Deleted in Colorectal Cancer Protein

8/12/2019 Deleted in Colorectal Cancer Protein

1/9

Deleted in Colorectal Cancer ProteinExpression as a Possible Predictor ofResponse to Adjuvant Chemotherapy inColorectal Cancer PatientsRivka Gal, M.D.,1,4 Evgeny Sadikov, M.D.,2 Jaqueline Sulkes, Ph.D.,3,4

Baruch Klein, M.D.,2,4 Rumelia Koren, M.D.1,4

1 Department of Pathology, Hasharon Hospital, Petah Tikva, Israel2Department of Oncology, Hasharon Hospital, Petah Tikva, Israel3 Epidemiology Unit, Rabin Medical Center, Petah Tikva, Israel4 Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel

PURPOSE: The deleted in colorectal cancer (DCC) gene pre-dicts a poor outcome for patients with colorectal carci-noma. This study was designed to investigate whether theexpression of the DCC protein also can predict response toadjuvant chemotherapy. METHODS: The expression of DCC

was eval uate d immu nohi stochemical ly in 74 paraffin-embedded tumor samples from patients with Stage II (n =41) and Stage III (n = 33) colorectal carcinomas. Follow-up

time was at least 60 (median, 64) months. Follow-up was atleast five years for all patients who are alive. End points ofthe study were recurrence of disease and death. Forty-eightpatients received adjuvant therapy of 5-fluorouracil + le-

vamisole; 28 were not treated. RESULTS: Fifty percent oftumors were deleted in colorectal cancer-positive (DCC+).Proportion of survival and disease-free survival were higherin the DCC+ patients (83 percent) than in deleted in colo-rectal cancer-negative (DCC; 54 percent). In the DCC+group, adjuvant treatment was a strong positive predictivefactor for survival and disease-free survival. All DCC+ pa-

tients who received adjuvant chemotherapy (CHEMO+) arealive with no evidence of disease, whereas without chemo-therapy (CHEMO) only 54 percent are alive (P= 0.0001).

When stratification was performed by stage, patients inStage II who were DCC+/CHEMO+ had survival and disease-free survival of 100 percent, whereas in DCC+/CHEMOsurvival rate was 75 percent and disease-free survival rate 62percent (P= 0.042). Patients in Stage III who were DCC+/

CHEMO+ had survival and disease-free survival of 100 per-cent, whereas in DCC+/CHEMO both dropped to zero(P= 0.0002). On the other hand, in the DCC tumors, there

was no statistical significant relationship between chemo-therapy and survival or disease-free survival (DCC/CHEMO had 57 percent survival; DCC/CHEMO+ had 52percent survival). CONCLUSIONS: DCC is a prognostic fac-tor for colorectal cancer. Positive expression of DCC iden-tifies a subgroup of patients who respond favorably to ad-

juvant chemotherapy, which resulted in our cases, in 100percent survival and disease-free survival rates. Withouttreatment, the survival rate of DCC+ patients dropped sig-nificantly. We suggest that DCC immunostaining should beperformed routinely. All DCC+ patients should receive ad-

juvant chemotherapy. For DCC tumors, a larger cohort of

patients should be studied before definitive conclusions canbe drawn; however, clinical trials of new drug combina-tions should focus on DCC patients. [Key words: Colorec-tal cancer; Chromosome 18q; Chemotherapy; Prognosis]

C arcinoma of the colon is one of the most com-mon malignant diseases of western civilization.Usually, the tumor is resectable and the prognosis

depends on the stage of the disease. Adjuvant che-

motherapy of fluorouracil plus levamisole is a toler-

Reprints are not available.

Supported in part by a grant from the Medical Research Fund of

the Rabin Medical Center.

Presented in part at the 4th World Congress on Advances inOncology and 2nd International Symposium on Molecular Medi-cine, Vouliagmeni, Athens, Greece, October 7 to 9, 1999.

Correspondence to: Rivka Gal, M.D., Pathology Department,Hasharon Hospital, Petah Tikva, Israel, e-mail: [email protected]

Dis Colon Rectum 2004; 47: 12161224DOI: 10.1007/s10350-004-0552-9 The American Society of Colon and Rectal SurgeonsPublished online: 19 May 2004

1216


2/9

able regimen that increases survival for patients in

Stage III.1,2 Approximately one-third of patients pre-

sent with Stage II or Astler-Coller Stage B2 (penetra-

tion of the tumor through the full-thickness of the

bowel wall but without lymph node metastases).

