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    Gut and Liver is an international journal of gastroenterology, focusing on the gastrointestinal tract, liver, biliary tree, pancreas, motility, and neurogastroenterology. Gut atnd Liver delivers up-to-date, authoritative papers on both clinical and research-based topics in gastroenterology. The Journal publishes original articles, case reports, brief communications, letters to the editor and invited review articles in the field of gastroenterology. The Journal is operated by internationally renowned editorial boards and designed to provide a global opportunity to promote academic developments in the field of gastroenterology and hepatology. +MORE

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    Veterans Affairs Medical Center, Univ. California San Francisco
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    Robert S. Bresalier University of Texas M. D. Anderson Cancer Center, Houston, USA
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Microsatellite Instability of Gastric and Colorectal Cancers as a Predictor of Synchronous Gastric or Colorectal Neoplasms

Young Beak Kim*, Sun-Young Lee*, Jeong Hwan Kim*, In-Kyung Sung*, Hyung Seok Park*, Chan Sup Shim*, and Hye Seung Han

*Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea, Department of Pathology, Konkuk University School of Medicine, Seoul, Korea

Correspondence to: Sun-Young Lee, Department of Internal Medicine, Konkuk University School of Medicine, 120 Neungdong-ro, Gwangjin-gu, Seoul 143-729, Korea, Tel: +82-2-2030-7747, Fax: +82-2-2030-7748, E-mail: sunyoung@kuh.ac.kr

Received: August 13, 2014; Accepted: January 2, 2015

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Gut Liver 2016;10(2):220-227. https://doi.org/10.5009/gnl14310

Published online June 19, 2015, Published date March 15, 2016

Copyright © Gut and Liver.

Background/Aims

Microsatellite instability (MSI) plays a crucial role in gastrointestinal carcinogenesis. The aim of this study was to clarify whether MSI is a useful marker for predicting synchronous gastric and colorectal neoplasms.

Methods

Consecutive patients who underwent both esophagogastroduodenoscopy and colonoscopy before the resection of gastric or colorectal cancers were included. MSI was analyzed using two mononucleotide and three dinucleotide markers.

Results

In total, 434 gastric cancers (372 microsatellite stability [MSS], 21 low incidence of MSI [MSI-L], and 41 high incidence of MSI [MSI-H]) and 162 colorectal cancers (138 MSS, 9 MSI-L, and 15 MSI-H) were included. Patients with MSI gastric cancer had a higher prevalence of synchronous colorectal cancer, colorectal adenoma, and gastric adenoma than those with MSS gastric cancers (4.8% vs 0.5%, p=0.023; 11.3% vs 3.2%, p=0.011; 3.2% vs 1.2%, p=0.00, respectively). The prevalence of synchronous colorectal adenomas was highest in MSI-L gastric cancers (19.0%), compared with MSI-H (7.3%) or MSS (3.2%) gastric cancers (p=0.002). In addition, there were no significant differences in the prevalence rates of synchronous colorectal adenoma among the MSI-H (13.3%), MSI-L (11.1%), and MSS (12.3%) colorectal cancers (p=0.987).

Conclusions

The presence of MSI in gastric cancer may be a predictor of synchronous gastric and colorectal neoplasms, whereas MSI in colorectal cancer is not a predictor of synchronous colorectal adenoma.

Keywords: Microsatellite instability, Stomach neoplasms, Colorectal neoplasms, Adenoma

Microsatellite instability (MSI), which is caused by the loss of DNA mismatch repair (MMR) activity, has a role in gastrointestinal (GI) carcinogenesis.1 MSI is associated mainly with the contraction or expansion of microsatellite sequences due to the frequent replication errors caused by MMR mutations and tumor suppressor genes.2 MSI is implicated in 8% to 39% of all gastric cancers, and in 15% of colorectal cancers.3,4

Gastric cancers with MSI tend to be associated with old age, an antral location, Lauren’s intestinal-type, and a high standard uptake value on 18fluoro-deoxyglucose positron emission tomography imaging.59 On the other hand, colorectal cancers with MSI tend to be associated with female gender, a proximal location, a mucinous phenotype, and an ulcerated appearance.3,1012 Both gastric and colorectal cancers with MSI are related to large-sized tumors, poor response to 5-fluorouracil chemotherapy, less metastasis, good prognosis, and increased metachronous neoplasms.1317 Synchronous colorectal neoplasm has recently been reported in gastric cancer patients.18,19 It was recommended that preoperative colonoscopy should be conducted to screen for colorectal neoplasm in gastric cancer patients over 50 years of age,18 whereas another study found that a family history of gastric cancer is a risk factor for the development of colorectal neoplasm in those younger than 50 years.19 Therefore, the predictors of synchronous GI neoplasm in gastric or colorectal cancer patients remain a matter of debate.

The aim of this study was to clarify whether MSI is a useful marker for predicting synchronous gastric and colorectal neoplasms. In addition, the prevalence of synchronous gastric or colorectal neoplasm in gastric and colorectal cancer patients with MSI was analyzed.

1. Study subjects

Consecutive gastric or colorectal cancer patients who underwent complete surgical resection between August 2005 and June 2013 at our center were enrolled. Inclusion criteria were subjects who underwent esophagogastroduodenoscopy (EGD) and colonoscopy before surgery and those who agreed with genetic analysis for MSI. Subjects were excluded when there is a known genetic disease such as hereditary nonpolyposis colorectal cancer (HNPCC) or familial adenomatous polyposis. To exclude any possibility of HNPCC, data on family history, past history, and presence of double primary malignancy were collected. In addition, those who underwent endoscopic resection for gastric or colorectal cancer were excluded from the study. Synchronous lesion was defined as another gastric or colorectal neoplasm(s) found within 12 months before or after the surgery.

All of the patients provided informed consent before undergoing the endoscopic procedure and MSI analysis, and the study was approved by Institutional Review Board of Konkuk University School of Medicine which confirmed that the study was performed in accordance with the ethical standards of the Helsinki Declaration (KUH 1010266). After the IRB approval, this study was registered in the Korean Clinical Trial Registry as ClinicalTrials.gov ID KCT0000948. All of the authors accessed to the study data and had reviewed and approved the final manuscript.

2. Upper and lower endoscopic examination before surgery

Using the electronic endoscopic system consisted of the EVIS-260 processor, the upper and lower endoscopic images were converted into a tagged image format using an EVIS LUCERA system (Olympus Optical, Tokyo, Japan). Any tumorous lesion that is suspicious for cancer was biopsied during the procedure. Characteristics including location and shape of the cancer were recorded.

3. Pathological analysis after surgical resection

The size of resected specimen was measured as the maximum diameter of cancer. Well differentiated adenocarcinomas were diagnosed when the gland-forming area encompassed over 95% of the high-power field, while poorly differentiated adenocarcinomas were diagnosed when it was less than 50%. Moderately differentiated adenocarcinomas were diagnosed when the gland-forming area were between 50% and 95%. If two different cell types are mingled, the diagnosis was made based on the predominant cell type. In gastric cancer, Lauren’s classification of intestinal, diffuse, or mixed type were analyzed.

4. Analysis for MSI

DNA preparation was performed as previously described in our study.8,11 With fluorescent dye-labeled primers of mononucleotide markers (BAT25 and BAT26) and dinucleotide markers (D2S123, D5S346, and D17S250), MSI was analyzed by polymerase chain reaction amplification. MSI was defined as a differently sized band in the tumor sample or a band shift in either of the two alleles. A high incidence of MSI (MSI-H) was defined as a detection of instability in more than 30% of markers, a low incidence of MSI (MSI-L) was defined as a detection of instability in less than 30% of markers, and microsatellite stability (MSS) was defined as no definite evidence of MSI.

5. Immunohistochemical stain for MMR proteins in colorectal cancer

Analysis for MMR proteins was performed as previously described in previous studies.9,11 Slides were deparaffinized in xylene and rehydrated in 100%, 95%, and 70% alcohols to water. The slides were immersed in sodium citrate buffer (pH 6.0) for hMLH1 or EDTA (PH 8.4 to 9.0) for hMSH2, hMSH6, hPMS2 and heated in an autoclave for antigen retrieval. Endogenous peroxidase activity was blocked by incubation with 3% H2O2 for 5 minutes. hMLH1 (Cell Marque, Rocklin, CA, USA), hMSH2 (Cell Marque), hMSH6 (Cell Marque), and hPMS2 (Cell Marque) antibodies were incubated for 1 hour. Slides were then processed using a DAKO Envision kit (DAKO Corp., Carpinteria, CA, USA) for hMLH1/hPMS2 and Optiview kit (Ventana, Tucson, AZ, USA) for hMSH2/hMSH6. The sections were incubated with 3,3-diaminobenzidine tetrahydrochloride and H2O2 for 3 minutes, counterstained with hematoxylin, dehydrated in graded alcohols, cleared in xylene, and coverslipped.

