division of Clinical Pathology, Institute of Pathology, University of Bern, Bern, Switzerland
| | - V H Koelzer
- 1] Translational Research Unit (TRU), Institute of Pathology, University of Bern, Bern, Switzerland [2] Division of Clinical Pathology, Institute of Pathology, University of Bern, Bern, Switzerland
| | - M Borner
- Department of Oncology, Hospital Centre Biel, Biel, Switzerland
| | - M Mallaev
- 1] Translational Research Unit (TRU), Institute of Pathology, University of Bern, Bern, Switzerland [2] Department of Visceral Surgery and Medicine, Bern University Hospital, Bern, Switzerland
| | - B Schnüriger
- Department of Visceral Surgery and Medicine, Bern University Hospital, Bern, Switzerland
| | - D Inderbitzin
- Department of Visceral Surgery and Medicine, Bern University Hospital, Bern, Switzerland
| | - A Lugli
- 1] Translational Research Unit (TRU), Institute of Pathology, University of Bern, Bern, Switzerland [2] Division of Clinical Pathology, Institute of Pathology, University of Bern, Bern, Switzerland
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Koelzer VH, Karamitopoulou E, Dawson H, Kondi-Pafiti A, Zlobec I, Lugli A. Geographic analysis of RKIP expression and its clinical relevance in colorectal cancer. Br J Cancer 2013; 108:2088-96. [PMID: 23632477 PMCID: PMC3670488 DOI: 10.1038/bjc.2013.197] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Background: This study evaluates the geographic expression pattern of Raf-1 Kinase Inhibitor Protein (RKIP) in colorectal cancer (CRC) in correlation with clinicopathological and molecular features, markers of epithelial-mesenchymal transition (EMT) and survival outcome. Methods: Whole-tissue sections of 220 well-characterised CRCs were immunostained for RKIP. NF-κB and E-Cadherin expression was assessed using a matched multi-punch tissue microarray. Analysis of mismatch repair (MMR) protein expression, B-Raf and KRAS mutations was performed. RKIP expression in normal mucosa, tumour centre, invasion front and tumour buds was each assessed for clinical relevance. Results: RKIP was diffusely expressed in normal mucosa and progressively lost towards tumour centre and front (P<0.0001). Only 0.9% of tumour buds were RKIP-positive. In the tumour centre, RKIP deficiency predicted metastatic disease (P=0.0307), vascular invasion (P=0.0506), tumour budding (P=0.0112) and an invasive border configuration (P=0.0084). Loss of RKIP correlated with NF-κB activation (P=0.0002) and loss of E-Cadherin (P<0.0001). Absence of RKIP was more common in MMR-deficient cancers (P=0.0191), while no impact of KRAS and B-Raf mutation was observed. RKIP in the tumour centre was identified as a strong prognostic indicator (HR (95% CI): 2.13 (1.27–3.56); P=0.0042) independently of TNM classification and therapy (P=0.0474). Conclusion: The clinical relevance of RKIP expression as an independent prognostic factor is restricted to the tumour centre. Loss of RKIP predicts features of EMT and correlates with frequent distant metastasis.
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Affiliation(s)
- V H Koelzer
- Clinical Pathology Division and Translational Research Unit, Institute of Pathology, University of Bern, Murtenstrasse 31, CH-3010 Bern, Switzerland.
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Karamitopoulou E, Zlobec I, Born D, Kondi-Pafiti A, Lykoudis P, Mellou A, Gennatas K, Gloor B, Lugli A. Tumour budding is a strong and independent prognostic factor in pancreatic cancer. Eur J Cancer 2012. [PMID: 23177090 DOI: 10.1016/j.ejca.2012.10.022] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Pancreatic ductal adenocarcinoma (PDAC) is a highly aggressive cancer that escapes detection and resists treatment. Tumour budding, defined as the presence of de-differentiated single tumour cells or small cell clusters at the invasive front of gastrointestinal carcinomas like colorectal, oesophageal, gastric and ampullary, is linked to adverse prognosis. Tumour budding has not yet been reported in PDAC. AIM To assess the frequency and prognostic impact of tumour budding in PDAC. METHODS Whole-tissue sections of 117 PDACs with full clinico-pathological and follow-up information, including postoperative therapy, were stained using a pancytokeratin marker. Tumour budding was assessed in 10 high-power fields (HPFs) by two pathologists. High-grade budding was defined as an average of >10buds across 10HPFs. Measurements were correlated to patient and tumour characteristics. The study was performed according to the REMARK guidelines. RESULTS Inter-observer agreement was considered strong (ICC=0.72). Low-grade budding was observed in 29.7% and high-grade budding in 70.3% cases. High-grade budding was linked to advanced pT classification (p=0.0463), lymphatic invasion (p=0.0192) and decreased disease-free (p=0.0005) and overall survival (p<0.0001). There was no association with pN, pM, R-status or blood vessel invasion. In multivariate analysis, the prognostic effect of tumour budding was independent of lymph node metastasis, lymphatic invasion and R-status (p<0.0001; HR (95% CI): 3.65 (2.1-6.4)). CONCLUSIONS Our results show that high-grade tumour budding occurs frequently in PDAC and is a strong, independent and reproducible, highly unfavourable prognostic factor that could be used to guide future individualised therapeutic approaches.
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Affiliation(s)
- E Karamitopoulou
- Institute of Pathology, University of Bern, Murtenstrasse 31, Bern, Switzerland.