These patients have a five-year survival of 70 to 80

percent3; therefore, adjuvant therapy would benefit

only a small proportion of this population. None ofthe clinical studies have yet demonstrated a benefit

for adjuvant chemotherapy in patients with Stage II

disease.4,5 Examination of biologic characteristics of

the tumor may define a subset of Stage II patients who

might benefit from adjuvant treatment. DNA aneu-

ploidy and S-phase fraction could identify Stage II

patients in whom the prognosis was similar to node-

positive patients,6 but response to treatment was not

investigated.

Deletion involving chromosome 18q has been

identified in colon carcinoma7 and was termed de-

leted in colorectal cancer (DCC) gene. Allelic loss of

chromosome 18q has been shown to be a negative

predictor of prognosis in colon cancer. Jen et al.8

found that the survival rate of Stage II patients whose

cancer had allelic loss of chromosome 18q was 54

percent, which is similar to patients in Stage III,

whereas those with no evidence of allelic loss had 93

percent survival rate, which is comparable to patients

in Stage I. These results were confirmed by others.9,10

Allelic loss of chromosome 18q also was associated

with metastatic potential of colorectal carcinoma.11

Several other studies1216

evaluated the expression ofDCC by immunohistochemistry and found that it was

a strong prognostic factor in all stages of colorectal

carcinoma. Shibata et al.12 concluded that further un-

derstanding of DCC might improve the usefulness of

this marker in selecting patients for adjuvant therapy.

Jessup and Loda17 analyzed the current state of sev-

eral molecular markers, including DCC, and con-

cluded that assessing the expression of molecules

within a primary cancer may predict the response to

therapy and outcome. This study was designed to ex-

amine the expression of DCC protein in Stages II and

III colorectal cancer by immunohistochemistry and toassess its predictive value for the prognosis and for

the efficacy of 5-fluorouracil (5-FU)-levammisole ad-

juvant chemotherapy.

PATIENTS AND METHODS

Seventy-four consecutive patients with colorectal

carcinoma operated on in 1995 were studied. Patients

with rectal cancer underwent low anterior resection

(10 patients) or abdominoperineal resection (12 pa-

tients), and patients with colon cancer underwent ab-

dominal resection (52 patients).

There were 42 patients with Stage II and 32 with

Stage III. Forty-six patients received adjuvant chemo-

therapy with 5-FU-levamisole for one year. Loading

dose of 5-FU was 450 mg/m2 on Days 1 to 5 for thefirst month. After the first cycle, treatment was

switched to 450 mg/m2 weekly and Levamisole 150

mg per day 3 days, biweekly, for one year. Patients

with rectal cancer also received radiotherapy.

Follow-up time was 60 to 96 (median, 64) months

(except for patients who died). Follow-up was at least

five years for all patients who are alive. All patients

were followed up every three months during the first

two years and every six months during subsequent

years. In addition to physical examination, colonos-

copy was performed yearly and hepatic ultrasonog-

raphy every six months. Blood chemistry, including

carcinoembryonic antigen and white blood cell count,

were performed every three months.

Tumor Specimens

Formalin-fixed, paraffin-embedded samples were

obtained from the archives of our department. All the

slides were reviewed, grade (according to the TNM

system18) and stage were recorded, and a represen-

tative paraffin block that contained tumor and adja-

cent mucosa was chosen for immunohistochemistry.

The sections that contained both normal mucosa andadjacent tumor were selected for immunostaining.

Immunohistochemistry

Four-micron tissue sections were mounted on poly-

lysine coated slides. They were deparaffinized and

rehydrated. Antigen was retrieved by heating the tis-

sue sections to 90C for 20 minutes in a microwave

oven in 10 nM of citric acid monophosphate buffer

(pH 6.0). Immunohistochemical staining was per-

formed manually using the mouse antihuman DCC

monoclonal antibody (clone G97-449, Pharmingen,San Diego, CA) at a dilution of 1:100 for 60 minutes.

