Int J Clin Exp Pathol 2015;8(1):862-866 www.ijcep.com /ISSN:1936-2625/IJCEP0003609
Original Article CA9 overexpression is an independent favorable prognostic marker in intrahepatic cholangiocarcinoma Mijin Gu Department of Pathology, Yeungnam University College of Medicine, Daegu, Rep of Korea Received November 4, 2014; Accepted December 23, 2014; Epub January 1, 2015; Published January 15, 2015 Abstract: The aim of this study is to evaluate the expression of carbonic anhydrase IX (CA9) and to identify its prognostic significance in intrahepatic cholangiocarcinoma (IHCC). We performed immunohistochemistry (IHC) for CA9 in a total of 85 IHCCs. CA9 overexpression was observed in 38 of 85 (44.7%) IHCCs. CA9 overexpression was related to tumors with intraductal growth than mass forming or periductal infiltrative type. CA9 overexpression was more observed in tumors with well/moderate differentiation than poor differentiation and without lymph node metastasis. No significant correlation was observed in CA9 overexpression with tumor size, pT, stage and lymphovascular invasion. Intrahepatic cholangiocarcinomas with CA9 overexpression showed better overall survival than that without expression (P = 0.001). In multivariate analysis, lymph node metastasis (95% CI: 2.103 (1.167-3.791), P = 0.013) was an independent poor prognostic factor. IHCC with CA9 overexpression showed a 0.5-fold (95% confidence interval, 0.328-0.944) lower risk of death compared with those of no or weak expression. CA9 overexpression was related to histologic differentiation and an independent good prognostic factor. Keywords: Cholangiocarcinoma, CA9, prognosis
Introduction Cholangiocarcinoma (CCC) is a highly malignant neoplasm with poor overall outcome. The five-year survival rate after a curative resection is ≤ 30% [1, 2]. Efforts have focused on identification of carcinogenesis, it is still poorly understood and there has been little improvement in survival over the last decade. CA9 expression has shown to be correlated with poor prognosis in many human cancers [3-8]. CA9 expression may serve as a predictive factor to guide the selection of the most appropriate adjuvant therapy because tumor hypoxia has been associated with tumor resistance to chemotherapy and radiotherapy as well as more aggressive phenotype and poor survival [5]. The purpose of this study was to evaluate the immunohistochemical overexpression of CA9 and their prognostic significance in patients with IHCC. Materials and methods Patients and clinicopathologic factors Data were obtained on 85 consecutive patients who underwent resection at Yeungnam
University Hospital from July 1988 to June 2012. Clinicopathologic parameters, including age, gender, tumor size, differentiation, presence of lymphovascular invasion, presence of lymph node metastasis, disease-free survival (DFS) and overall survival (OS) were evaluated by review of medical records and pathological reports. Overall patients’ survival was defined as the time from surgical resection to death of patients or patients’ last follow-up. Follow-up lasted through June 2012 (range 0-180 months, mean 24.98 months). Tissue microarray construction Five tissue microarray (TMA) blocks were made with 83 cases; three 2 mm cores were obtained from the most representative tumor area of each case and arrayed in a new recipient block. Four normal liver tissue cores included in each TMA and normal rectal mucosa were used as controls. For the other two cases, ordinary blocks were used. Immunohistochemistry After deparaffinization and rehydration, 4-µm sections were immunostained for CA9 (1:250, clone EPR4151, rabbit monoclonal antibody,
CA9 overexpression in cholangiocarcinoma
Figure 1. Immunohistochemical results for CA9 (A) overexpression; (B) not expression. HE, × 100.