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Lugli A, Karamitopoulou E, Zlobec I. Tumour budding: a promising parameter in colorectal cancer. Br J Cancer 2012; 106:1713-7. [PMID: 22531633 PMCID: PMC3364122 DOI: 10.1038/bjc.2012.127] [Citation(s) in RCA: 126] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2011] [Revised: 03/13/2012] [Accepted: 03/13/2012] [Indexed: 02/07/2023] Open
Abstract
In 2011, the Tumour Node Metastasis (TNM) staging system still remains the gold standard for stratifying colorectal cancer (CRC) patients into prognostic subgroups, and is considered a solid basis for treatment management. Nevertheless, there is still a challenge with regard to therapeutic strategy; stage II patients are not typically selected for postoperative adjuvant chemotherapy, although some stage II patients have a comparable outcome to stage III patients who, themselves do receive such treatment. Consequently, there has been an inundation of 'prognostic biomarker' studies aiming to improve the prognostic stratification power of the TNM staging system. Most proposed biomarkers are not implemented because of lack of reproducibility, validation and standardisation. This problem can be partially resolved by following the REMARK guidelines. In search of novel prognostic factors for patients with CRC, one might glance at a table in the book entitled 'Prognostic Factors in Cancer' published by the International Union against Cancer (UICC) in 2006, in which TNM stage, L and V classifications are considered 'essential' prognostic factors, whereas tumour grade, perineural invasion, tumour budding and tumour-border configuration among others are proposed as 'additional' prognostic factors. Histopathology reports normally include the 'essential' features and are accompanied by tumour grade, histological subtype and information on perineural invasion, but interestingly, the tumour-border configuration (i.e., growth pattern) and especially tumour budding are rarely reported. Although scoring systems such as the 'BRE' in breast and 'Gleason' in prostate cancer are solidly based on histomorphological features and used in daily practice, no such additional scoring system to complement TNM staging is available for CRC. Regardless of differences in study design and methods for tumour-budding assessment, the prognostic power of tumour budding has been confirmed by dozens of study groups worldwide, suggesting that tumour budding may be a valuable candidate for inclusion into a future prognostic scoring system for CRC. This mini-review therefore attempts to present a short and concise overview on tumour budding, including morphological, molecular and prognostic aspects underlining its inter-disciplinary relevance.
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Affiliation(s)
- A Lugli
- Clinical Pathology Division, Institute of Pathology, University of Bern, Murtenstrasse 31, Bern 3010, Switzerland.
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Khanlari B, Buser A, Lugli A, Tichelli A, Dirnhofer S. The Expression Pattern of CD56 (N-CAM) in Human Bone Marrow Biopsies Infiltrated by Acute Leukemia. Leuk Lymphoma 2011; 44:2055-9. [PMID: 14959847 DOI: 10.1080/1042819031000119307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
In hematological neoplasms CD56 (N-CAM) is expressed by T/natural killer (NK) cell lymphoma, by most neoplastic plasma cells in multiple myeloma and also in a subset of acute myelogenous leukemias (AML). In the latter, it is an indicator of poor clinical outcome. Most of the data on CD56 expression in acute leukemia have been obtained by flow cytometric analysis. Up to now, no systematic analysis of the expression pattern of CD56 in formalin fixed paraffin embedded bone marrow biopsies of acute leukemias has been performed. We immunohistochemically studied the expression of CD56 in a series of 141 bone marrow biopsies fixed in Sublimat Mercury II Chloride (SUSA) including 100 cases of AML FAB M0-M7, 11 cases of AML not further specified, 3 cases of biphenotypical leukemia, 20 cases of acute lymphoblastic leukemia (ALL) and 7 cases of reactive bone marrow biopsies. Overall, 14 of 134 (10%) leukemia cases were positive for CD56. Detail analysis revealed positivity in 5/13 cases of AML M5 (38%), 3/9 AML M1 (33%), 1/8 AML M0 (13%), 1/11 AML not specified (9%), 2/31 AML M2 (7%) and 2/26 AML M4 (8%). All cases of ALL and biphenotypic leukemias were CD56 negative. The CD56 expression in AML M5 was statistically significant (p = 0.003). On paraffin embedded bone marrow biopsies CD56 expression occurs in de novo AML with an overall frequency of 13%. It is significantly correlated with AML M5, which is positive in 38% of the cases. Cases of ALL are consistently CD56 negative.
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Affiliation(s)
- B Khanlari
- Institute of Pathology, University Hospital Basel, Schoenbeinstrasse 40, 4031 Basel, Switzerland
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Minoo P, Zlobec I, Peterson M, Terracciano L, Lugli A. Characterization of rectal, proximal and distal colon cancers based on clinicopathological, molecular and protein profiles. Int J Oncol 2010; 37:707-18. [PMID: 20664940 DOI: 10.3892/ijo_00000720] [Citation(s) in RCA: 143] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Accumulating evidence suggests that colorectal cancer (CRC) should be viewed as a heterogeneous disease, with proximal and distal CRCs showing multiple biological and clinical differences. The aim of this study was to develop a clinicopathological, molecular and protein profile for CRCs based on their region and thus providing insight into their heterogeneity. CRC patients (n=399) were evaluated for clinicopathologic and molecular features including K-RAS, BRAF and MSI status. Tumors were also screened for expression of 50 immunohistochemical markers linked to major signaling pathways involved in tumor-progression or immune response. Proximally located tumors show significantly larger tumor size, higher T-stage, higher tumor grade and more frequent mucinous histologic subtype compared to the distal colon and rectum. The frequency of BRAF mutation and MSI-high phenotype were significantly higher in proximal colon cancers. There is a significant difference in regional expression of 10 tumor-associated markers (CDX2, CD44v6, CD44s, TOPK, nuclear beta-catenin, pERK, APAF-1, E-cadherin, p21 and bcl2) and 4 immune response markers (CD68, CD163, FoxP3 and TIA-1). In multivariate analysis CD44s, CD44v6, nuclear beta-catenin and CD68 expression was found to best discriminate left- versus right-sided colon cancers. Tumor diameter, pT stage and MSI status best distinguish right-sided colon cancers from rectal cancers and pT stage and E-cadherin best discriminate left-sided colon cancers and rectal cancers. These data along with existing evidence for the presence of distinct regional embryological origin and gene expression profile are highly supportive of the concept that proximal and distal CRCs are distinct clinicopathologic entities.