A broad-spectrum secondary antibody (The Histo-

stain Plus Bulk Kit 2nd generation, Zymed Lab Inc.,

San Francisco, CA) was used according to the manu-

facturers instructions. Slides were counterstained

with Mayers hematoxylin, rehydrated, and mounted

with glycerol gelatin. The normal mucosa served as

positive control, and omission of the antihuman DCC

1217DCC AND CHEMOTHERAPY IN COLORECTAL CANCERVol. 47, No. 7


3/9

antibody served as a negative control. Two surgical

pathologists, who were blinded to the clinical data of

the patients, assessed DCC protein expression.

Statistical Analysis

To analyze statistically significant relationships in

the distribution of categorical variables (e.g., DCC,stage, treatment), chi-squared test was performed or

Fishers exact test if appropriate. To analyze statisti-

cally significant differences in the distribution of con-

tinuous variable (e.g., age) between two groups of

patients (i.e., with or without DCC), Students t-test

was performed. Pearson correlation coefficients (r)

and significance (P) were calculated between the vari-

ables. Two major end points were studied: survival

and disease-free survival (DFS) interval. Survival was

measured from surgery to death or end of the study

(April 1999). DFS was measured from surgery until a

local recurrence or a metastatic disease was found orto the end of the study. The prognostic factors ana-

lyzed in terms of survival or DFS were as follows: age,

gender, stage, grade, treatment, etc. The product limit

method of Kaplan-Meier19 was used to estimate sur-

vival and DFS. To compare survival or DFS curves,

log-rank test was used. The Cox proportional hazard

model20 was used to assess the joint effect of the

prognostic factors on survival or DFS. P 0.05 was

considered statistically significant.

RESULTS

Immunohistochemical Staining

Strong staining was observed in the crypts and lu-

minal epithelial cells of the normal mucosa. This pro-

vided a positive internal control. The tumor cells

showed a strong cytoplasmatic staining throughout all

the cells, which was considered positive (Fig. 1), or a

very faint staining, which was less than that of the

normal mucosa, and was considered negative (Fig. 2).

Usually, it was an all or nothing phenomenon, except

for one case that showed small areas of intense stain-

ing intermingled with areas of faint staining (this case

was considered negative for the statistical analysis).

Clinical Characteristics of Patients andDCC Status

Table 1 shows the relevant clinical characteristics of

the patients by DCC status. There were 74 patients (47

males; 63.5 percent; mean age, 69.12 + 9.27 years).

Fifty percent of tumors were deleted in colorectal can-

cer-positive (DCC+) and 50 percent were deleted in

colorectal cancer-negative (DCC). There were no

significant differences between DCC status and age,

gender, tumor location, stage, grade, or proportion of

patients who received chemotherapy. Twenty-four

patients (32.4 percent) died of disease, 8 are alive

with metastases or local recurrence, and 42 are alive

with no evidence of disease. Eighty-two percent of

DCC+ patients are alive compared with 54 percent of

those with DCC tumors (P= 0.126).

Variables that Influence Prognosis

The overall five-year survival rate was 85 percent

for Stage II and 45 percent for Stage III. Statistically

Figure 1. Immunohistochemical stain of deleted in colo-

rectal cancer-positive protein expression (hematoxylin

and eosin; 200). Strong and homogeneous expression in

the cytoplasm of the tumor cells.

Figure 2. Immunohistochemical stain of deleted in colo-

rectal cancer (DCC)-negative protein expression (hema-

toxylin and eosin; 200). Tumor cells that have lost the

DCC protein expression show only very faint brown cyto-

plasmatic staining.

1218 GAL ET AL Dis Colon Rectum, July 2004


4/9

significant prognostic factors for survival were stage,

DCC status, and chemotherapy, both in the univariate

and multivariate analysis (Table 2). For DFS, only

DCC was a prognostic factor both in the univariate

and multivariate analysis (Table 2).

Kaplan-Meier curves for all patients showed a sig-

nificantly better survival for DCC+ patients compared

with DCCpatients (P= 0.0112; for DFS, P= 0.0001;

Fig. 3). When survival was plotted in relation to stage

and DCC status, the differences were still statisticallysignificant (P= 0.0152).

Survival and DFS in Relation toChemotherapy and DCC Status

Table 3 outlines the outcome of patients according

to stage, by DCC status and by chemotherapy. In all

patients with DCC+ tumors, chemotherapy had sig-

nificant influence on the outcome. All 24 patients (100

percent) who received chemotherapy (CHEMO+)

are alive and well with no evidence of disease,

whereas of 13 DCC+ patients without chemotherapy

(CHEMO), only 5 (38 percent) are alive and well; 1

is alive with metastasis, and 7 are dead of disease.