Table 1. Comparison between CA9 overexpression and clinicopathological parameters Factors Size < 5 cm ≥ 5 cm Gross type Mass forming Periductal infiltrate Intraductal Differentiation Well/Moderate Poor Vascular invasion Present Absent Perineural invasion Present Absent Resection margin involve Present Absent Lymph node metastasis Present Absent Stage I II III IV
CA9 Overexpression Not expression
P 0.530
16 (41.0%) 22 (47.8%)
23 (59.0%) 24 (52.2%)
27 (38.0%) 4 (80.0%) 7 (77.8%)
44 (62.0%) 1 (20.0%) 2 (22.2%)
33 (50.0%) 5 (26.3%)
33 (50.0%) 14 (73.7%)
24(42.9%) 14(48.3%)
32 (57.1%) 15 (51.7%)
0.019
0.067
0.634
0.466 18 (40.9%) 20 (48.8%)
26 (59.1%) 21 (51.2%) 0.577
16 (48.5%) 22 (42.3%)
17 (51.5%) 30 (57.7%) 0.090
14 (35.0%) 24 (53.3%)
26 (65.0%) 21 (46.7%)
10 (52.6%) 13 (59.1%) 12 (36.4%) 3 (27.3%)
9 (47.4%) 9 (40.9%) 21 (63.6%) 8 (72.7%)
0.203
Epitomics, CA, USA). The staining was performed on the Ventana BenchMark® platform automated slide stainer 863
(Ventana Medical Systems, Tucson, AZ, USA) using the onboard heatinduced epitope retrieval method in high pH CC1 buffer (99°C, 1 h). Slides were then incubated with primary antibody CA9 at room temperature for 40min. The staining was visualized using the UltraViewTM DAB detection Kit (Automated BenchMark®, Ventana), which included a hydrogen peroxide substrate and a 3,3’-diaminobenzidine chromogen solution. The slides were subsequently counterstained with hematoxylin. Evaluation of the immunohistochemical results We assessed CA9 expression by using a four-step scoring system, previously described [3]. The scoring was: negative = score 0 (no staining or membranous staining < 10% of tumor cells), weak = score 1 (partial membrane staining > 10% of tumor cells), moderate = score 2 (weak to moderate complete membrane staining in > 10% of tumor cells), and strong = score 3 (strong and complete membrane staining in > 10% of tumor cells). Finally, we considered CA9 overexpression if more than score 2. Statistical analysis SPSS version 19.0 (SPSS Inc., Chicago, IL, USA) was used in perforInt J Clin Exp Pathol 2015;8(1):862-866
CA9 overexpression in cholangiocarcinoma patients (38.8%). Forty (47.1%) patients showed metastasis to regional lymph nodes. Comparison IHC results with clinicopathological factors CA9 overexpression was observed in 38 of 85 (44.7%) IHCCs (Figure 1). CA9 overexpression was related to tumors with intraductal growth than mass forming or periductal infiltrative type. CA9 overexpression was more observed in tumors with well/moderate differentiation than poor differentiation and that without lymph node metastasis. No significant correlation was observed in CA9 overexpression with tumor size, pT, stage and vascular invasion (Table 1). IHCC with CA9 overexpression showed better overall survival than that with no or weak expression (P = 0.001) Figure 2. Overall survival analysis: CA9 overexpression (E) intrahepatic (Figure 2). In multivariate analysis, cholangiocarcinoma shows better overall survival than that with no or lymph node metastasis (95% confiweak expression (NE). dence interval 2.103, 1.167-3.791, P = P = 0.013) was an independent mance of statistical comparisons. Pearson’s poor prognostic factor. IHCC with CA9 overexChi-square test and Fisher’s exact test were pression showed a 0.5-fold (95% confidence performed in order to examine associations interval, 0.328-0.944) lower risk of death combetween clinicopathologic parameters and pared with those of no or weak expression. expression. DFS and OS were calculated using Discussion the Kaplan-Meier method. The Cox proportional Hazard Model was used for evaluation of the CA9 is a transmemebrane zinc metalloenzyme association between clinicopathological and has a function in cell-cell adhesion and parameters and survival. A P value of less than plays an important role in