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Affiliation(s)
- P Minoo
- Department of Pathology, University of California San Diego, San Diego, CA 92103, USA.
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Lugli A, Molinari F, Saletti P, de Dosso S, Mazzucchelli L, Frattini M, Zlobec I. Use of tumor budding with K-RAS gene analysis to identify potentially responsive metastatic colorectal cancer patients treated with anti-EGFR therapies. J Clin Oncol 2010. [DOI: 10.1200/jco.2010.28.15_suppl.e14042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Zlobec I, Terracciano L, Lugli A. Immune response to tumor budding ratio: A new potential prognostic score to improve risk stratification for patients with colorectal cancer. J Clin Oncol 2010. [DOI: 10.1200/jco.2010.28.15_suppl.e14033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Fischer CA, Kampmann M, Zlobec I, Green E, Tornillo L, Lugli A, Wolfensberger M, Terracciano LM. p16 expression in oropharyngeal cancer: its impact on staging and prognosis compared with the conventional clinical staging parameters. Ann Oncol 2010; 21:1961-1966. [PMID: 20423915 DOI: 10.1093/annonc/mdq210] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Currently, staging of head neck squamous cell carcinoma (HNSCC) is on the basis of primary tumor extension (cT), lymph node involvement (cN) and distant metastasis (cM). The aim of cancer staging was to improve diagnosis, prognosis and to compare outcome results. A new subgroup of oropharyngeal squamous cell carcinoma (OPSCC) induced by human papillomavirus (HPV) infection is reported to show an increasing incidence. These HPV-positive OPSCC show distinct molecular differences, specific p16 overexpression and a significantly better prognosis. Therefore, the aim of this study was to evaluate the prognostic influence of p16 expression in OPSCC and compare its relevance with the established prognostic markers cT and cN classification and the clinical stages I-IV. PATIENTS AND METHODS Immunohistochemistry for p16 was carried out on the basis of a tissue microarray including 102 OPSCC patients with corresponding retrospective clinicopathological and follow-up data. RESULTS p16 is the strongest independent prognostic marker in OPSCC, surpassing the significance of cT and cN classification as well as the clinical stages I-IV. Prognosis of p16-positive OPSCC of an advanced stage reached or even exceeded prognosis of the next clinically smaller conventionally staged group of tumors. CONCLUSION p16 is the most relevant prognostic marker in OPSCC and should be considered for inclusion into the official staging system of HNSCC.
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Affiliation(s)
- C A Fischer
- Departments of Otolaryngology, Head and Neck Surgery.
| | - M Kampmann
- Departments of Otolaryngology, Head and Neck Surgery
| | - I Zlobec
- Departments of Pathology, University Hospital, Basel, Switzerland
| | - E Green
- Departments of Otolaryngology, Head and Neck Surgery
| | - L Tornillo
- Departments of Pathology, University Hospital, Basel, Switzerland
| | - A Lugli
- Departments of Pathology, University Hospital, Basel, Switzerland
| | | | - L M Terracciano
- Departments of Pathology, University Hospital, Basel, Switzerland
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Burri E, Nüesch R, Lugli A, Noll P, Vavricka SR. [Early gastric cancer--or not]. Praxis (Bern 1994) 2008; 97:1351-1355. [PMID: 19085848 DOI: 10.1024/1661-8157.97.25.1351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
A 46-year old female patient presented with non-specific epigastric discomfort that had been present for 6 months. Endoscopic work-up showed a small gastric polyp and biopsy samples revealed adenocarcinoma. There was no evidence of metastatic disease or penetration of the muscle layer on endosonography, rating the tumor as early gastric cancer. Endoscopic submucosal dissection was unsuccessful due to bleeding complications and the patient was treated with subtotal gastrectomy. Surprisingly, the final histological diagnosis revealed a highly differentiated neuroendocrine tumor and the initial diagnosis had to be revised.
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Affiliation(s)
- E Burri
- Medizinische Poliklinik, Universitätsspital Basel, Basel.
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Zlobec I, Baker K, Terracciano L, Peter S, Degen L, Beglinger C, Lugli A. Two-marker protein profile predicts poor prognosis in patients with early rectal cancer. Br J Cancer 2008; 99:1712-7. [PMID: 18985041 PMCID: PMC2584947 DOI: 10.1038/sj.bjc.6604729] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
The aim of this study was to establish an immunohistochemical protein profile to complement preoperative staging and identify rectal cancer patients at high-risk of adverse outcome. Immunohistochemistry was performed on a tissue microarray including 482 rectal cancers for APAF-1, EphB2, MST1, Ki67, p53, RHAMM, RKIP and CD8+ tumour infiltrating lymphocytes (TILs). After resampling of the data and multivariable analysis, the most reproducible markers were combined and prognosis evaluated as stratified by pT and pN status. In multivariable analysis, only positive RHAMM (P<0.001; HR=1.94 (1.44–2.61)) and loss of CD8+ TILs (P=0.006; HR=0.63 (0.45–0.88)) were independent prognostic factors. The 5-year cancer-specific survival rate for RHAMM+/TIL− patients was 30% (95% CI 21–40%) compared to 76% (95% CI: 66–84%) for RHAMM−/TIL+ patients (P<0.001). The 5-year cancer-specific survival of T1/T2/RHAMM+/TIL− patients was 48% (20–72%) and significantly worse compared to T3/T4/RHAMM−/TIL+ patients (71% 95% CI 56–82%); P=0.039). Stratifying by nodal status, only N+/RHAMM+/TIL− patients demonstrated a significantly worse prognosis than N0/RHAMM+/TIL− patients (P=0.005). Loss of CD8+ TILs was predictive of local recurrence in RHAMM+ tumours (P=0.009) only. RHAMM and CD8+ TILs may assist in identifying early stage rectal cancer patients facing a particularly poor prognosis and who may derive a benefit from preoperative therapy.