This is shown in the Kaplan-Meier plot (Fig. 4). There

is a significantly better survival for DCC+/ CHEMO+

patients compared with DCC+/CHEMOpatients (P=

0.0001). Similar results were observed for DFS (P=0.0001; data not shown).

Conversely, in DCCpatients, there was no signifi-

cant difference in survival (Fig. 5) between those who

received chemotherapy and those who did not (P=

0.457). Similarly, no significance was seen in DFS (P=

0.196; data not shown).

When analyzing survival and DFS by stage and che-

motherapy, in Stage II, of 13 DCC+/CHEMO+ pa-

Table 2.

Univariate and Multivariate Analysis by Prognostic Factors of DFS and Survival in Colorectal Cancer

DFS Survival

Prognostic Factor Univariate Multivariate Univariate Multivariate

Stage 0.59 0.192 0.037 0.012DCC 0.0013 0.005 0.01 0.038Chemotherapy 0.1768 0.089 0.037 0.012Grade NS NS NS NSAge NS NS NS NSGender NS NS NS NS

DFS = disease-free survival; DCC = deleted in colorectal cancer; NS = not statistically significant

Data are Pvalues.

Table 1.

Clinical Characteristics of Patients by DCC Status

DCC-Positive (n = 37) DCC-Negative (n = 37) PValue

Age (yr) 69.12 9.27 62.32 70.9 0.11Male/female ratio 47/27 22/15 25/12 NSSite

Rectum 22 9 13 NS

Colon 52 28 24StageII 41 21 20 NSIII 33 16 17

Grade1 21 11 10 NS2 48 25 233 5 1 4

ChemotherapyYes 47 24 23 NSNo 27 13 14

Vital statusAlive 50 30 (81.8%) 20 (54.1%) 0.0126Dead 24 7 (18.9%) 17 (45.9%)

DCC = deleted in colorectal cancer; NS = not statistically significant.



5/9

tients, all are alive and well compared with 5 of 7

DCC+/CHEMOpatients. This difference was not sta-

tistically significant (P= 0.13). However, a statistically

significant relationship was found between the distri-

bution of DFS with chemotherapy (P= 0.042; data not

shown). In DCC patients, both with and without

chemotherapy, four of ten patients are alive.

In Stage III, DCC+/CHEMO+ patients had signifi-

cantly better survival (11/11) compared with DCC+/CHEMO(0/5;P= 0.0001). In the DCCgroup, che-

motherapy did not affect survival (P= 0.457) or DFS

(P= 0.196).

DISCUSSION

Adjuvant therapy is clearly of great benefit for cer-

tain patients with colorectal carcinoma. However,

these therapies have side effects, and thus they should

be given to those who really would benefit from

them.21

It is important to further define this subgroupof patients, because even a small improvement in the

outcome of colon carcinoma patients may translate

into substantial numbers of survivors. On the other

hand, it is also important to exclude therapy from

patients who are unlikely to respond. The results of

our study indicate that DCC protein expression may

be a helpful predictor for selecting patients who are

likely to benefit from adjuvant chemotherapy.

In 1997, a specific region of chromosome 18 was

found to be deleted in 73 percent of colorectal carci-

nomas22 and was identified as a candidate for a tu-

mor-suppressor gene, termed DCC. Allelic loss of

chromosome 18q, or decreased expression of the

DCC protein, have been found in different types of

malignant tumors, such as colorectal,8,10,12,13,23 gas-

tric,24 endometrial,25 breast,26 and other tumors, and itwas reported to correlate with tumor progression and

metastatic potential. Shibata et al.12 found that pa-

tients with Stage II/DCC+ colon carcinoma had a sig-

nificantly better prognosis than patients with Stage

II/DCC(P< 0.01). Cartherset al.27 and Laurent-Puig

et al.28 did not confirm that loss of heterozygosity for

18q had a significant prognostication power.

Most of our results are similar to those reported by

Shibata et al.12 We also found that Stage II/DCC tu-

mors had a poor prognosis comparable to those with

Stage III and that patients with DCC+ tumors had

lower recurrence and death rates than DCCpatients.