tumor growth and 0.05 was considered statistically significant. survival under normoxia and hypoxia [9]. Its expression is mostly restricted to the premaligResults nant and malignant cells and rarely found in Clinicopathologic characteristics normal tissue or benign lesions [4]. Tumor hypoxia leads to resistant to chemotherapy and Fifty three male and 32 female patients with a radiation therapy and increases risk of tumor median age of 60.5 years (range 39-79 years) invasion and metastasis, and considered as an were included in this study. Regarding growth indicator of more aggressive outcome [5, 10]. type, 71 cases were mass-forming type, 5 Studies on breast, upper gastrointestinal tract, cases were periductal infiltrating type, and 9 cervix, ovary, and lung cancer have showed cases were intraductal-growth type. Regarding that CA9 overexpression was associated with histologic subtypes, there were 66 well/moderpoor outcome [3-5, 11-13]. Hussain et al. [5] ately differentiated adenocarcinomas (77.6%) suggested that CA9 expression is associated and 19 poorly differentiated adenocarcinomas with poor survival in invasive breast cancer. (22.4%). Vascular invasion was observed in 45 Hynninen et al. [6] demonstrated that CA9 over(64.7%) patients. Neural invasion was observed expression in ovarian cancer could be a useful in 44 patients (51.8%). Resection margin histopathological marker for hypoxia and a involvement by IHCC was observed in 33 864
Int J Clin Exp Pathol 2015;8(1):862-866
CA9 overexpression in cholangiocarcinoma potential target for therapy. Driessen et al. [4] demonstrated that tumors with CA9 overexpression was associated with intestinal type than diffuse type and showed poor prognosis in esophageal and gastric adenocarcinomas. CA9 expression was associated with tumor progression and lymph node metastasis in vulva cancer [14]. However, the correlation between CA9 overexpression and clinicopathologic parameters has shown to be diverse, depending on the tumors sites, and researchers. Studies on rectal cancers showed controversial results. Rasheed et al. [15] investigated that rectal cancer with CA9 overexpression showed long term survival than that of without expression. In contrast, Korkelia et al. [13] demonstrated that CA9 overexpression is a poor prognostic predictor. And some studies have demonstrated that the relationship between low CA9 expression and poor prognosis in cervical carcinoma, colorectal carcinoma, and esophageal carcinoma [16-18]. Patard et al. [19] demonstrated that low CA9 expression and absence of VHL mutation was associated with a poor clinicopathological phenotype and diminished survival. Sergeant et al. [10] demonstrated that CA9 expression was less prevalent in poorly differentiated carcinomas and was associated with favorable prognosis in gallbladder carcinoma. These findings are consistent with this study. This study has shown that CA9 overexpression was associated with well/moderate differentiated IHCC and was an independent good prognostic factor. And CA9 overexpression was more evident in IHCC with intraductal growth and was more observed in IHCC without lymph node metastasis. This findings support that CA9 overexpression may not be involved in tumor progression, invasion and metastasis in IHCC. Recently, CA9-targeting antibodies (WX-G250, Rencarex®) are being evaluated in phase III adjuvant immunotherapy and radiotherapy trial in renal cell carcinoma [20]. However, this study supports that CA9-targeting therapy may not be useful for IHCC. In summary, this study demonstrated that CA9 overexpression was related to well/moderate differentiated IHCC and an independent good prognostic factor. Disclosure of conflict of interest None.
865