6. Immunostaining for mucin phenotypes in gastric cancer

Analysis for mucin phenotypes was performed as previously described in our study.20 Using the iVIEW DAB detection kit (Ventana Medical Systems Inc., Tucson, AZ, USA) by the Benchmark XT (Ventana Medical Systems Inc.), the immunohistochemical staining with primary antibodies, MUC5AC (45M/1; Neomarker, Fremont, CA, USA, 1:2,000), MUC6 (MCN6.01; Neomarker, 1:200), MUC2 (996/1; Neomarker, 1:2,000) and CD10 (56C6; Neomarker, 1:50) was carried out. Heat-induced antigen retrieval was carried out, and Hematoxylin was used for counterstaining. Gastric mucin phenotype was defined if more than 10% of cancer cells exhibited MUC5AC and/or MUC6. Intestinal mucin phenotype was defined if more than 10% of cancer cells exhibited MUC2 and/or CD10 markers. Mixed mucin phenotype was defined if more than 10% of neoplastic cells showed both gastric and intestinal markers. Unclassified mucin phenotype was defined if less than 10% of neoplastic cells showed gastric and intestinal markers.

7. Statistical analysis

Using PASW statistics 17.0 for windows (SPSS, Chicago, IL, USA), a p-value less than 0.05 was considered statistically significant. Continuous variables were compared by t-test and presented as mean±standard deviation. For the continuous values showing asymmetric distribution, Kruskal-Wallis test was used for the comparison between three groups (cancers with MSS, cancers with MSI-L, and cancers with MSI-H). Differences on clinicopathological factors among three groups (MSS, MSI-L, and MSI-H groups) were analyzed by one-way analyses of variance (ANOVAs) followed by Bonferroni post-hoc tests for numerical variables and chi-square tests for categorical variables. Presence or absence of synchronous GI neoplasm served as the primary exposure of interest. Logistic regression analysis was performed to determine the independent significant clinicopathological factors that showed a causal relationship with a dependent variable in cancer patients with synchronous GI neoplasm.

1. Characteristics of the subjects

A total of 595 patients were included, and one patient showed synchronous gastric and rectal cancers. Of 434 gastric cancer patients, 9.4% showed MSI-H and 4.8% showed MSI-L. Of 162 colorectal cancer patients, 9.3% showed MSI-H and 5.5% showed MSI-L (Fig. 1). Double primary cancer was noticed in 21 (8 colon, 3 rectal, 2 lung, 2 breast, 1 esophagus, 1 thyroid, 1 liver, 1 pancreas, 1 ovary, and 1 cervical cancers) of 434 gastric cancer patients and 3 (1 gastric, 1 thyroid, and 1 lung cancers) of 162 colorectal cancer patients.

2. Gastric cancers according to the status of MSI

Of 434 gastric cancers, 372 showed MSS, 21 showed MSI-L, and 41 showed MSI-H (Table 1). Patients with MSI gastric cancer showed higher prevalence of synchronous colorectal cancer (4.8%, p=0.023), colorectal adenoma (11.3%, p=0.011), and gastric adenoma (3.2%, p=0.004) than those with MSS gastric cancers (0.5%, 3.2%, and 1.0%, respectively) (Fig. 2). Prevalence of the synchronous colorectal adenoma was highest in MSI-L gastric cancers (19.0%) than those with MSI-H (7.3%) or MSS (3.2%) gastric cancers (p=0.002). In one-way ANOVA tests, the mean age was significantly different among the patients with MSS, MSI-L, and MSI-H gastric cancers (Table 1). Bonferroni post-hoc test exhibited that patients with MSI-H gastric cancer and those with MSI-L gastric cancer were older than those with MSS gastric cancer.

3. Synchronous GI neoplasm in gastric cancer patients

Gastric cancers were reanalyzed according to the presence of synchronous GI neoplasm. Of all significant variables, logistic regression analysis between synchronous GI neoplasm and correlated variables revealed that presence of MSI was the only significant factor (p=0.004). According to the logistic regression analysis, age of the subject (p=0.059), size (p=0.736), location (p=0.303), and stage (p=0.326) of the gastric cancer were not significant for synchronous GI neoplasm in gastric cancer patients.

4. Colorectal cancers according to the status of MSI

Of 162 colorectal cancers, 138 showed MSS, 9 showed MSI-L, and 15 showed MSI-H (Table 2). There was no synchronous gastric adenoma in all three groups, and there was no significant difference in the prevalence of synchronous colorectal adenoma between the MSI-H (13.3%), MSI-L (11.1%), and MSS (12.3%) colorectal cancers (p=0.987). In one-way ANOVA tests, there were no significant differences between the patients with MSS, MSI-L, and MSI-H gastric cancers (Table 2).

5. Synchronous GI neoplasm in colorectal cancer patients

In colorectal cancer patients, the presence of synchronous GI neoplasm was related to cell types and TNM staging. Neither MSI status nor MMR protein expression was related to the presence of synchronous GI neoplasm. There was no significant difference on the prevalence of colorectal adenoma between colon and rectal cancers according to the presence of MSI. Of 162 colorectal cancer patients, 23 showed abnormal MMR protein expression on immunohistochemical stain (Table 3). Of these 23 colorectal cancer patients, only three showed synchronous GI neoplasm, and only one showed extraintestinal cancer.

The prevalence of synchronous colorectal cancer, colorectal adenoma, and gastric adenoma in this study was significantly higher among the patients with MSI-associated gastric cancers than in those with MSS-associated gastric cancers. In addition, the prevalence of synchronous colorectal adenoma was higher in MSI-L gastric cancers than in either MSI-H or MSS gastric cancers. However, the prevalence of synchronous colorectal adenoma did not differ significantly among MSI-H, MSI-L, and MSS colorectal cancers. These findings suggest that the role of MSI during carcinogenesis differs between the stomach and the colon. Helicobacter pylori infection is known to be associated with genetic instability leading to MSI-associated premalignant lesions.21 Different from colorectal cancer, H. pylori infection leads to a deficiency of DNA MMR in gastric epithelial cells, which increases the risks of mutation and cancer.21,22 However, the suppressor pathway related to alterations in the p53, APC, and K-ras genes seems to be more important than the mutator pathway for colorectal carcinogenesis, especially for distal colon and rectal cancers.3,10

Gastric cancers with MSI in the present study exhibited not only a higher prevalence of synchronous colorectal neoplasm, but also a higher prevalence of synchronous gastric adenoma than those without MSI. The tumor multiplicity of gastric neoplasms is believed to be related to the MMR system, which plays a role in the carcinogenesis of multiple gastric carcinomas and adenomas.7,23 Since MSI is associated with intestinal-type gastric cancer, the chances of developing a synchronous gastric neoplasm would be greater during chronic H. pylori infection. Therefore, care must be taken to determine the presence and development of synchronous and metachronous gastric neoplasms in gastric cancer patients with MSI. With regard to the frequency of synchronous colorectal neoplasm in patients with MSI-related gastric cancers, the present findings are consistent with those of previous studies showed that older gastric cancer patients or those with MSI have an increased risk of developing synchronous neoplasm.13,18

Notably, the prevalence of synchronous GI neoplasms among all gastric cancer patients was highest in the MSI-L group in this study. Our finding is consistent with a previous study finding that the frequency of MSI-L was significantly higher in patients with multiple gastric cancers than in those with a single gastric cancer.24 In the study, MSI-L was detected more frequently than MSI-H in patients with a single gastric cancer, synchronous multiple gastric cancers, or metachronous multiple gastric cancers. Another study of the incidence of MSI in patients with multiple primary GI cancers showed that patients with multiple cancers in different organs had a tendency to exhibit the MSI-L or MSS phenotypes.25 Taken together, MSI-L is frequently accompanied by oncogene and tumor suppressor gene mutations during the slow process of gastric carcinogenesis, therefore increasing the risk of synchronous GI neoplasms.

