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. 1999 Sep;45(3):409–415. doi: 10.1136/gut.45.3.409

Choice of management strategy for colorectal cancer based on a diagnostic immunohistochemical test for defective mismatch repair

L Cawkwell 1, S Gray 1, H Murgatroyd 1, F Sutherland 1, L Haine 1, M Longfellow 1, S O'Loughlin 1, D Cross 1, O Kronborg 1, C Fenger 1, N Mapstone 1, M Dixon 1, P Quirke 1
PMCID: PMC1727633  PMID: 10446111

Abstract

BACKGROUND—Despite intensive research into the molecular abnormalities associated with colorectal cancer (CRC), no diagnostic tests have emerged which usefully complement standard histopathological assessments.
AIMS—To assess the feasibility of using immunohistochemistry to detect replication error (RER) positive CRCs and determine the incidence of RER positivity within distinct patient subgroups.
METHODS—502 CRCs were analysed for RER positivity (at least two markers affected) and/or expression of hMSH2 and hMLH1.
RESULTS—There were 15/30 (50%) patients with metachronous CRCs, 16/51 (31%) with synchronous CRCs, 14/45 (31%) with a proximal colon carcinoma, and 4/23 (17%) who developed a CRC under the age of 50 showed RER positivity. However, 0/54 patients who developed a solitary carcinoma of the rectum/left colon over the age of 50 showed RER positivity. Immunohistochemical analysis revealed that 66/66 (100%) RER positive carcinomas were associated with complete lack of expression of either hMSH2 or hMLH1. This correlation was confirmed using a further 101 proximal colon carcinomas. Patients with a mismatch repair defective carcinoma showed improved survival but a 5.54 times relative risk of developing a metachronous CRC. A prospective immunohistochemical study revealed 13/117 (11%) patients had a mismatch repair defective carcinoma. A fivefold excess of hMLH1 defective cases was noted.
CONCLUSIONS—All RER positive carcinomas were identified by the immunohistochemical test. This is the first simple laboratory test which can be performed routinely on all CRCs. It will provide a method for selecting patients who should be investigated for HNPCC, offered long term follow up, and who may not respond to standard chemotherapy regimens.


Keywords: colorectal cancer; mismatch repair; hMSH2; hMLH1; microsatellite instability; immunohistochemistry

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Figure 1  .

Figure 1  

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Detection of microsatellite instability using the MycL1 marker and the fluorescent PCR based assay. On the cross sectional representation the alleles from the carcinoma DNA and the corresponding normal DNA have been superimposed. The constitutional alleles, which are common to both DNA samples, are colocalised and the novel alleles in the carcinoma DNA (arrowed) are clearly evident.

Figure 2  .

Figure 2  

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Immunohistochemical staining of hMSH2 and hMLH1 using consecutive tissue sections (original magnification × 160). (A) Positive staining of normal control mucosa (N) and adjacent carcinoma (C) with hMSH2. (B) Positive staining of normal control mucosa (N); loss of hMLH1 protein expression in the adjacent carcinoma (C) is clearly evident. Intervening stromal cells are positive.

Figure 3  .

Figure 3  

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Kaplan-Meier survival curve for mismatch repair status, as defined by the expression of hMSH2 and hMLH1, for proximally located sporadic colon carcinomas. A significantly increased patient survival (p=0.01) was associated with the 15 mismatch repair defective (MMR negative) cases (14 lacking hMLH1, one lacking hMSH2) versus the 84 mismatch repair proficient (MMR positive) cases.

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