Address correspondence to: Dr. Mijin Gu, Department of Pathology, Yeungnam University College of Medicine, 317-1 Hyunchung-Ro, Nam-Gu, Daegu 705-717, Korea. Tel: +82-53-640-6756; Fax: +8253-622-8432; E-mail: [email protected]
References [1]
[2]
[3]
[4]
[5]
[6]
[7]
[8]
[9]
Yoshikawa D, Ojima H, Iwasaki M, Hiraoka N, Kosuge T, Kasai S, Hirohashi S, Shibata T. Clinicopathological and prognostic significance of EGFR, VEGF, and HER2 expression in cholangiocarcinoma. Br J Cancer 2008; 98: 41825. Xu L, Hausmann M, Dietmaier W, Kellermeier S, Pesch T, Stieber-Gunckel M, Lippert E, Klebl F, Rogler G. Expression of growth factor receptors and targeting of EGFR in cholangiocarcinoma cell lines. BMC Cancer 2010; 10: 302. Choschzick M, Oosterwijk E, Müller V, Woelber L, Simon R, Moch H, Tennstedt P. Overexpression of carbonic anhydrase IX (CAIX) is an independent unfavorable prognostic marker in endometrioid ovarian cancer. Virchows Arch 2011; 459: 193-200. Driessen A, Landuyt W, Pastorekova S, Moons A, Goethals L, Hausterman K, Nafteux P, Penninckx F, Goboes K, Lerut T, Ectors N. Expression of carbonic anhydrase IX (CA IX), a hypoxia-related protein, rather than vascularendothelial growth factor (VEGF), a pro-angiogenic factor, correlates with an extremely poor prognosis in esophageal and gastric adenocarcinomas. Ann Surg 2006; 243: 334-40. Hussain SA, Ganesan R, Reynolds G, Gross L, Stevens A, Pastorek J, Murray PG, Perunovic B, Anwar MS, Billingham L, James ND, Spooner D, Poole CJ, Rea DW, Palmer DH. Hypoxiaregulated carbonic anhydrase IX expression is associated with poor survival in patients with invasive breast cancer. Br J Cancer 2007; 96: 104-9. Hynninen P, Vaskivuo L, Saarnio J, Haapasalo H, Kivelä J, Pastoreková S, Pastorek J, Waheed A, Sly WS, Puistola U, Parkkila S. Expression of transmembrane carbonic anhydrases IX and XII in ovarian tumours. Histopathology 2006; 49: 594-602. Span PN, Nagtegaal ID, Bussink J. Expression of carbonic anhydrase IX suggests poor response to therapy in rectal cancer. Br J Cancer 2009; 101: 372; author reply 373. Williams E, Martin S, Moss R, Durrant L, Deen S. Co-expression of VEGF and CA9 in ovarian high-grade serous carcinoma and relationship to survival. Virchows Arch 2012; 461: 33-9. Robertson N, Potter C, Harris AL. Role of carbonic anhydrase IX in human tumor cell growth, survival, and invasion. Cancer Res 2004; 64: 6160-5.
Int J Clin Exp Pathol 2015;8(1):862-866
CA9 overexpression in cholangiocarcinoma [10] Sergeant G, Lerut E, Ectors N, Hendrickx T, Aerts R, Yopal B. The prognostic relevance of tumor hypoxia markers in resected carcinoma of the gallbladder. Eur J Surg Oncol 2011; 37: 80-6. [11] Ilie M, Mazure NM, Hofman V, Ammadi RE, Ortholan C, Bonnetaud C, Havet K, Venissac N, Mograbi B, Mouroux J, Pouysségur J, Hofman P. High levels of carbonic anhydrase IX in tumour tissue and plasma are biomarkers of poor prognostic in patients with non-small cell lung cancer. Br J Cancer 2010; 102: 1627-35. [12] Kim SJ, Rabbani ZN, Dewhirst MW, Vujaskovic Z, Vollmer RT, Schreiber EG, Oosterwijk E, Kelley MJ. Expression of HIF-1alpha, CA IX, VEGF, and MMP-9 in surgically resected nonsmall cell lung cancer. Lung Cancer 2005; 49: 325-35. [13] Korkeila E, Talvinen K, Jaakkola PM, Minn H, Syrjänen K, Sundström J, Pyrhönen S. Expression of carbonic anhydrase IX suggests poor outcome in rectal cancer. Br J Cancer 2009; 100: 874-80. [14] Choschzick M, Woelber L, Hess S, zu Eulenburg C, Schwarz J, Simon R, Mahner S, Jaenicke F, Müller V. Overexpression of carbonic anhydrase IX (CAIX) in vulvar cancer is associated with tumor progression and development of locoregional lymph node metastases. Virchows Arch 2010; 456: 483-90. [15] Rasheed S, Harris AL, Tekkis PP, Turley H, Silver A, McDonald PJ, Talbot IC, Glynne-Jones R, Northover JM, Guenther T. Assessment of microvessel density and carbonic anhydrase-9 (CA-9) expression in rectal cancer. Pathol Res Pract 2009; 205: 1-9.