With regard to the colorectal cancer patients, gastric cancer surveillance is recommended especially when the patient is old and male, has a positive family history of solid tumors, or lacks MSH2 expression in the cancer tissue.26 Previous studies of synchronous neoplasms in GI cancers with MSI have revealed that patients with MMR defects tend to have neoplasms characterized by synchronous colorectal adenomas.14,15,26 The frequency of MSI-H adenomas in patients with multiple colorectal cancers is known to be higher,14 and MSI is more frequent in colorectal cancers with a double primary malignancy.15 These findings are consistent with the present finding that MSI might be a predictor for detecting synchronous GI neoplasms. However, in this study, there was no significant correlation between synchronous colorectal adenoma and the presence of MSI in colorectal cancer. This suggests that synchronous colorectal adenoma occurs irrespective of MSI in colorectal cancer patients, and that the role of the suppressor pathway, which is related to chromosomal instability, is more important than that of the mutator pathway, which is related to MSI. Of the two subtypes of sporadic synchronous multiple colorectal cancers, right-sided colon cancers are related to multiple occurrences of consecutive MSI-H tumors, whereas the other types exhibits multiple occurrence irrespective of MSI.27

In the present study, more than half of the colorectal cancer patients with hMLH1 loss exhibited MSI-H. As suggested previously, methylation of the MLH1 gene promoter region may be an underlying cause of colorectal cancer with high MSI-H in patients without a germ-line mutation in an MMR gene.28 In addition, our finding is consistent with a previous finding that the occurrence of GI neoplasms increases with age.29 Since both aging and carcinogenesis show DNA damage and abnormal proteins, it is reasonable for synchronous GI neoplasm to occur more frequently in the elderly population. In the previous study, the proportion of gastric and colorectal carcinomas with hypermethylation of the hMLH1 promoter increased with age.29 Gastric and colorectal cancers in elderly patients exhibited loss of hMLH1 expression, MSI, poorly differentiated histology, peri-tumoral inflammatory cell infiltration, low incidence of lymph node metastasis, and a favorable prognosis than those in young patients. The present study found gastric cancers with MSI to be related to old age. However, in colorectal cancer patients, MSI seems to be less strongly related to synchronous colorectal adenomas rather to chromosomal instability, which is linked to the development of most carcinomas.

The limitation of our study is that immunohistochemical stain for MMR protein was performed only for colorectal cancers and not for gastric cancers. For gastric cancers, MSI is not associated to MMR genetic alterations.30 Therefore, we performed mucin phenotype analysis for gastric cancers instead of MMR protein analysis based on the previous studies.5,8,9,20,30 In conclusion, MSI of gastric cancer is a predictor of synchronous colorectal neoplasm and gastric adenoma, and therefore both esophagogastroduodenoscopy and colonoscopy should be performed in these patients. On the other hand, synchronous colorectal adenoma occurs irrespective of MSI in colorectal cancer patients, suggesting that the suppressor pathway is more important than the mutator pathway in colorectal carcinogenesis.

This work was supported by Konkuk University Medical Center Research Grant 2015.

Fig. 1.Study flow. A total of 434 gastric cancers and 162 colorectal cancers were analyzed. One patient had synchronous gastric and rectal cancers.

MSI-L, low incidence of microsatellite instability; MSI-H, high incidence of microsatellite instability; MSS, microsatellite stability. *Includes one patient with synchronous gastric and rectal cancer.


Fig. 2.Prevalence of synchronous neoplasms according to the microsatellite instability (MSI) status in gastric cancer. Gastric cancer patients with MSI had a higher prevalence of synchronous colorectal cancer, colorectal adenoma, and gastric adenoma than those with microsatellite stable gastric cancers.

Characteristics of MSS, MSI-L, and MSI-H Gastric Cancers

CharacteristicGastric cancers with MSS (n=372)Gastric cancers with MSI-L (n=21)Gastric cancers with MSI-H (n=41)Fp-value
Age, yr61.9±11.366.8±14.771.1±10.36.790.001
Male:female251:12115:629:12χ2=0.300.860
Synchronous GI neoplasm
 Colorectal cancer2 (0.5)2 (9.5)1 (2.4)χ2=14.750.001
 Colorectal adenoma12 (3.2)4 (19.0)3 (7.3)χ2=12.820.002
 Gastric adenoma4 (1.0)2 (9.5)0χ2=11.070.004
Cell type, WD:MD:PD:signet ring:mucinous39:137:118:65:133:10:3:5:02:25:10:3:11.380.241
Mucin phenotype, gastric:intestinal:mixed:unclassified108:100:86:789:4:7:115:8:9:91.860.136
Location, antrum:corpus:fundus160:164:489:8:430:11:04.440.012
Size, cm*3.6 (0.3–15.8)4.3 (1.2–23.0)4.6 (0.7–11.3)1.140.320
T stage, T1:T2:T3:T4232:40:53:4712:0:4:516:13:7:52.000.114
N stage, N0:N1:N2:N3253:44:28:4712:2:1:624:10:3:40.890.444
M stage, M0:M1360:1219:239:2χ2=2.400.301
TNM stage, I:II:III:IV245:51:59:1711:3:3:420:14:5:20.950.415
Microinvasion
 Lymphatic invasion119918χ2=3.190.203
 Venous invasion4742χ2=3.030.219
 Perineural invasion7565χ2=2.540.281

Data are expressed as mean±SD, number (%), or median (range).

MSS, microsatellite stable; MSI-L, low incidence of microsatellite instability; MSI-H, high incidence of microsatellite instability; SD, standard deviation; GI, gastrointestinal; WD, well differentiated adenocarcinoma; MD, moderately differentiated adenocarcinoma; PD, poorly differentiated adenocarcinoma; signet ring, signet ring cell carcinoma (poorly-cohesive carcinoma); mucinous, mucinous adenocarcinoma.

*Kruskal-Wallis test was used.


Characteristics of MSS, MSI-L, and MSI-H Colorectal Cancers

CharacteristicColorectal cancers with MSS (n=138)Colorectal cancers with MSI-L (n=9)Colorectal cancers with MSI-H (n=15)Fp-value
Age, yr63.0±11.861.6±11.263.3±10.10.670.649
Male:female86:523:68:7χ2=3.250.860
Synchronous GI neoplasm
 Colorectal adenoma17 (12.3)1 (11.1)2 (13.3)χ2=0.030.987
 Gastric adenoma000--
Cell type, WD:MD:PD:signet ring:mucinous1:128:3:1:51:7:0:0:10:14:1:0:00.250.862
Location, right:left:RS junction:rectum29:65:14:306:1:0:210:4:0:12.010.116
Size, cm4.1 (0.3–10.5)5.0 (1.5–8.5)4.5 (0.3–11.5)0.450.638
CEA, mg/dL3.5 (0.5–601.3)2.6 (1.0–400.0)2.2 (0.8–12.3)0.520.595
T stage, T1:T2:T3:T413:12:98:152:0:3:42:3:8:21.870.138
N stage, N0:N1:N2:N374:32:323:2:411:4:00.850.431
M stage, M0:M1114:246:315:0χ2=4.850.088
TNM stage, I:II:III:IV20:52:42:242:1:3:34:7:4:00.280.758
Microinvasion
 Lymphatic invasion4831χ2=4.910.086
 Venous invasion820χ2=5.020.081
 Perineural invasion3741χ2=4.560.102
IHC results of MMR protein
 Loss of MLH1 expression809χ2=42.16<0.001
 Loss of MSH2 expression204χ2=23.78<0.001
 Loss of MSH6 expression104χ2=29.89<0.001
 Loss of PMS2 expression808χ2=34.33<0.001

Clinicopathological Findings of Colorectal Cancers with Either MSI or Abnormal MMR Protein Expression

Status of MSIAge/sexLocationStage (TNM)Cell typeMLH1MSH2MSH6PMS2Presence of synchronous neoplasm
MSS58/MRectum2 (T3N0M0)MDLossIntactIntactLossColorectal adenoma
34/FLeft colon1 (T2N0M0)MDLossIntactIntactLossNone
55/MRectum1 (T2N0M0)MDLossIntactIntactLossNone
59/MRectosigmoid junction3 (T3N2M0)MDLossIntactIntactLossNone
64/MRectum3 (T3N2M0)MDLossIntactIntactLossNone
74/FLeft colon3 (T3N2M0)MDLossIntactIntactLossNone
81/MRight colon3 (T3N1M0)MDLossIntactIntactLossNone
74/MRectum4 (T3N2M1)MDLossIntactIntactLossNone
59/MRight colon2 (T3N0M0)MDIntactLossLossIntactNone
52/FRight colon3 (T3N1M0)MDIntactLossIntactIntactNone
MSI-H45/MLeft colon1 (T1N0M0)MDLossIntactIntactLossColorectal adenoma
57/MRight colon2 (T3N0M0)MDLossIntactIntactLossColorectal adenoma
65/FRight colon2 (T3N0M0)MDLossIntactIntactLossThyroid cancer
51/FRight colon2 (T3N0M0)MDLossIntactIntactLossNone
63/FRight colon1 (T2N0M0)MDLossIntactIntactLossNone
72/FRight colon1 (T2N0M0)MDLossIntactIntactLossNone
73/FLeft colon3 (T2N1M0)MDLossIntactIntactLossNone
74/MRight colon2 (T3N0M0)MDLossIntactIntactLossNone
71/MRight colon2 (T3N0M0)PDLossIntactIntactIntactNone
54/FLeft colon2 (T3N0M0)MDIntactLossLossIntactNone
73/MRight colon3 (T3N1M0)MDIntactLossLossIntactNone
79/MRight colon2 (T4N0M0)MDIntactLossLossIntactNone
58/MRight colon3 (T3N1M0)MDIntactLossLossIntactNone
55/MRectum1 (T1N0M0)MDIntactIntactIntactIntactNone
59/FLeft colon3 (T4N1M0)MDIntactIntactIntactIntactNone
MSI-L71/FRight colon3 (T3N1M0)MDIntactIntactIntactIntactColorectal adenoma
54/MRight colon1 (T1N0M0)WDIntactIntactIntactIntactNone
57/MRectum1 (T1N0M0)MDIntactIntactIntactIntactNone
61/FRight colon3 (T3N1M0)MucinousIntactIntactIntactIntactNone
65/FRight colon3 (T4N2M0)MDIntactIntactIntactIntactNone
78/MRight colon2 (T4N0M0)MDIntactIntactIntactIntactNone
68/FRectum4 (T3N2M1)MDIntactIntactIntactIntactNone
61/FRight colon4 (T4N2M1)MDIntactIntactIntactIntactNone
39/FLeft colon4 (T4N2M1)MDIntactIntactIntactIntactNone