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Affiliation(s)
- I Zlobec
- Institute of Pathology, University Hospital of Basel, Basel, Switzerland.
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Adams H, Tzankov A, Lugli A, Zlobec I. New time-dependent approach to analyse the prognostic significance of immunohistochemical biomarkers in colon cancer and diffuse large B-cell lymphoma. J Clin Pathol 2008; 62:986-97. [PMID: 18977805 DOI: 10.1136/jcp.2008.059063] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIMS Receiver operating characteristic (ROC) curve analysis is a well-established method to study the accuracies of biological markers. It may, however, be suboptimal for analysing outcomes over time, such as prognosis. Here, the clinical value of time-dependent ROC curve analysis for improving the identification of high-risk patients with colon cancers and diffuse large B-cell lymphomas (DLBCL) is explored. METHODS Using tissue microarrays, immunohistochemistry was performed on two matched sets (N = 469, each) of colon cancers (p53, CD8(+) tumour infiltrating lymphocytes (TILs), mammalian sterile-like 20 kinase 1 (MST1), mucin 2 (MUC2) and urokinase plasminogen activator receptor (uPAR)) and on 208 DLBCL (Bcl2, Bcl6, CD10, FOXP1 and Ki67). The area-under-the-curve (AUC)-over-time plots, cut-off scores for tumour marker positivity and Kaplan-Meier survival curves were analysed. RESULTS With the exception of uPAR, all markers were most accurate within the first 18 months following diagnosis. Expression of p53 (AUC = 0.75), uPAR (AUC = 0.64), Bcl2 (AUC = 0.58) and FOXp1 (AUC = 0.68) was linked to more aggressive tumours, while TILs (AUC = 0.38), MST1 (AUC = 0.39), MUC2 (AUC = 0.38), Bcl6 (AUC = 0.4), CD10 (AUC = 0.49) and Ki67 (AUC = 0.41) were predictive of improved survival. Cut-off scores for markers at their peak accuracies as well as survival time differences were reproducible between colon cancer groups. Only FOXp1 at its optimal cut-off of 60% had significant effects on survival in DLBCL (p = 0.019). CONCLUSIONS Time-dependent ROC curve analysis is a novel tool for identifying potential immunohistochemical prognostic markers across varying follow-up times. Use of this tool could facilitate the identification of high-risk patients not only with colon cancer and DLBCL but with a range of other tumour types.
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Affiliation(s)
- H Adams
- Institute of Pathology, University Hospital of Basel, Basel, Switzerland
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Zlobec I, Terracciano L, Tornillo L, Günthert U, Vuong T, Jass JR, Lugli A. Role of RHAMM within the hierarchy of well-established prognostic factors in colorectal cancer. Gut 2008; 57:1413-9. [PMID: 18436576 DOI: 10.1136/gut.2007.141192] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To compare the independent prognostic effect of a panel of immunohistochemical protein markers in colorectal cancer (CRC) and determine their ranking among the established prognostic factors T stage, N stage, vascular invasion, tumour budding and tumour grade. DESIGN A tissue microarray of 1420 CRCs was immunostained for 23 markers and mismatch repair (MMR) proteins. Immunoreactivity was assessed semi-quantitatively. Receiver operating characteristic (ROC) curves were used to determine cut-off scores for tumour marker positivity. Survival time was investigated for each marker in multivariable analysis with T stage, N stage, vascular invasion, tumour budding and tumour grade. The hazard ratio (HR) was used to compare the prognostic effect of each marker on 5 year survival. RESULTS To the standard prognostic features, only six markers added independent prognostic information including receptor for hyaluronic acid mediated motility (RHAMM) (HR = 2.39 (1.88 to 3.05)), epidermal growth factor receptor (HR = 1.65 (1.31 to 2.09)), tumour infiltrating lymphocytes (HR = 0.7 (0.54 to 0.92)), urokinase plasminogen activator (HR = 1.38 (1.09 to 1.75)), Raf-1 kinase inhibitor protein (HR = 0.75 (0.58 to 0.96)) and mammalian sterile 20-like kinase 1 (MST1) (HR = 0.75 (0.58 to 0.95). Diffuse (>90% staining) expression of RHAMM ranked above T stage, vascular invasion, tumour budding and tumour grade in terms of adverse prognostic significance and was associated with distant metastasis (p = 0.012) and with worse outcome in patients with metastatic disease (p = 0.031). CONCLUSIONS The strong adverse effect of RHAMM on outcome in addition to its position within the hierarchy of well-established prognostic factors suggest that RHAMM should be considered a more important prognosticator than tumour grade, tumour budding and vascular invasion in patients with CRC.
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Affiliation(s)
- I Zlobec
- Institute of Pathology, University Hospital of Basel, Schönbeinstrasse 40, Basel, CH-4031, Switzerland.
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Abstract
Prognostication of newly diagnosed colorectal cancer (CRC) predominantly relies on stage as defined by the UICC-TNM and American Joint Committee on Cancer classifications. Tumour extent, lymph node status, tumour grade and the assessment of lymphatic and venous invasion are still the most important morphological prognostic factors. Evidence suggests that tumour budding and tumour border configuration are important, additional histological parameters but are not regarded as essential in prognosis. Although several molecular features, such as LOH18q and TP53 mutation analysis, have shown promising results in terms of their prognostic value, the American Society of Clinical Oncology Tumor Markers Expert Panel does not currently recommend their use in routine practice. cDNA-microarray, PCR and fluorescence in situ hybridisation are now frequently used to identity potential prognostic indicators in CRC, but the applicability of these methods in routine use is likely to have limited impact. Reliable prognostic markers identified by immunohistochemical protein profiling have yet to be established. Randomisation of data sets, assessment of interobserver variability for protein markers and scoring systems, as well as the use of receiver operating characteristic curve analysis in combination with multimarker-phenotype analysis of several different markers may be an effective tactical approach to increase the value of immunohistochemical findings. This article reviews the well established and additional prognostic factors in CRC and explores the contribution of molecular studies to the prognostication of patients with this disease. Additionally, an approach to improve the prognostic value of immunohistochemical protein markers is proposed.