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[16] Brewer CA, Liao SY, Wilczynski SP, Pastorekova S, Pastorek J, Zavada J, Kurosaki T, Manetta A, Berman ML, DiSaia PJ, Stanbridge EJ. A study of biomarkers in cervical carcinoma and clinical correlation of the novel biomarker MN. Gynecol Oncol 1996; 63: 337-44. [17] Saarnio J, Parkkila S, Parkkila AK, Waheed A, Casey MC, Zhou XY, Pastoreková S, Pastorek J, Karttunen T, Haukipuro K, Kairaluoma MI, Sly WS. Immunohistochemistry of carbonic anhydrase isozyme IX (MN/CA IX) in human gut reveals polarized expression in the epithelial cells with the highest proliferative capacity. J Histochem Cytochem 1998; 46: 497-504. [18] Turner JR, Odze RD, Crum CP, Resnick MB. MN antigen expression in normal, preneoplastic, and neoplastic esophagus: a clinicopathological study of a new cancer-associated biomarker. Hum Pathol 1997; 28: 740-4. [19] Patard JJ, Fergelot P, Karakiewicz PI, Klatte T, Trinh QD, Rioux-Leclercq N, Said JW, Belldegrun AS, Pantuck AJ. Low CAIX expression and absence of VHL gene mutation are associated with tumor aggressiveness and poor survival of clear cell renal cell carcinoma. Int J Cancer 2008; 123: 395-400. [20] Wilex: Phase III ARISER Study (Adjuvant RENCAREX® Immunotherpy Phase III trial to Study Efficacy in non-metastatic RCC). http:// www.wilex.de/R&D/RENCAREX_PhaseIII.htm
Int J Clin Exp Pathol 2015;8(1):862-866
Original Article CA9 overexpression is an independent favorable prognostic marker in intrahepatic cholangiocarcinoma Mijin Gu Department of Pathology, Yeungnam University College of Medicine, Daegu, Rep of Korea Received November 4, 2014; Accepted December 23, 2014; Epub January 1, 2015; Published January 15, 2015 Abstract: The aim of this study is to evaluate the expression of carbonic anhydrase IX (CA9) and to identify its prognostic significance in intrahepatic cholangiocarcinoma (IHCC). We performed immunohistochemistry (IHC) for CA9 in a total of 85 IHCCs. CA9 overexpression was observed in 38 of 85 (44.7%) IHCCs. CA9 overexpression was related to tumors with intraductal growth than mass forming or periductal infiltrative type. CA9 overexpression was more observed in tumors with well/moderate differentiation than poor differentiation and without lymph node metastasis. No significant correlation was observed in CA9 overexpression with tumor size, pT, stage and lymphovascular invasion. Intrahepatic cholangiocarcinomas with CA9 overexpression showed better overall survival than that without expression (P = 0.001). In multivariate analysis, lymph node metastasis (95% CI: 2.103 (1.167-3.791), P = 0.013) was an independent poor prognostic factor. IHCC with CA9 overexpression showed a 0.5-fold (95% confidence interval, 0.328-0.944) lower risk of death compared with those of no or weak expression. CA9 overexpression was related to histologic differentiation and an independent good prognostic factor. Keywords: Cholangiocarcinoma, CA9, prognosis
Introduction Cholangiocarcinoma (CCC) is a highly malignant neoplasm with poor overall outcome. The five-year survival rate after a curative resection is ≤ 30% [1, 2]. Efforts have focused on identification of carcinogenesis, it is still poorly understood and there has been little improvement in survival over the last decade. CA9 expression has shown to be correlated with poor prognosis in many human cancers [3-8]. CA9 expression may serve as a predictive factor to guide the selection of the most appropriate adjuvant therapy because tumor hypoxia has been associated with tumor resistance to chemotherapy and radiotherapy as well as more aggressive phenotype and poor survival [5]. The purpose of this study was to evaluate the immunohistochemical overexpression of CA9 and their prognostic significance in patients with IHCC. Materials and methods Patients and clinicopathologic factors Data were obtained on 85 consecutive patients who underwent resection at Yeungnam
University Hospital from July 1988 to June 2012. Clinicopathologic parameters, including age, gender, tumor size, differentiation, presence of lymphovascular invasion, presence of lymph node metastasis, disease-free survival (DFS) and overall survival (OS) were evaluated by review of medical records and pathological reports. Overall patients’ survival was defined as the time from surgical resection to death of patients or patients’ last follow-up. Follow-up lasted through June 2012 (range 0-180 months, mean 24.98 months). Tissue microarray construction Five tissue microarray (TMA) blocks were made with 83 cases; three 2 mm cores were obtained from the most representative tumor area of each case and arrayed in a new recipient block. Four normal liver tissue cores included in each TMA and normal rectal mucosa were used as controls. For the other two cases, ordinary blocks were used. Immunohistochemistry After deparaffinization and rehydration, 4-µm sections were immunostained for CA9 (1:250, clone EPR4151, rabbit monoclonal antibody,
CA9 overexpression in cholangiocarcinoma
Figure 1. Immunohistochemical results for CA9 (A) overexpression; (B) not expression. HE, × 100.