  1. Boland, CR, Thibodeau, SN, and Hamilton, SR (1998). A National Cancer Institute Workshop on Microsatellite Instability for cancer detection and familial predisposition: development of international criteria for the determination of microsatellite instability in colorectal cancer. Cancer Res. 58, 5248-5257.
    Pubmed
  2. Shah, SN, Hile, SE, and Eckert, KA (2010). Defective mismatch repair, microsatellite mutation bias, and variability in clinical cancer phenotypes. Cancer Res. 70, 431-435.
    Pubmed KoreaMed CrossRef
  3. Boland, CR, and Goel, A (2010). Microsatellite instability in colorectal cancer. Gastroenterology. 138, 2073-2087.e3.
    Pubmed KoreaMed CrossRef
  4. Liu, P, Zhang, XY, Shao, Y, and Zhang, DF (2005). Microsatellite instability in gastric cancer and pre-cancerous lesions. World J Gastroenterol. 11, 4904-4907.
    Pubmed KoreaMed CrossRef
  5. Seo, HM, Chang, YS, and Joo, SH (2009). Clinicopathologic characteristics and outcomes of gastric cancers with the MSI-H phenotype. J Surg Oncol. 99, 143-147.
    Pubmed CrossRef
  6. Arai, T, Sakurai, U, and Sawabe, M (2013). Frequent microsatellite instability in papillary and solid-type, poorly differentiated adenocarcinomas of the stomach. Gastric Cancer. 16, 505-512.
    Pubmed CrossRef
  7. Kim, SH, Ahn, BK, Nam, YS, Pyo, JY, Oh, YH, and Lee, KH (2010). Microsatellite instability is associated with the clinicopathologic features of gastric cancer in sporadic gastric cancer patients. J Gastric Cancer. 10, 149-154.
    CrossRef
  8. Chung, HW, Lee, SY, and Han, HS (2013). Gastric cancers with microsatellite instability exhibit high fluorodeoxyglucose uptake on positron emission tomography. Gastric Cancer. 16, 185-192.
    CrossRef
  9. Choe, WH, Lee, SY, and Lee, JH (2005). High frequency of microsatellite instability in intestinal-type gastric cancer in Korean patients. Korean J Intern Med. 20, 116-122.
    Pubmed KoreaMed CrossRef
  10. Markowitz, S (2000). DNA repair defects inactivate tumor suppressor genes and induce hereditary and sporadic colon cancers. J Clin Oncol. 18, 75S-80S.
    Pubmed
  11. Lee, SY, Chung, H, and Devaraj, B (2010). Microsatellite alterations at selected tetranucleotide repeats are associated with morphologies of colorectal neoplasias. Gastroenterology. 139, 1519-1525.
    Pubmed KoreaMed CrossRef
  12. Yoon, YS, Yu, CS, and Kim, TW (2011). Mismatch repair status in sporadic colorectal cancer: immunohistochemistry and microsatellite instability analyses. J Gastroenterol Hepatol. 26, 1733-1739.
    Pubmed CrossRef
  13. Cho, I, An, JY, and Kwon, IG (2014). Risk factors for double primary malignancies and their clinical implications in patients with sporadic gastric cancer. Eur J Surg Oncol. 40, 338-344.
    CrossRef
  14. Ueda, E, Watanabe, T, Umetani, N, Ishigami, H, Sasaki, S, and Nagawa, H (2002). Microsatellite instability of cancers and concomitant adenomas in synchronous multiple colorectal cancer patients. J Exp Clin Cancer Res. 21, 149-154.
    Pubmed
  15. Yun, HR, Yi, LJ, and Cho, YK (2009). Double primary malignancy in colorectal cancer patients: MSI is the useful marker for predicting double primary tumors. Int J Colorectal Dis. 24, 369-375.
    CrossRef
  16. An, JY, Kim, H, Cheong, JH, Hyung, WJ, Kim, H, and Noh, SH (2012). Microsatellite instability in sporadic gastric cancer: its prognostic role and guidance for 5-FU based chemotherapy after R0 resection. Int J Cancer. 131, 505-511.
    CrossRef
  17. Tajima, A, Hess, MT, Cabrera, BL, Kolodner, RD, and Carethers, JM (2004). The mismatch repair complex hMutS alpha recognizes 5-fluorouracil-modified DNA: implications for chemosensitivity and resistance. Gastroenterology. 127, 1678-1684.
    Pubmed CrossRef
  18. Kim, HO, Hwang, SI, Yoo, CH, and Kim, H (2009). Preoperative colonoscopy for patients with gastric adenocarcinoma. J Gastroenterol Hepatol. 24, 1740-1744.
    Pubmed CrossRef
  19. Hata, K, Shinozaki, M, and Toyoshima, O (2013). Impact of family history of gastric cancer on colorectal neoplasias in young Japanese. Colorectal Dis. 15, 42-46.
    CrossRef
  20. Han, HS, Lee, SY, and Lee, KY (2009). Unclassified mucin phenotype of gastric adenocarcinoma exhibits the highest invasiveness. J Gastroenterol Hepatol. 24, 658-666.
    Pubmed CrossRef
  21. Chung, WC, Jung, SH, and Lee, KM (2010). Genetic instability in gastric epithelial neoplasias categorized by the revised Vienna classification. Gut Liver. 4, 179-185.
    Pubmed KoreaMed CrossRef
  22. Kim, JS, Chung, WC, and Lee, KM (2012). Association between genetic instability and Helicobacter pylori infection in gastric epithelial dysplasia. Gastroenterol Res Pract. 2012, 360929.
    CrossRef
  23. Lee, HS, Lee, BL, Kim, SH, Woo, DK, Kim, HS, and Kim, WH (2001). Microsatellite instability in synchronous gastric carcinomas. Int J Cancer. 91, 619-624.
    Pubmed CrossRef
  24. Miyoshi, E, Haruma, K, and Hiyama, T (2001). Microsatellite instability is a genetic marker for the development of multiple gastric cancers. Int J Cancer. 95, 350-353.
    Pubmed CrossRef
  25. Yamashita, K, Arimura, Y, and Kurokawa, S (2000). Microsatellite instability in patients with multiple primary cancers of the gastrointestinal tract. Gut. 46, 790-794.
    Pubmed KoreaMed CrossRef
  26. Yoon, SN, Oh, ST, and Lim, SB (2010). Clinicopathologic characteristics of colorectal cancer patients with synchronous and metachronous gastric cancer. World J Surg. 34, 2168-2176.
    Pubmed CrossRef
  27. Abe, Y, Masuda, H, and Okubo, R (2001). Microsatellite instability of each tumor in sporadic synchronous multiple colorectal cancers. Oncol Rep. 8, 299-304.
    Pubmed
  28. Levine, AJ, Win, AK, and Buchanan, DD (2012). Cancer risks for the relatives of colorectal cancer cases with a methylated MLH1 promoter region: data from the Colorectal Cancer Family Registry. Cancer Prev Res (Phila). 5, 328-335.
    CrossRef
  29. Arai, T, Kasahara, I, Sawabe, M, Honma, N, Aida, J, and Tabubo, K (2010). Role of methylation of the hMLH1 gene promoter in the development of gastric and colorectal carcinoma in the elderly. Geriatr Gerontol Int. 10, S207-S212.
    Pubmed CrossRef
  30. Leite, M, Corso, G, and Sousa, S (2011). MSI phenotype and MMR alterations in familial and sporadic gastric cancer. Int J Cancer. 128, 1606-1613.
    CrossRef

Article

Original Article

Gut and Liver 2016; 10(2): 220-227

Published online March 15, 2016 https://doi.org/10.5009/gnl14310

Copyright © Gut and Liver.