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Affiliation(s)
- I Zlobec
- Institute of Pathology, University Hospital of Basel, Basel, Switzerland
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Zlobec I, Vuong T, Compton CC, Lugli A, Michel RP, Hayashi S, Jass JR. Combined analysis of VEGF and EGFR predicts complete tumour response in rectal cancer treated with preoperative radiotherapy. Br J Cancer 2008; 98:450-6. [PMID: 18182986 PMCID: PMC2361457 DOI: 10.1038/sj.bjc.6604172] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The ability to predict complete pathologic response or sensitivity to radiation before treatment would have a significant impact on the selection of patients for preoperative radiotherapy or chemo-radiation therapy schedules. The aim of this study was to determine the value of epidermal growth factor receptor (EGFR), vascular endothelial growth factor (VEGF), p53, Bcl-2 and apoptosis protease-activating factor-1 (APAF-1) as predictors of complete pathologic tumour regression in patients undergoing preoperative radiotherapy for advanced rectal cancer. Pretreatment tumour biopsies from predominantly cT3 patients undergoing a preoperative high-dose-rate brachytherapy protocol were immunostained for EGFR, VEGF, p53, Bcl-2 and APAF-1. Immunoreactivity was evaluated by three pathologists. Cut-off scores for tumour marker positivity were obtained by receiver-operating characteristic (ROC) curve analysis. The association of marker expression with complete pathologic response was analysed in univariate and multivariable analysis. Multi-marker phenotypes of the independent protein markers were evaluated. In multivariable analysis, loss of VEGF (P-value=0.009; odds ratio (OR) (95% CI)=0.24 (0.08–0.69)) and positive EGFR (P-value=0.01; OR (95% CI)=3.82 (1.37–10.6)) both demonstrated independent predictive value for complete pathologic response. The odds of complete response were 12.8 for the multi-marker combination of VEGF-negative and EGFR-positive tumours. Of the 34 EGFR-negative- and VEGF-positive cases, 32 (94.1%) had no complete pathologic response. The combined analysis of VEGF and EGFR is predictive of complete pathologic response in patients undergoing preoperative radiotherapy. In addition, the findings of this study have identified a subgroup of simultaneous EGFR-negative and VEGF-positive patients who are highly resistant to radiotherapy and should perhaps be considered candidates for innovative neoadjuvant combined modalities.
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Affiliation(s)
- I Zlobec
- Institute of Pathology, University Hospital of Basel, Schönbeinstrasse 40, Basel 4031, Switzerland.
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Zlobec I, Lugli A, Baker K, Roth S, Minoo P, Hayashi S, Terracciano L, Jass JR. Role of APAF-1, E-cadherin and peritumoral lymphocytic infiltration in tumour budding in colorectal cancer. J Pathol 2007; 212:260-8. [PMID: 17516584 DOI: 10.1002/path.2164] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Tumour budding or dedifferentiation at the invasive margin of colorectal cancer (CRC) is an important prognostic marker and linked mechanistically to dysregulation of Wnt pathway signalling. Since budding is observed in only 40% of CRCs, we hypothesized that Wnt pathway dysregulation may be a necessary but insufficient explanation for budding and that buds may be destroyed selectively by tumour immune mechanisms. Twenty potential markers of tumour budding were evaluated in tissue microarrays (TMAs) obtained from the main tumour body of 1164 DNA mismatch repair-proficient CRCs and the findings were correlated with tumour budding, lymphocytic infiltration and survival. Loss of expression of E-cadherin and APAF-1 were independent predictors of budding (sensitivity 70.3% and specificity 48.2% when one or the other was lost). Peritumoral lymphocytes (PTLs) were observed more frequently in CRCs with loss of either E-cadherin or APAF-1 that were budding-negative. PTLs and tumour-infiltrating lymphocytes (TILs) were strongly correlated. The absence of TILs increased the adverse prognostic impact of E-cadherin and APAF-1 loss. Co-occurrence of E-cadherin loss, APAF-1 loss and low TIL counts in CRCs was an independent prognostic factor. The findings were verified in whole tissue sections from 88 CRCs with known KRAS mutation status (which was not associated with budding). Loss of E-cadherin and APAF-1 within the main body of CRCs are independent predictors of tumour budding. The prognostic benefit of lymphocytic infiltration may be explained by the immune destruction of budding cells.
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Affiliation(s)
- I Zlobec
- Department of Pathology, McGill University, Montreal, Canada.