Table 1. Comparison between CA9 overexpression and clinicopathological parameters Factors Size < 5 cm ≥ 5 cm Gross type Mass forming Periductal infiltrate Intraductal Differentiation Well/Moderate Poor Vascular invasion Present Absent Perineural invasion Present Absent Resection margin involve Present Absent Lymph node metastasis Present Absent Stage I II III IV
CA9 Overexpression Not expression
P 0.530
16 (41.0%) 22 (47.8%)
23 (59.0%) 24 (52.2%)
27 (38.0%) 4 (80.0%) 7 (77.8%)
44 (62.0%) 1 (20.0%) 2 (22.2%)
33 (50.0%) 5 (26.3%)
33 (50.0%) 14 (73.7%)
24(42.9%) 14(48.3%)
32 (57.1%) 15 (51.7%)
0.019
0.067
0.634
0.466 18 (40.9%) 20 (48.8%)
26 (59.1%) 21 (51.2%) 0.577
16 (48.5%) 22 (42.3%)
17 (51.5%) 30 (57.7%) 0.090
14 (35.0%) 24 (53.3%)
26 (65.0%) 21 (46.7%)
10 (52.6%) 13 (59.1%) 12 (36.4%) 3 (27.3%)
9 (47.4%) 9 (40.9%) 21 (63.6%) 8 (72.7%)
0.203
Epitomics, CA, USA). The staining was performed on the Ventana BenchMark® platform automated slide stainer 863
(Ventana Medical Systems, Tucson, AZ, USA) using the onboard heatinduced epitope retrieval method in high pH CC1 buffer (99°C, 1 h). Slides were then incubated with primary antibody CA9 at room temperature for 40min. The staining was visualized using the UltraViewTM DAB detection Kit (Automated BenchMark®, Ventana), which included a hydrogen peroxide substrate and a 3,3’-diaminobenzidine chromogen solution. The slides were subsequently counterstained with hematoxylin. Evaluation of the immunohistochemical results We assessed CA9 expression by using a four-step scoring system, previously described [3]. The scoring was: negative = score 0 (no staining or membranous staining < 10% of tumor cells), weak = score 1 (partial membrane staining > 10% of tumor cells), moderate = score 2 (weak to moderate complete membrane staining in > 10% of tumor cells), and strong = score 3 (strong and complete membrane staining in > 10% of tumor cells). Finally, we considered CA9 overexpression if more than score 2. Statistical analysis SPSS version 19.0 (SPSS Inc., Chicago, IL, USA) was used in perforInt J Clin Exp Pathol 2015;8(1):862-866
CA9 overexpression in cholangiocarcinoma patients (38.8%). Forty (47.1%) patients showed metastasis to regional lymph nodes. Comparison IHC results with clinicopathological factors CA9 overexpression was observed in 38 of 85 (44.7%) IHCCs (Figure 1). CA9 overexpression was related to tumors with intraductal growth than mass forming or periductal infiltrative type. CA9 overexpression was more observed in tumors with well/moderate differentiation than poor differentiation and that without lymph node metastasis. No significant correlation was observed in CA9 overexpression with tumor size, pT, stage and vascular invasion (Table 1). IHCC with CA9 overexpression showed better overall survival than that with no or weak expression (P = 0.001) Figure 2. Overall survival analysis: CA9 overexpression (E) intrahepatic (Figure 2). In multivariate analysis, cholangiocarcinoma shows better overall survival than that with no or lymph node metastasis (95% confiweak expression (NE). dence interval 2.103, 1.167-3.791, P = P = 0.013) was an independent mance of statistical comparisons. Pearson’s poor prognostic factor. IHCC with CA9 overexChi-square test and Fisher’s exact test were pression showed a 0.5-fold (95% confidence performed in order to examine associations interval, 0.328-0.944) lower risk of death combetween clinicopathologic parameters and pared with those of no or weak expression. expression. DFS and OS were calculated using Discussion the Kaplan-Meier method. The Cox proportional Hazard Model was used for evaluation of the CA9 is a transmemebrane zinc metalloenzyme association between clinicopathological and has a function in cell-cell adhesion and parameters and