Microsatellite Instability of Gastric and Colorectal Cancers as a Predictor of Synchronous Gastric or Colorectal Neoplasms

Young Beak Kim*, Sun-Young Lee*, Jeong Hwan Kim*, In-Kyung Sung*, Hyung Seok Park*, Chan Sup Shim*, and Hye Seung Han

*Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea, Department of Pathology, Konkuk University School of Medicine, Seoul, Korea

Correspondence to: Sun-Young Lee, Department of Internal Medicine, Konkuk University School of Medicine, 120 Neungdong-ro, Gwangjin-gu, Seoul 143-729, Korea, Tel: +82-2-2030-7747, Fax: +82-2-2030-7748, E-mail: sunyoung@kuh.ac.kr

Received: August 13, 2014; Accepted: January 2, 2015

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background/Aims

Microsatellite instability (MSI) plays a crucial role in gastrointestinal carcinogenesis. The aim of this study was to clarify whether MSI is a useful marker for predicting synchronous gastric and colorectal neoplasms.

Methods

Consecutive patients who underwent both esophagogastroduodenoscopy and colonoscopy before the resection of gastric or colorectal cancers were included. MSI was analyzed using two mononucleotide and three dinucleotide markers.

Results

In total, 434 gastric cancers (372 microsatellite stability [MSS], 21 low incidence of MSI [MSI-L], and 41 high incidence of MSI [MSI-H]) and 162 colorectal cancers (138 MSS, 9 MSI-L, and 15 MSI-H) were included. Patients with MSI gastric cancer had a higher prevalence of synchronous colorectal cancer, colorectal adenoma, and gastric adenoma than those with MSS gastric cancers (4.8% vs 0.5%, p=0.023; 11.3% vs 3.2%, p=0.011; 3.2% vs 1.2%, p=0.00, respectively). The prevalence of synchronous colorectal adenomas was highest in MSI-L gastric cancers (19.0%), compared with MSI-H (7.3%) or MSS (3.2%) gastric cancers (p=0.002). In addition, there were no significant differences in the prevalence rates of synchronous colorectal adenoma among the MSI-H (13.3%), MSI-L (11.1%), and MSS (12.3%) colorectal cancers (p=0.987).

Conclusions

The presence of MSI in gastric cancer may be a predictor of synchronous gastric and colorectal neoplasms, whereas MSI in colorectal cancer is not a predictor of synchronous colorectal adenoma.

Keywords: Microsatellite instability, Stomach neoplasms, Colorectal neoplasms, Adenoma

INTRODUCTION

Microsatellite instability (MSI), which is caused by the loss of DNA mismatch repair (MMR) activity, has a role in gastrointestinal (GI) carcinogenesis.1 MSI is associated mainly with the contraction or expansion of microsatellite sequences due to the frequent replication errors caused by MMR mutations and tumor suppressor genes.2 MSI is implicated in 8% to 39% of all gastric cancers, and in 15% of colorectal cancers.3,4

Gastric cancers with MSI tend to be associated with old age, an antral location, Lauren’s intestinal-type, and a high standard uptake value on 18fluoro-deoxyglucose positron emission tomography imaging.59 On the other hand, colorectal cancers with MSI tend to be associated with female gender, a proximal location, a mucinous phenotype, and an ulcerated appearance.3,1012 Both gastric and colorectal cancers with MSI are related to large-sized tumors, poor response to 5-fluorouracil chemotherapy, less metastasis, good prognosis, and increased metachronous neoplasms.1317 Synchronous colorectal neoplasm has recently been reported in gastric cancer patients.18,19 It was recommended that preoperative colonoscopy should be conducted to screen for colorectal neoplasm in gastric cancer patients over 50 years of age,18 whereas another study found that a family history of gastric cancer is a risk factor for the development of colorectal neoplasm in those younger than 50 years.19 Therefore, the predictors of synchronous GI neoplasm in gastric or colorectal cancer patients remain a matter of debate.

The aim of this study was to clarify whether MSI is a useful marker for predicting synchronous gastric and colorectal neoplasms. In addition, the prevalence of synchronous gastric or colorectal neoplasm in gastric and colorectal cancer patients with MSI was analyzed.

MATERIALS AND METHODS

1. Study subjects

Consecutive gastric or colorectal cancer patients who underwent complete surgical resection between August 2005 and June 2013 at our center were enrolled. Inclusion criteria were subjects who underwent esophagogastroduodenoscopy (EGD) and colonoscopy before surgery and those who agreed with genetic analysis for MSI. Subjects were excluded when there is a known genetic disease such as hereditary nonpolyposis colorectal cancer (HNPCC) or familial adenomatous polyposis. To exclude any possibility of HNPCC, data on family history, past history, and presence of double primary malignancy were collected. In addition, those who underwent endoscopic resection for gastric or colorectal cancer were excluded from the study. Synchronous lesion was defined as another gastric or colorectal neoplasm(s) found within 12 months before or after the surgery.

All of the patients provided informed consent before undergoing the endoscopic procedure and MSI analysis, and the study was approved by Institutional Review Board of Konkuk University School of Medicine which confirmed that the study was performed in accordance with the ethical standards of the Helsinki Declaration (KUH 1010266). After the IRB approval, this study was registered in the Korean Clinical Trial Registry as ClinicalTrials.gov ID KCT0000948. All of the authors accessed to the study data and had reviewed and approved the final manuscript.

2. Upper and lower endoscopic examination before surgery

Using the electronic endoscopic system consisted of the EVIS-260 processor, the upper and lower endoscopic images were converted into a tagged image format using an EVIS LUCERA system (Olympus Optical, Tokyo, Japan). Any tumorous lesion that is suspicious for cancer was biopsied during the procedure. Characteristics including location and shape of the cancer were recorded.

3. Pathological analysis after surgical resection

The size of resected specimen was measured as the maximum diameter of cancer. Well differentiated adenocarcinomas were diagnosed when the gland-forming area encompassed over 95% of the high-power field, while poorly differentiated adenocarcinomas were diagnosed when it was less than 50%. Moderately differentiated adenocarcinomas were diagnosed when the gland-forming area were between 50% and 95%. If two different cell types are mingled, the diagnosis was made based on the predominant cell type. In gastric cancer, Lauren’s classification of intestinal, diffuse, or mixed type were analyzed.

4. Analysis for MSI

DNA preparation was performed as previously described in our study.8,11 With fluorescent dye-labeled primers of mononucleotide markers (BAT25 and BAT26) and dinucleotide markers (D2S123, D5S346, and D17S250), MSI was analyzed by polymerase chain reaction amplification. MSI was defined as a differently sized band in the tumor sample or a band shift in either of the two alleles. A high incidence of MSI (MSI-H) was defined as a detection of instability in more than 30% of markers, a low incidence of MSI (MSI-L) was defined as a detection of instability in less than 30% of markers, and microsatellite stability (MSS) was defined as no definite evidence of MSI.

5. Immunohistochemical stain for MMR proteins in colorectal cancer

Analysis for MMR proteins was performed as previously described in previous studies.9,11 Slides were deparaffinized in xylene and rehydrated in 100%, 95%, and 70% alcohols to water. The slides were immersed in sodium citrate buffer (pH 6.0) for hMLH1 or EDTA (PH 8.4 to 9.0) for hMSH2, hMSH6, hPMS2 and heated in an autoclave for antigen retrieval. Endogenous peroxidase activity was blocked by incubation with 3% H2O2 for 5 minutes. hMLH1 (Cell Marque, Rocklin, CA, USA), hMSH2 (Cell Marque), hMSH6 (Cell Marque), and hPMS2 (Cell Marque) antibodies were incubated for 1 hour. Slides were then processed using a DAKO Envision kit (DAKO Corp., Carpinteria, CA, USA) for hMLH1/hPMS2 and Optiview kit (Ventana, Tucson, AZ, USA) for hMSH2/hMSH6. The sections were incubated with 3,3-diaminobenzidine tetrahydrochloride and H2O2 for 3 minutes, counterstained with hematoxylin, dehydrated in graded alcohols, cleared in xylene, and coverslipped.

6. Immunostaining for mucin phenotypes in gastric cancer

Analysis for mucin phenotypes was performed as previously described in our study.20 Using the iVIEW DAB detection kit (Ventana Medical Systems Inc., Tucson, AZ, USA) by the Benchmark XT (Ventana Medical Systems Inc.), the immunohistochemical staining with primary antibodies, MUC5AC (45M/1; Neomarker, Fremont, CA, USA, 1:2,000), MUC6 (MCN6.01; Neomarker, 1:200), MUC2 (996/1; Neomarker, 1:2,000) and CD10 (56C6; Neomarker, 1:50) was carried out. Heat-induced antigen retrieval was carried out, and Hematoxylin was used for counterstaining. Gastric mucin phenotype was defined if more than 10% of cancer cells exhibited MUC5AC and/or MUC6. Intestinal mucin phenotype was defined if more than 10% of cancer cells exhibited MUC2 and/or CD10 markers. Mixed mucin phenotype was defined if more than 10% of neoplastic cells showed both gastric and intestinal markers. Unclassified mucin phenotype was defined if less than 10% of neoplastic cells showed gastric and intestinal markers.