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Lugli A, Zlobec I, Minoo P, Baker K, Tornillo L, Terracciano L, Jass JR. Prognostic significance of the wnt signalling pathway molecules APC, beta-catenin and E-cadherin in colorectal cancer: a tissue microarray-based analysis. Histopathology 2007; 50:453-64. [PMID: 17448021 DOI: 10.1111/j.1365-2559.2007.02620.x] [Citation(s) in RCA: 105] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
AIMS To investigate dysregulation of the wnt signalling pathway by assessing beta-catenin expression/increasing expression and loss of cytoplasmic adenomatous polyposis coli (APC) and membranous E-cadherin in colorectal cancer (CRC) and determining the prognostic significance of these variables. METHODS AND RESULTS Unselected, non-consecutive CRC resections (n = 1420) were subdivided into three groups: mismatch repair (MMR)-proficient, MLH1- and presumed hereditary non-polyposis colonic cancer (HNPCC). Immunohistochemical analysis of beta-catenin expression (0% versus > 0%) and increasing expression (increasing percentage-positivity) and loss of APC and E-cadherin was performed using the tissue microarray technique. In MMR-proficient CRC, increased nuclear beta-catenin expression and loss of membranous E-cadherin were independently associated with higher N stage (P = 0.03 and < 0.0001), vascular invasion (P < 0.01 and < 0.001) and worse survival (P < 0.01 and < 0.001). Additionally, there was an association between loss of membranous E-cadherin and higher T stage (P = 0.03). In MLH1- CRC, loss of membranous E-cadherin was associated with higher N stage (P = 0.05) and worse survival (P = 0.03). In presumed HNPCC CRC nuclear beta-catenin and membranous E-cadherin were not associated with tumour progression or worse survival. In all CRC subsets loss of cytoplasmic APC was not associated with clinicopathological features. CONCLUSIONS Increasing nuclear beta-catenin expression and loss of membranous E-cadherin are independent, adverse prognostic factors in MMR-proficient and MLH1- CRC.
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Affiliation(s)
- A Lugli
- Department of Pathology, McGill University, Montreal, Canada
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Lugli A, Zlobec I, Baker K, Minoo P, Tornillo L, Terracciano L, Jass JR. Prognostic significance of mucins in colorectal cancer with different DNA mismatch-repair status. J Clin Pathol 2007; 60:534-9. [PMID: 16816167 PMCID: PMC1994556 DOI: 10.1136/jcp.2006.039552] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2006] [Indexed: 12/13/2022]
Abstract
BACKGROUND Expression of mucin antigen MUC1 and down regulation of MUC2 are associated with adverse prognosis in colorectal cancer (CRC), but their prognostic significance with respect to differing DNA mis- match repair (MMR) status is poorly understood. OBJECTIVE To determine the prognostic significance of MUC1 and MUC2 in CRC with different MMR statuses. METHODS Using the tissue microarray (TMA) technique, a series of 1420 unselected, non-consecutive CRC resections was subdivided into three groups: (1) MMR-proficient; (2) MLH1-negative; and (3) presumed hereditary non-polyposis colon cancer (HNPCC). Immunohistochemical analysis of MUC1 and MUC2 expression (>0%) and loss (0%) was performed, and the results were correlated with clinicopathological parameters. RESULTS In MMR-proficient CRC, MUC1 expression was more frequently found in tumours with higher tumour stage (p=0.004) and higher tumour grade (p=0.041) and loss of MUC2 was associated with higher tumour stage (p=0.028), node stage (p=0.001), presence of vascular invasion (p=0.028) and worse survival (p=0.034). In MLH1-negative CRC, MUC2 loss was associated with the presence of lymph node metastasis (p=0.028) and worse survival (p=0.015), but there was no association between MUC1 expression and clinicopathological features. In presumed HNPCC, MUC1 expression and MUC2 loss were not associated with clinicopathological parameters. CONCLUSIONS Mucins have a prognostic significance in sporadic CRC, but not in hereditary CRC. Loss of MUC2 is an adverse prognostic factor in MMR-proficient and MLH1-negative CRC, whereas MUC1 expression is associated with tumour progression in MMR-proficient CRC only.
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Affiliation(s)
- A Lugli
- Department of Pathology, McGill University, Duff Medical Building, Montreal, Quebec, Canada
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Zlobec I, Vuong T, Hayashi S, Haegert D, Tornillo L, Terracciano L, Lugli A, Jass J. A simple and reproducible scoring system for EGFR in colorectal cancer: application to prognosis and prediction of response to preoperative brachytherapy. Br J Cancer 2007; 96:793-800. [PMID: 17311026 PMCID: PMC2360062 DOI: 10.1038/sj.bjc.6603619] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
The aim of this study was to determine the predictive and prognostic value of epidermal growth factor receptor (EGFR) expression in rectal cancers treated with preoperative high-dose rate brachytherapy and in mismatch-repair (MMR)-proficient colorectal cancers (CRCs), respectively. We validate the use of receiver operating characteristic (ROC) curve analysis to select cutoff scores for EGFR overexpression for the end points studied. Immunohistochemistry (IHC) for EGFR was performed on 82 rectal tumour biopsies and 1197 MMR-proficient CRCs using a tissue microarray. Immunoreactivity was scored as the percentage of positive tumour cells by three pathologists and the inter-observer reliability was assessed. ROC curve-derived cutoffs were used to analyse the association of EGFR overexpression, tumour response and several clinicopathological features including survival. The scoring method was found to be reproducible in rectal cancer biopsies and CRCs. The selected cutoff scores from ROC curve analysis for each clinicopathological feature were highly consistent among pathologists. EGFR overexpression was associated with response to radiotherapy (P-value <0.001) and with worse survival time (P-value <0.001). In multivariate analysis, EGFR overexpression was independently associated with adverse prognosis (P-value <0.001). Epidermal growth factor receptor is a predictive marker of response to preoperative radiotherapy and an independent adverse prognostic factor CRC.
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Affiliation(s)
- I Zlobec
- Department of Pathology, McGill University, Montreal, Québec, Canada.