survival. A P value of less than plays an important role in tumor growth and 0.05 was considered statistically significant. survival under normoxia and hypoxia [9]. Its expression is mostly restricted to the premaligResults nant and malignant cells and rarely found in Clinicopathologic characteristics normal tissue or benign lesions [4]. Tumor hypoxia leads to resistant to chemotherapy and Fifty three male and 32 female patients with a radiation therapy and increases risk of tumor median age of 60.5 years (range 39-79 years) invasion and metastasis, and considered as an were included in this study. Regarding growth indicator of more aggressive outcome [5, 10]. type, 71 cases were mass-forming type, 5 Studies on breast, upper gastrointestinal tract, cases were periductal infiltrating type, and 9 cervix, ovary, and lung cancer have showed cases were intraductal-growth type. Regarding that CA9 overexpression was associated with histologic subtypes, there were 66 well/moderpoor outcome [3-5, 11-13]. Hussain et al. [5] ately differentiated adenocarcinomas (77.6%) suggested that CA9 expression is associated and 19 poorly differentiated adenocarcinomas with poor survival in invasive breast cancer. (22.4%). Vascular invasion was observed in 45 Hynninen et al. [6] demonstrated that CA9 over(64.7%) patients. Neural invasion was observed expression in ovarian cancer could be a useful in 44 patients (51.8%). Resection margin histopathological marker for hypoxia and a involvement by IHCC was observed in 33 864
Int J Clin Exp Pathol 2015;8(1):862-866
CA9 overexpression in cholangiocarcinoma potential target for therapy. Driessen et al. [4] demonstrated that tumors with CA9 overexpression was associated with intestinal type than diffuse type and showed poor prognosis in esophageal and gastric adenocarcinomas. CA9 expression was associated with tumor progression and lymph node metastasis in vulva cancer [14]. However, the correlation between CA9 overexpression and clinicopathologic parameters has shown to be diverse, depending on the tumors sites, and researchers. Studies on rectal cancers showed controversial results. Rasheed et al. [15] investigated that rectal cancer with CA9 overexpression showed long term survival than that of without expression. In contrast, Korkelia et al. [13] demonstrated that CA9 overexpression is a poor prognostic predictor. And some studies have demonstrated that the relationship between low CA9 expression and poor prognosis in cervical carcinoma, colorectal carcinoma, and esophageal carcinoma [16-18]. Patard et al. [19] demonstrated that low CA9 expression and absence of VHL mutation was associated with a poor clinicopathological phenotype and diminished survival. Sergeant et al. [10] demonstrated that CA9 expression was less prevalent in poorly differentiated carcinomas and was associated with favorable prognosis in gallbladder carcinoma. These findings are consistent with this study. This study has shown that CA9 overexpression was associated with well/moderate differentiated IHCC and was an independent good prognostic factor. And CA9 overexpression was more evident in IHCC with intraductal growth and was more observed in IHCC without lymph node metastasis. This findings support that CA9 overexpression may not be involved in tumor progression, invasion and metastasis in IHCC. Recently, CA9-targeting antibodies (WX-G250, Rencarex®) are being evaluated in phase III adjuvant immunotherapy and radiotherapy trial in renal cell carcinoma [20]. However, this study supports that CA9-targeting therapy may not be useful for IHCC. In summary, this study demonstrated that CA9 overexpression was related to well/moderate differentiated IHCC and an independent good prognostic factor. Disclosure of conflict of interest None.