7. Statistical analysis

Using PASW statistics 17.0 for windows (SPSS, Chicago, IL, USA), a p-value less than 0.05 was considered statistically significant. Continuous variables were compared by t-test and presented as mean±standard deviation. For the continuous values showing asymmetric distribution, Kruskal-Wallis test was used for the comparison between three groups (cancers with MSS, cancers with MSI-L, and cancers with MSI-H). Differences on clinicopathological factors among three groups (MSS, MSI-L, and MSI-H groups) were analyzed by one-way analyses of variance (ANOVAs) followed by Bonferroni post-hoc tests for numerical variables and chi-square tests for categorical variables. Presence or absence of synchronous GI neoplasm served as the primary exposure of interest. Logistic regression analysis was performed to determine the independent significant clinicopathological factors that showed a causal relationship with a dependent variable in cancer patients with synchronous GI neoplasm.

RESULTS

1. Characteristics of the subjects

A total of 595 patients were included, and one patient showed synchronous gastric and rectal cancers. Of 434 gastric cancer patients, 9.4% showed MSI-H and 4.8% showed MSI-L. Of 162 colorectal cancer patients, 9.3% showed MSI-H and 5.5% showed MSI-L (Fig. 1). Double primary cancer was noticed in 21 (8 colon, 3 rectal, 2 lung, 2 breast, 1 esophagus, 1 thyroid, 1 liver, 1 pancreas, 1 ovary, and 1 cervical cancers) of 434 gastric cancer patients and 3 (1 gastric, 1 thyroid, and 1 lung cancers) of 162 colorectal cancer patients.

2. Gastric cancers according to the status of MSI

Of 434 gastric cancers, 372 showed MSS, 21 showed MSI-L, and 41 showed MSI-H (Table 1). Patients with MSI gastric cancer showed higher prevalence of synchronous colorectal cancer (4.8%, p=0.023), colorectal adenoma (11.3%, p=0.011), and gastric adenoma (3.2%, p=0.004) than those with MSS gastric cancers (0.5%, 3.2%, and 1.0%, respectively) (Fig. 2). Prevalence of the synchronous colorectal adenoma was highest in MSI-L gastric cancers (19.0%) than those with MSI-H (7.3%) or MSS (3.2%) gastric cancers (p=0.002). In one-way ANOVA tests, the mean age was significantly different among the patients with MSS, MSI-L, and MSI-H gastric cancers (Table 1). Bonferroni post-hoc test exhibited that patients with MSI-H gastric cancer and those with MSI-L gastric cancer were older than those with MSS gastric cancer.

3. Synchronous GI neoplasm in gastric cancer patients

Gastric cancers were reanalyzed according to the presence of synchronous GI neoplasm. Of all significant variables, logistic regression analysis between synchronous GI neoplasm and correlated variables revealed that presence of MSI was the only significant factor (p=0.004). According to the logistic regression analysis, age of the subject (p=0.059), size (p=0.736), location (p=0.303), and stage (p=0.326) of the gastric cancer were not significant for synchronous GI neoplasm in gastric cancer patients.

4. Colorectal cancers according to the status of MSI

Of 162 colorectal cancers, 138 showed MSS, 9 showed MSI-L, and 15 showed MSI-H (Table 2). There was no synchronous gastric adenoma in all three groups, and there was no significant difference in the prevalence of synchronous colorectal adenoma between the MSI-H (13.3%), MSI-L (11.1%), and MSS (12.3%) colorectal cancers (p=0.987). In one-way ANOVA tests, there were no significant differences between the patients with MSS, MSI-L, and MSI-H gastric cancers (Table 2).

5. Synchronous GI neoplasm in colorectal cancer patients

In colorectal cancer patients, the presence of synchronous GI neoplasm was related to cell types and TNM staging. Neither MSI status nor MMR protein expression was related to the presence of synchronous GI neoplasm. There was no significant difference on the prevalence of colorectal adenoma between colon and rectal cancers according to the presence of MSI. Of 162 colorectal cancer patients, 23 showed abnormal MMR protein expression on immunohistochemical stain (Table 3). Of these 23 colorectal cancer patients, only three showed synchronous GI neoplasm, and only one showed extraintestinal cancer.

DISCUSSION

The prevalence of synchronous colorectal cancer, colorectal adenoma, and gastric adenoma in this study was significantly higher among the patients with MSI-associated gastric cancers than in those with MSS-associated gastric cancers. In addition, the prevalence of synchronous colorectal adenoma was higher in MSI-L gastric cancers than in either MSI-H or MSS gastric cancers. However, the prevalence of synchronous colorectal adenoma did not differ significantly among MSI-H, MSI-L, and MSS colorectal cancers. These findings suggest that the role of MSI during carcinogenesis differs between the stomach and the colon. Helicobacter pylori infection is known to be associated with genetic instability leading to MSI-associated premalignant lesions.21 Different from colorectal cancer, H. pylori infection leads to a deficiency of DNA MMR in gastric epithelial cells, which increases the risks of mutation and cancer.21,22 However, the suppressor pathway related to alterations in the p53, APC, and K-ras genes seems to be more important than the mutator pathway for colorectal carcinogenesis, especially for distal colon and rectal cancers.3,10

Gastric cancers with MSI in the present study exhibited not only a higher prevalence of synchronous colorectal neoplasm, but also a higher prevalence of synchronous gastric adenoma than those without MSI. The tumor multiplicity of gastric neoplasms is believed to be related to the MMR system, which plays a role in the carcinogenesis of multiple gastric carcinomas and adenomas.7,23 Since MSI is associated with intestinal-type gastric cancer, the chances of developing a synchronous gastric neoplasm would be greater during chronic H. pylori infection. Therefore, care must be taken to determine the presence and development of synchronous and metachronous gastric neoplasms in gastric cancer patients with MSI. With regard to the frequency of synchronous colorectal neoplasm in patients with MSI-related gastric cancers, the present findings are consistent with those of previous studies showed that older gastric cancer patients or those with MSI have an increased risk of developing synchronous neoplasm.13,18

Notably, the prevalence of synchronous GI neoplasms among all gastric cancer patients was highest in the MSI-L group in this study. Our finding is consistent with a previous study finding that the frequency of MSI-L was significantly higher in patients with multiple gastric cancers than in those with a single gastric cancer.24 In the study, MSI-L was detected more frequently than MSI-H in patients with a single gastric cancer, synchronous multiple gastric cancers, or metachronous multiple gastric cancers. Another study of the incidence of MSI in patients with multiple primary GI cancers showed that patients with multiple cancers in different organs had a tendency to exhibit the MSI-L or MSS phenotypes.25 Taken together, MSI-L is frequently accompanied by oncogene and tumor suppressor gene mutations during the slow process of gastric carcinogenesis, therefore increasing the risk of synchronous GI neoplasms.

With regard to the colorectal cancer patients, gastric cancer surveillance is recommended especially when the patient is old and male, has a positive family history of solid tumors, or lacks MSH2 expression in the cancer tissue.26 Previous studies of synchronous neoplasms in GI cancers with MSI have revealed that patients with MMR defects tend to have neoplasms characterized by synchronous colorectal adenomas.14,15,26 The frequency of MSI-H adenomas in patients with multiple colorectal cancers is known to be higher,14 and MSI is more frequent in colorectal cancers with a double primary malignancy.15 These findings are consistent with the present finding that MSI might be a predictor for detecting synchronous GI neoplasms. However, in this study, there was no significant correlation between synchronous colorectal adenoma and the presence of MSI in colorectal cancer. This suggests that synchronous colorectal adenoma occurs irrespective of MSI in colorectal cancer patients, and that the role of the suppressor pathway, which is related to chromosomal instability, is more important than that of the mutator pathway, which is related to MSI. Of the two subtypes of sporadic synchronous multiple colorectal cancers, right-sided colon cancers are related to multiple occurrences of consecutive MSI-H tumors, whereas the other types exhibits multiple occurrence irrespective of MSI.27

In the present study, more than half of the colorectal cancer patients with hMLH1 loss exhibited MSI-H. As suggested previously, methylation of the MLH1 gene promoter region may be an underlying cause of colorectal cancer with high MSI-H in patients without a germ-line mutation in an MMR gene.28 In addition, our finding is consistent with a previous finding that the occurrence of GI neoplasms increases with age.29 Since both aging and carcinogenesis show DNA damage and abnormal proteins, it is reasonable for synchronous GI neoplasm to occur more frequently in the elderly population. In the previous study, the proportion of gastric and colorectal carcinomas with hypermethylation of the hMLH1 promoter increased with age.29 Gastric and colorectal cancers in elderly patients exhibited loss of hMLH1 expression, MSI, poorly differentiated histology, peri-tumoral inflammatory cell infiltration, low incidence of lymph node metastasis, and a favorable prognosis than those in young patients. The present study found gastric cancers with MSI to be related to old age. However, in colorectal cancer patients, MSI seems to be less strongly related to synchronous colorectal adenomas rather to chromosomal instability, which is linked to the development of most carcinomas.