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Lugli A, Jass JR. Types of colorectal adenoma. Verh Dtsch Ges Pathol 2006; 90:18-24. [PMID: 17867575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
While most colorectal polyps can be classified as either adenomas (AD) or hyperplastic polyps (HP), approximately 5 % have some of the features of these lesions but are distinguishable from both. These lesions include sessile serrated adenoma or polyp (SSP), mixed polyp (MP), and traditional serrated adenoma (SA). These relatively recently described entities account for only about 3%, 1% and 1% of colorectal polyps respectively. Nevertheless, they may serve as the precursor lesions of the subset of colorectal cancer (15-20%) with extensive DNA methylation, mutation of BRAF, and DNA microsatellite instability. This overview summarises the key morphological features of traditional and newer types of colorectal polyps. It also discusses the differing molecular signatures of polyps, focusing on mutation of BRAF and KRAS and alterations of TP53 and the DNA repair genes O-6-Methylguanine DNA Methyltransferase (MGMT) and MLH1. A more detailed description of the features of MPs and SA is then developed and it is shown that these polyps are highly heterogeneous lesions in terms of both morphology and molecular pathology. Finally, a simple working nomenclature for the diagnostic reporting of colorectal polyps is suggested. In this system, MPs and SAs are combined as 'serrated polyps with dysplasia'. It is likely that the recognition and diagnosis of serrated polyps of the colorectum will assume increasing importance in the coming years and that their complex morphology and molecular heterogeneity will present interesting challenges for pathologists, scientists and clinicians.
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Affiliation(s)
- A Lugli
- Department of Pathology, McGill University, Montreal, Canada
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Abstract
In 1821 Napoleon died in exile on the Island of St. Helena. Although the autopsy had suggested stomach cancer as the cause of death, in 1961 an elevated arsenic concentration was found in Napoleon's hair. This finding elicited numerous theories of conspiracy, treachery, and poisoning. Most recent reports even suggested inappropriate medical treatment may have contributed to the exiled Emperor's death. Napoleon's apparent obesity at the time of his demise was interpreted as a strong argument against stomach cancer as the cause of death; however, his weight changes over the course of his life, noticeable from the contemporary iconography, have not been systematically analyzed. To test the hypothesis that Napoleon's weight at death could be compatible with a diagnosis of terminal gastric cancer, we performed several studies to determine: a) Napoleon's weight at death; and b) the changes of his weight during the last 20 years of his life. Our weight modeling was based on the collection of 12 different pairs of trousers worn by Napoleon between 1800 and 1821, the year of his death. Modeling trouser sizes with control data suggested a weight increase from 67 kg to 90 kg by 1820. The trousers worn at the time of death suggested a subsequent weight loss of 11 kg (to 79 kg) during the last year of his life. This weight was confirmed by a second modeling approach based on the subcutaneous fat measurement performed at autopsy (1.5 inches) and a control group of 270 men dying from various causes. This provides a reasonable validation for both weight measurement methods. Napoleon's terminal weight loss of more than 10 kg is suggestive of a severe progressive chronic illness and is highly consistent with a diagnosis of gastric cancer.
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Affiliation(s)
- A Lugli
- Institute of Pathology, University Hospital of Basel, Schônbeinstrasse 40, $031 Basel, Switherland.
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Zimpfer A, Went P, Tzankov A, Pehrs AC, Lugli A, Maurer R, Terracciano L, Pileri S, Dirnhofer S. Rare expression of KIT (CD117) in lymphomas: a tissue microarray study of 1166 cases. Histopathology 2004; 45:398-404. [PMID: 15469479 DOI: 10.1111/j.1365-2559.2004.01968.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIMS Imatinib mesylate specifically inhibits KIT tyrosine kinase activity, and has been proven to be effective in the treatment of gastrointestinal stromal tumours. Because other KIT-expressing malignancies might benefit from Imatinib therapy, we evaluated the distribution and expression of KIT in 1166 cases of malignant lymphoma. MATERIALS AND RESULTS Tissue microarrays (TMAs) containing 824 non-Hodgkin's lymphoma (NHL) and 342 Hodgkin's lymphoma (HL) cases were immunohistochemically analysed for the expression of the KIT protein. Two KIT-positive NHLs were sequenced using polymerase chain reaction analysis. One T-cell lymphoma and one follicular lymphoma of the 747 NHL cases (0.3%) were positive for KIT. All HLs were Kit-negative. None of the KIT-positive cases showed a kit gene mutation. CONCLUSIONS KIT expression is a very rare event in NHL and virtually absent in HL. In the few positive cases, the aberrant expression is not caused by a mutation in the 'hot-spots' of the kit gene, indicating that treatment of these tumours with Imatinib may be ineffective.
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Affiliation(s)
- A Zimpfer
- Institute of Pathology, University of Basel, Basel, Switzerland
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Kühne M, Sidler D, Hofer S, Lugli A, Ludwig C. Challenging manifestations of malignancies. Case 1. Polycythemia and high serum erythropoietin level as a result of hemangioblastoma. J Clin Oncol 2004; 22:3639-40. [PMID: 15337812 DOI: 10.1200/jco.2004.08.137] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- M Kühne
- Department of Oncology, Claraspital, Basel, Switzerland
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Paltrinieri S, Bertaccini A, Lugli A, Monari W. THREE YEARS OF MOLECULAR MONITORING OF PHYTOPLASMA SPREADING IN A PLUM GROWING AREA IN ITALY. ACTA ACUST UNITED AC 2004. [DOI: 10.17660/actahortic.2004.657.81] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Abstract
AIMS To assess the value of homeobox protein CDX-2 expression in the distinction between primary ovarian carcinomas and carcinomas metastatic to the ovary. METHODS CDX-2 expression was assessed by immunohistochemistry in 120 serous, 68 endometrioid, 24 clear cell, and 16 mucinous carcinomas of the ovary. In addition, CDX-2 immunoreactivity was investigated in 20 metastases from adenocarcinomas to the ovary (15 of colorectal, two of gastric, one of appendiceal, one of pancreatic, and one of cervical origin) and their corresponding primary tumours. RESULTS Almost all of the primary ovarian carcinomas lacked immunoreactivity for CDX-2. In contrast, 14 of the 16 metastases to the ovary from intestinal primaries showed CDX-2 immunoexpression. CONCLUSION CDX-2 is a useful marker for differentiating primary ovarian carcinoma from carcinomas metastatic to the ovary.