865
Address correspondence to: Dr. Mijin Gu, Department of Pathology, Yeungnam University College of Medicine, 317-1 Hyunchung-Ro, Nam-Gu, Daegu 705-717, Korea. Tel: +82-53-640-6756; Fax: +8253-622-8432; E-mail: [email protected]
References [1]
[2]
[3]
[4]
[5]
[6]
[7]
[8]
[9]
Yoshikawa D, Ojima H, Iwasaki M, Hiraoka N, Kosuge T, Kasai S, Hirohashi S, Shibata T. Clinicopathological and prognostic significance of EGFR, VEGF, and HER2 expression in cholangiocarcinoma. Br J Cancer 2008; 98: 41825. Xu L, Hausmann M, Dietmaier W, Kellermeier S, Pesch T, Stieber-Gunckel M, Lippert E, Klebl F, Rogler G. Expression of growth factor receptors and targeting of EGFR in cholangiocarcinoma cell lines. BMC Cancer 2010; 10: 302. Choschzick M, Oosterwijk E, Müller V, Woelber L, Simon R, Moch H, Tennstedt P. Overexpression of carbonic anhydrase IX (CAIX) is an independent unfavorable prognostic marker in endometrioid ovarian cancer. Virchows Arch 2011; 459: 193-200. Driessen A, Landuyt W, Pastorekova S, Moons A, Goethals L, Hausterman K, Nafteux P, Penninckx F, Goboes K, Lerut T, Ectors N. Expression of carbonic anhydrase IX (CA IX), a hypoxia-related protein, rather than vascularendothelial growth factor (VEGF), a pro-angiogenic factor, correlates with an extremely poor prognosis in esophageal and gastric adenocarcinomas. Ann Surg 2006; 243: 334-40. Hussain SA, Ganesan R, Reynolds G, Gross L, Stevens A, Pastorek J, Murray PG, Perunovic B, Anwar MS, Billingham L, James ND, Spooner D, Poole CJ, Rea DW, Palmer DH. Hypoxiaregulated carbonic anhydrase IX expression is associated with poor survival in patients with invasive breast cancer. Br J Cancer 2007; 96: 104-9. Hynninen P, Vaskivuo L, Saarnio J, Haapasalo H, Kivelä J, Pastoreková S, Pastorek J, Waheed A, Sly WS, Puistola U, Parkkila S. Expression of transmembrane carbonic anhydrases IX and XII in ovarian tumours. Histopathology 2006; 49: 594-602. Span PN, Nagtegaal ID, Bussink J. Expression of carbonic anhydrase IX suggests poor response to therapy in rectal cancer. Br J Cancer 2009; 101: 372; author reply 373. Williams E, Martin S, Moss R, Durrant L, Deen S. Co-expression of VEGF and CA9 in ovarian high-grade serous carcinoma and relationship to survival. Virchows Arch 2012; 461: 33-9. Robertson N, Potter C, Harris AL. Role of carbonic anhydrase IX in human tumor cell growth, survival, and invasion. Cancer Res 2004; 64: 6160-5.
Int J Clin Exp Pathol 2015;8(1):862-866
CA9 overexpression in cholangiocarcinoma [10] Sergeant G, Lerut E, Ectors N, Hendrickx T, Aerts R, Yopal B. The prognostic relevance of tumor hypoxia markers in resected carcinoma of the gallbladder. Eur J Surg Oncol 2011; 37: 80-6. [11] Ilie M, Mazure NM, Hofman V, Ammadi RE, Ortholan C, Bonnetaud C, Havet K, Venissac N, Mograbi B, Mouroux J, Pouysségur J, Hofman P. High levels of carbonic anhydrase IX in tumour tissue and plasma are biomarkers of poor prognostic in patients with non-small cell lung cancer. Br J Cancer 2010; 102: 1627-35. [12] Kim SJ, Rabbani ZN, Dewhirst MW, Vujaskovic Z, Vollmer RT, Schreiber EG, Oosterwijk E, Kelley MJ. Expression of HIF-1alpha, CA IX, VEGF, and MMP-9 in surgically resected nonsmall cell lung cancer. Lung Cancer 2005; 49: 325-35. [13] Korkeila E, Talvinen K, Jaakkola PM, Minn H, Syrjänen K, Sundström J, Pyrhönen S. Expression of carbonic anhydrase IX suggests poor outcome in rectal cancer. Br J Cancer 2009; 100: 874-80. [14] Choschzick M, Woelber L, Hess S, zu Eulenburg C, Schwarz J, Simon R, Mahner S, Jaenicke F, Müller V. Overexpression of carbonic anhydrase IX (CAIX) in vulvar cancer is associated with tumor progression and development of locoregional lymph node metastases. Virchows Arch 2010; 456: 483-90. [15] Rasheed S, Harris AL, Tekkis PP, Turley H, Silver A, McDonald PJ, Talbot IC, Glynne-Jones R, Northover JM, Guenther T. Assessment of microvessel density and carbonic anhydrase-9 (CA-9) expression in rectal cancer. Pathol Res Pract 2009; 205: 1-9.
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