The limitation of our study is that immunohistochemical stain for MMR protein was performed only for colorectal cancers and not for gastric cancers. For gastric cancers, MSI is not associated to MMR genetic alterations.30 Therefore, we performed mucin phenotype analysis for gastric cancers instead of MMR protein analysis based on the previous studies.5,8,9,20,30 In conclusion, MSI of gastric cancer is a predictor of synchronous colorectal neoplasm and gastric adenoma, and therefore both esophagogastroduodenoscopy and colonoscopy should be performed in these patients. On the other hand, synchronous colorectal adenoma occurs irrespective of MSI in colorectal cancer patients, suggesting that the suppressor pathway is more important than the mutator pathway in colorectal carcinogenesis.

ACKNOWLEDGEMENTS

This work was supported by Konkuk University Medical Center Research Grant 2015.

Fig 1.

Figure 1.Study flow. A total of 434 gastric cancers and 162 colorectal cancers were analyzed. One patient had synchronous gastric and rectal cancers.

MSI-L, low incidence of microsatellite instability; MSI-H, high incidence of microsatellite instability; MSS, microsatellite stability. *Includes one patient with synchronous gastric and rectal cancer.

Gut and Liver 2016; 10: 220-227https://doi.org/10.5009/gnl14310

Fig 2.

Figure 2.Prevalence of synchronous neoplasms according to the microsatellite instability (MSI) status in gastric cancer. Gastric cancer patients with MSI had a higher prevalence of synchronous colorectal cancer, colorectal adenoma, and gastric adenoma than those with microsatellite stable gastric cancers.
Gut and Liver 2016; 10: 220-227https://doi.org/10.5009/gnl14310

Table 1 Characteristics of MSS, MSI-L, and MSI-H Gastric Cancers

CharacteristicGastric cancers with MSS (n=372)Gastric cancers with MSI-L (n=21)Gastric cancers with MSI-H (n=41)Fp-value
Age, yr61.9±11.366.8±14.771.1±10.36.790.001
Male:female251:12115:629:12χ2=0.300.860
Synchronous GI neoplasm
 Colorectal cancer2 (0.5)2 (9.5)1 (2.4)χ2=14.750.001
 Colorectal adenoma12 (3.2)4 (19.0)3 (7.3)χ2=12.820.002
 Gastric adenoma4 (1.0)2 (9.5)0χ2=11.070.004
Cell type, WD:MD:PD:signet ring:mucinous39:137:118:65:133:10:3:5:02:25:10:3:11.380.241
Mucin phenotype, gastric:intestinal:mixed:unclassified108:100:86:789:4:7:115:8:9:91.860.136
Location, antrum:corpus:fundus160:164:489:8:430:11:04.440.012
Size, cm*3.6 (0.3–15.8)4.3 (1.2–23.0)4.6 (0.7–11.3)1.140.320
T stage, T1:T2:T3:T4232:40:53:4712:0:4:516:13:7:52.000.114
N stage, N0:N1:N2:N3253:44:28:4712:2:1:624:10:3:40.890.444
M stage, M0:M1360:1219:239:2χ2=2.400.301
TNM stage, I:II:III:IV245:51:59:1711:3:3:420:14:5:20.950.415
Microinvasion
 Lymphatic invasion119918χ2=3.190.203
 Venous invasion4742χ2=3.030.219
 Perineural invasion7565χ2=2.540.281

Data are expressed as mean±SD, number (%), or median (range).

MSS, microsatellite stable; MSI-L, low incidence of microsatellite instability; MSI-H, high incidence of microsatellite instability; SD, standard deviation; GI, gastrointestinal; WD, well differentiated adenocarcinoma; MD, moderately differentiated adenocarcinoma; PD, poorly differentiated adenocarcinoma; signet ring, signet ring cell carcinoma (poorly-cohesive carcinoma); mucinous, mucinous adenocarcinoma.

*Kruskal-Wallis test was used.


Table 2 Characteristics of MSS, MSI-L, and MSI-H Colorectal Cancers

CharacteristicColorectal cancers with MSS (n=138)Colorectal cancers with MSI-L (n=9)Colorectal cancers with MSI-H (n=15)Fp-value
Age, yr63.0±11.861.6±11.263.3±10.10.670.649
Male:female86:523:68:7χ2=3.250.860
Synchronous GI neoplasm
 Colorectal adenoma17 (12.3)1 (11.1)2 (13.3)χ2=0.030.987
 Gastric adenoma000--
Cell type, WD:MD:PD:signet ring:mucinous1:128:3:1:51:7:0:0:10:14:1:0:00.250.862
Location, right:left:RS junction:rectum29:65:14:306:1:0:210:4:0:12.010.116
Size, cm4.1 (0.3–10.5)5.0 (1.5–8.5)4.5 (0.3–11.5)0.450.638
CEA, mg/dL3.5 (0.5–601.3)2.6 (1.0–400.0)2.2 (0.8–12.3)0.520.595
T stage, T1:T2:T3:T413:12:98:152:0:3:42:3:8:21.870.138
N stage, N0:N1:N2:N374:32:323:2:411:4:00.850.431
M stage, M0:M1114:246:315:0χ2=4.850.088
TNM stage, I:II:III:IV20:52:42:242:1:3:34:7:4:00.280.758
Microinvasion
 Lymphatic invasion4831χ2=4.910.086
 Venous invasion820χ2=5.020.081
 Perineural invasion3741χ2=4.560.102
IHC results of MMR protein
 Loss of MLH1 expression809χ2=42.16<0.001
 Loss of MSH2 expression204χ2=23.78<0.001
 Loss of MSH6 expression104χ2=29.89<0.001
 Loss of PMS2 expression808χ2=34.33<0.001

Data are expressed as mean±SD, number (%), or median (range).

MSS, microsatellite stable; MSI-L, low incidence of microsatellite instability; MSI-H, high incidence of microsatellite instability; SD, standard deviation; GI, gastrointestinal; WD, well-differentiated adenocarcinoma; MD, moderately differentiated adenocarcinoma; PD, poorly differentiated adenocarcinoma; signet ring, signet ring cell carcinoma (poorly-cohesive carcinoma); mucinous, mucinous adenocarcinoma; RS, rectosigmoid; CEA, carcinoembryonic antigen; IHC, immunohistochemical stain; MMR, mismatch repair.


Table 3 Clinicopathological Findings of Colorectal Cancers with Either MSI or Abnormal MMR Protein Expression

Status of MSIAge/sexLocationStage (TNM)Cell typeMLH1MSH2MSH6PMS2Presence of synchronous neoplasm
MSS58/MRectum2 (T3N0M0)MDLossIntactIntactLossColorectal adenoma
34/FLeft colon1 (T2N0M0)MDLossIntactIntactLossNone
55/MRectum1 (T2N0M0)MDLossIntactIntactLossNone
59/MRectosigmoid junction3 (T3N2M0)MDLossIntactIntactLossNone
64/MRectum3 (T3N2M0)MDLossIntactIntactLossNone
74/FLeft colon3 (T3N2M0)MDLossIntactIntactLossNone
81/MRight colon3 (T3N1M0)MDLossIntactIntactLossNone
74/MRectum4 (T3N2M1)MDLossIntactIntactLossNone
59/MRight colon2 (T3N0M0)MDIntactLossLossIntactNone
52/FRight colon3 (T3N1M0)MDIntactLossIntactIntactNone
MSI-H45/MLeft colon1 (T1N0M0)MDLossIntactIntactLossColorectal adenoma
57/MRight colon2 (T3N0M0)MDLossIntactIntactLossColorectal adenoma
65/FRight colon2 (T3N0M0)MDLossIntactIntactLossThyroid cancer
51/FRight colon2 (T3N0M0)MDLossIntactIntactLossNone
63/FRight colon1 (T2N0M0)MDLossIntactIntactLossNone
72/FRight colon1 (T2N0M0)MDLossIntactIntactLossNone
73/FLeft colon3 (T2N1M0)MDLossIntactIntactLossNone
74/MRight colon2 (T3N0M0)MDLossIntactIntactLossNone
71/MRight colon2 (T3N0M0)PDLossIntactIntactIntactNone
54/FLeft colon2 (T3N0M0)MDIntactLossLossIntactNone
73/MRight colon3 (T3N1M0)MDIntactLossLossIntactNone
79/MRight colon2 (T4N0M0)MDIntactLossLossIntactNone
58/MRight colon3 (T3N1M0)MDIntactLossLossIntactNone
55/MRectum1 (T1N0M0)MDIntactIntactIntactIntactNone
59/FLeft colon3 (T4N1M0)MDIntactIntactIntactIntactNone
MSI-L71/FRight colon3 (T3N1M0)MDIntactIntactIntactIntactColorectal adenoma
54/MRight colon1 (T1N0M0)WDIntactIntactIntactIntactNone
57/MRectum1 (T1N0M0)MDIntactIntactIntactIntactNone
61/FRight colon3 (T3N1M0)MucinousIntactIntactIntactIntactNone
65/FRight colon3 (T4N2M0)MDIntactIntactIntactIntactNone
78/MRight colon2 (T4N0M0)MDIntactIntactIntactIntactNone
68/FRectum4 (T3N2M1)MDIntactIntactIntactIntactNone
61/FRight colon4 (T4N2M1)MDIntactIntactIntactIntactNone
39/FLeft colon4 (T4N2M1)MDIntactIntactIntactIntactNone

MSI, microsatellite instability; MMR, mismatch repair; MSS, microsatellite stable; M, male; MD, moderately differentiated adenocarcinoma; F, female; MSI-H, high incidence of microsatellite instability; PD, poorly differentiated adenocarcinoma; MSI-L, low incidence of microsatellite instability; WD, well-differentiated adenocarcinoma; mucinous, mucinous adenocarcinoma.