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Affiliation(s)
- L Tornillo
- Institute of Pathology, University of Basel, Schoenbeinstrasse 40, 4031 Basel, Switzerland
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Lugli A, Went P, Khanlari B, Nikolova Z, Dirnhofer S. Rare KIT (CD117) expression in multiple myeloma abrogates the usefulness of imatinib mesylate treatment. Virchows Arch 2004; 444:264-8. [PMID: 14677065 DOI: 10.1007/s00428-003-0934-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2003] [Accepted: 10/28/2003] [Indexed: 10/26/2022]
Abstract
BACKGROUND Imatinib mesylate blocks the tyrosine kinase activity of KIT (CD117) and is an effective treatment for gastrointestinal stromal tumors. In multiple myeloma, KIT expression has been detected by flow cytometry in about 33% of specimens, but no previous immunohistochemical assessment has yet been made of the expression pattern of KIT. MATERIALS AND METHODS We performed immunohistochemical analyses of 100 patients, including 72 with multiple myeloma (MM), 8 with lymphoplasmacytic lymphoma (LPL), 10 with monoclonal gammopathy of undetermined significance (MGUS) and 10 with reactive plasmocytosis. One KIT-positive MM was sequenced using polymerase chain reaction analysis. RESULTS In MM, only 2 cases (2.8%) were KIT positive. The great majority of the cases (97, 2%) did not express the KIT receptor tyrosine kinase. No mutation of the c-kit gene was detected. CONCLUSIONS KIT expression is a rare event in MM and not detectable in MGUS and LPL. Therefore, treatment with imatinib is unlikely to be effective in these patients.
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Affiliation(s)
- A Lugli
- Institute of Pathology, Kantonsspital Basel, Schönbeinstrasse 40, 4031, Basel, Switzerland
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Tzankov A, Pehrs AC, Zimpfer A, Ascani S, Lugli A, Pileri S, Dirnhofer S. Prognostic significance of CD44 expression in diffuse large B cell lymphoma of activated and germinal centre B cell-like types: a tissue microarray analysis of 90 cases. J Clin Pathol 2003; 56:747-52. [PMID: 14514777 PMCID: PMC1770073 DOI: 10.1136/jcp.56.10.747] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Gene expression profiling of diffuse large B cell lymphoma (DLBCL) revealed three disease types: germinal centre B cell-like (GC), activated B cell-like (ABC), and a "third" type. Expression of CD44 variant isoforms (CD44v) is associated with an unfavourable clinical outcome in DLBCL, but previous studies did not consider the clinicopathological heterogeneity of this disease. AIMS To analyse the expression and prognostic significance of CD44 in DLBCL types. METHODS A tissue microarray (TMA) comprising 90 DLBCLs was constructed. CD10, CD20, bcl-2, bcl-6, CD44 standard isoform (CD44s), and CD44v4, CD44v6, and CD44v9 were analysed immunohistochemically and correlated with clinical follow up. RESULTS TMA expression of CD10, CD20, bcl-2, and bcl-6 showed 100% concordance with results from conventional sections in 60 cases. Samples were segregated into 22 GC (bcl-6+/CD10+/bcl-2-), 25 ABC (bcl-6-/CD10-/bcl-2+), and 35 unclassifiable DLBCLs. Overall survival (OS) at 30 months was 89%, 44%, and 58% in GC, ABC, and unclassified types, respectively. CD44v6 was coexpressed with bcl-2, appeared predominantly on bcl-6 negative cases, and correlated with disease stage. Cases negative for CD44s could be separated into CD44v6 negative (OS, 82% at 70 months) and CD44v6 positive (OS, 58%). CONCLUSIONS TMA technology is useful for immunophenotyping and clinicopathological analysis of large lymphoma populations. The GC phenotype of DLBCL is of independent prognostic significance for OS. Expression of CD44v6 correlates with disease stage, and might contribute to lymphoma dissemination. CD44v6 is expressed predominantly in ABC DLBCL, and in CD44 negative cases is associated with worse OS.
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Affiliation(s)
- A Tzankov
- Institute of Pathology, University of Innsbruck, A-6020 Innsbruck, Austria
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Tessema M, Bock O, Kröber S, Büsche G, Lugli A, Bock O, Berndt A, Huss R, Schmitt-Gräff A. Bone Marrow, Abstract 262–270, Symposium. Pathol Res Pract 2003. [DOI: 10.1078/0344-0338-00405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Lugli A, Stoffe F, Terracciano L, Dirnhofer S, Mihatsch MJ, Moch H. [Differentiated papillary kidney tumors. Differentiation between metanephric adenoma and papillary adenoma]. Pathologe 2002; 23:303-7. [PMID: 12185784 DOI: 10.1007/s00292-002-0548-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Metanephric adenoma of the kidney is a well described tumor entity. The differential diagnosis between papillary adenoma or papillary carcinoma type 1 and metanephric adenoma of the kidney can be challenging in single cases. We report two cases of metanephric adenomas and compare their immunophenotype with a papillary adenoma. The analysis of these metanephric adenomas and a review of the literature shows that CD-57 positivity and lack of EMA expression are helpful in distinguishing metanephric adenoma from papillary adenoma and papillary carcinoma. Glomeruloid structures, Psammoma bodies, necrosis or expression of cytokeratin 7 and vimentin are common features in metanephric adenoma and papillary adenoma or papillary carcinoma. The knowledge of the immunohistochemical constellation is important, because metanephric adenoma can be very large and often have some necrosis.
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Affiliation(s)
- A Lugli
- Institut für Pathologie der Universität Basel, Basel.
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Cavagna R, Lugli A, Moretto E, Carandina G. [Dissociative anesthesia with ketamine and hemocoagulation otolaryngological surgery in children]. Minerva Anestesiol 1975; 41:449-54. [PMID: 1230657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Cavagna R, Lugli A. [Benzodiazepinone in preanesthesia]. Minerva Anestesiol 1967; 33:287-9. [PMID: 5613769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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