References

  1. Boland, CR, Thibodeau, SN, and Hamilton, SR (1998). A National Cancer Institute Workshop on Microsatellite Instability for cancer detection and familial predisposition: development of international criteria for the determination of microsatellite instability in colorectal cancer. Cancer Res. 58, 5248-5257.
    Pubmed
  2. Shah, SN, Hile, SE, and Eckert, KA (2010). Defective mismatch repair, microsatellite mutation bias, and variability in clinical cancer phenotypes. Cancer Res. 70, 431-435.
    Pubmed KoreaMed CrossRef
  3. Boland, CR, and Goel, A (2010). Microsatellite instability in colorectal cancer. Gastroenterology. 138, 2073-2087.e3.
    Pubmed KoreaMed CrossRef
  4. Liu, P, Zhang, XY, Shao, Y, and Zhang, DF (2005). Microsatellite instability in gastric cancer and pre-cancerous lesions. World J Gastroenterol. 11, 4904-4907.
    Pubmed KoreaMed CrossRef
  5. Seo, HM, Chang, YS, and Joo, SH (2009). Clinicopathologic characteristics and outcomes of gastric cancers with the MSI-H phenotype. J Surg Oncol. 99, 143-147.
    Pubmed CrossRef
  6. Arai, T, Sakurai, U, and Sawabe, M (2013). Frequent microsatellite instability in papillary and solid-type, poorly differentiated adenocarcinomas of the stomach. Gastric Cancer. 16, 505-512.
    Pubmed CrossRef
  7. Kim, SH, Ahn, BK, Nam, YS, Pyo, JY, Oh, YH, and Lee, KH (2010). Microsatellite instability is associated with the clinicopathologic features of gastric cancer in sporadic gastric cancer patients. J Gastric Cancer. 10, 149-154.
    CrossRef
  8. Chung, HW, Lee, SY, and Han, HS (2013). Gastric cancers with microsatellite instability exhibit high fluorodeoxyglucose uptake on positron emission tomography. Gastric Cancer. 16, 185-192.
    CrossRef
  9. Choe, WH, Lee, SY, and Lee, JH (2005). High frequency of microsatellite instability in intestinal-type gastric cancer in Korean patients. Korean J Intern Med. 20, 116-122.
    Pubmed KoreaMed CrossRef
  10. Markowitz, S (2000). DNA repair defects inactivate tumor suppressor genes and induce hereditary and sporadic colon cancers. J Clin Oncol. 18, 75S-80S.
    Pubmed
  11. Lee, SY, Chung, H, and Devaraj, B (2010). Microsatellite alterations at selected tetranucleotide repeats are associated with morphologies of colorectal neoplasias. Gastroenterology. 139, 1519-1525.
    Pubmed KoreaMed CrossRef
  12. Yoon, YS, Yu, CS, and Kim, TW (2011). Mismatch repair status in sporadic colorectal cancer: immunohistochemistry and microsatellite instability analyses. J Gastroenterol Hepatol. 26, 1733-1739.
    Pubmed CrossRef
  13. Cho, I, An, JY, and Kwon, IG (2014). Risk factors for double primary malignancies and their clinical implications in patients with sporadic gastric cancer. Eur J Surg Oncol. 40, 338-344.
    CrossRef
  14. Ueda, E, Watanabe, T, Umetani, N, Ishigami, H, Sasaki, S, and Nagawa, H (2002). Microsatellite instability of cancers and concomitant adenomas in synchronous multiple colorectal cancer patients. J Exp Clin Cancer Res. 21, 149-154.
    Pubmed
  15. Yun, HR, Yi, LJ, and Cho, YK (2009). Double primary malignancy in colorectal cancer patients: MSI is the useful marker for predicting double primary tumors. Int J Colorectal Dis. 24, 369-375.
    CrossRef
  16. An, JY, Kim, H, Cheong, JH, Hyung, WJ, Kim, H, and Noh, SH (2012). Microsatellite instability in sporadic gastric cancer: its prognostic role and guidance for 5-FU based chemotherapy after R0 resection. Int J Cancer. 131, 505-511.
    CrossRef
  17. Tajima, A, Hess, MT, Cabrera, BL, Kolodner, RD, and Carethers, JM (2004). The mismatch repair complex hMutS alpha recognizes 5-fluorouracil-modified DNA: implications for chemosensitivity and resistance. Gastroenterology. 127, 1678-1684.
    Pubmed CrossRef
  18. Kim, HO, Hwang, SI, Yoo, CH, and Kim, H (2009). Preoperative colonoscopy for patients with gastric adenocarcinoma. J Gastroenterol Hepatol. 24, 1740-1744.
    Pubmed CrossRef
  19. Hata, K, Shinozaki, M, and Toyoshima, O (2013). Impact of family history of gastric cancer on colorectal neoplasias in young Japanese. Colorectal Dis. 15, 42-46.
    CrossRef
  20. Han, HS, Lee, SY, and Lee, KY (2009). Unclassified mucin phenotype of gastric adenocarcinoma exhibits the highest invasiveness. J Gastroenterol Hepatol. 24, 658-666.
    Pubmed CrossRef
  21. Chung, WC, Jung, SH, and Lee, KM (2010). Genetic instability in gastric epithelial neoplasias categorized by the revised Vienna classification. Gut Liver. 4, 179-185.
    Pubmed KoreaMed CrossRef
  22. Kim, JS, Chung, WC, and Lee, KM (2012). Association between genetic instability and Helicobacter pylori infection in gastric epithelial dysplasia. Gastroenterol Res Pract. 2012, 360929.
    CrossRef
  23. Lee, HS, Lee, BL, Kim, SH, Woo, DK, Kim, HS, and Kim, WH (2001). Microsatellite instability in synchronous gastric carcinomas. Int J Cancer. 91, 619-624.
    Pubmed CrossRef
  24. Miyoshi, E, Haruma, K, and Hiyama, T (2001). Microsatellite instability is a genetic marker for the development of multiple gastric cancers. Int J Cancer. 95, 350-353.
    Pubmed CrossRef
  25. Yamashita, K, Arimura, Y, and Kurokawa, S (2000). Microsatellite instability in patients with multiple primary cancers of the gastrointestinal tract. Gut. 46, 790-794.
    Pubmed KoreaMed CrossRef
  26. Yoon, SN, Oh, ST, and Lim, SB (2010). Clinicopathologic characteristics of colorectal cancer patients with synchronous and metachronous gastric cancer. World J Surg. 34, 2168-2176.
    Pubmed CrossRef
  27. Abe, Y, Masuda, H, and Okubo, R (2001). Microsatellite instability of each tumor in sporadic synchronous multiple colorectal cancers. Oncol Rep. 8, 299-304.
    Pubmed
  28. Levine, AJ, Win, AK, and Buchanan, DD (2012). Cancer risks for the relatives of colorectal cancer cases with a methylated MLH1 promoter region: data from the Colorectal Cancer Family Registry. Cancer Prev Res (Phila). 5, 328-335.
    CrossRef
  29. Arai, T, Kasahara, I, Sawabe, M, Honma, N, Aida, J, and Tabubo, K (2010). Role of methylation of the hMLH1 gene promoter in the development of gastric and colorectal carcinoma in the elderly. Geriatr Gerontol Int. 10, S207-S212.
    Pubmed CrossRef
  30. Leite, M, Corso, G, and Sousa, S (2011). MSI phenotype and MMR alterations in familial and sporadic gastric cancer. Int J Cancer. 128, 1606-1613.
    CrossRef
Gut and Liver

Vol.17 No.1
January, 2023

pISSN 1976-2283
eISSN 2005-1212

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