In contrast, unlike all other previous studies, we have

shown that in patients with DCC+ tumors, adjuvant

chemotherapy had a significant beneficial effect,

whereas DCCpatients in our cohort did not seem to

benefit much from adjuvant therapy. In the study by

Shibata et al.,12 the use of adjuvant therapy did not

prove to be a significant independent prognostic in-

dicator. However, only 21 of 66 of their DCC+ patients

received adjuvant therapy, and the protocol is not

given. Jen et al.8 also did not find that adjuvant

therapy had an effect on outcome; however, only fivepatients without 18q loss received adjuvant chemo-

therapy. Therefore, we cannot compare these results

to ours.

The most significant result of our study is that all the

DCC+ patients who received adjuvant therapy were

alive and free of recurrence at the end of the study

(median follow-up, 64 months). This suggests that all

DCC+ patients, irrespective of stage, should receive

adjuvant chemotherapy if they can tolerate it. On the

other hand, our results do not indicate that adjuvant

therapy influences the outcome of patients with

DCC tumors in both stages examined.The observation that DCCpatients do not seem to

benefit from chemotherapy is unexpected, because it

is conceivable to assume that patients with DCCtu-

mors, who have a worse prognosis, would probably

benefit from adjuvant chemotherapy more than DCC+

patients, who have a better prognosis.29

What could be the possible explanation for the high

sensitivity of DCC+ cells to 5-FU-levamisole treat-

Figure 3. Kaplan-Meier life-table analysis of the overall

disease-free survival (DFS) of patients with colorectal

cancer according to deleted in colorectal cancer (DCC)

expression. Patients with positive DCC expression had a

significantly better survival than DCC patients (P =

0.0112). DCC+ = deleted in colorectal cancer positive;DCC = deleted in colorectal cancer negative.



6/9

ment? It was reported that the DCC gene product in-duces apoptosis in settings in which the ligand, net-

rin-1 is unavailable, for example, during metastases or

tumor growth beyond local blood supply.30 It also

was shown that 5-FU induced apoptosis in gastric car-

cinoma, in vivo,31 in human colon carcinoma cell

lines32,33 and that 5-FU-induced apoptosis correlated

with its the efficacy against human gastric and colon

cancer xenografts in nude mice.34 Therefore, it is pos-

sible that the DCC protein and 5-FU have a synergistic

effect on apoptosis, which allows the eradication of

cancer cells that are still viable after the resection of

the primary tumor. Another explanation is that le-

vamisole, which is an immunopotentiator in cancer

Table 3.

Outcome of Patients According to Stage, DCC Status, and Chemotherapy

Colon Rectum

Chemo+ Chemo Chemo+ Chemo

DCC+/Stage IIAlive and well 8 5 5 0Alive with recurrence 0 1 0 0

Dead of disease 0 1 0 1DCC+/Stage III

Alive and well 9 0 2 0Alive with recurrence 0 0 0 0Dead of disease 0 4 0 1

DCC/Stage IIAlive and well 0 3 4 1Alive with recurrence 3 1 0 1Dead of disease 1 2 2 2

DCC/Stage IIIAlive and well 3 2 0 0Alive with recurrence 2 0 0 0Dead of disease 6 1 2 1

DCC = deleted in colorectal cancer; DCC+ = deleted in colorectal cancer positive; DCC = deleted in colorectal cancer

negative; CHEMO+ = patients who received chemotherapy; CHEMO = patients who did not receive chemotherapy.

Figure 4. Kaplan-Meier life-table analysis of deleted in

colorectal cancer-positive (DCC+) patients according to

chemotherapy. Patients who received chemotherapy had

statistically significantly better prognosis than those with-

out therapy (P = 0.001). CHEMO+ = patients who re-

ceived adjuvant chemotherapy; CHEMO= patients with-

out chemotherapy.Figure 5. Kaplan-Meier life-table analysis of deleted in

colorectal cancer-negative (DCC) patients according to

chemotherapy. There was no statistical difference in sur-

vival between patients who received or did not receive

chemotherapy. CHEMO+ = patients who received adju-vant chemotherapy; CHEMO = patients without chemo-

therapy.



7/9

therapy, induces apoptosis of the tumoral vascula-

ture.35

As for the DCC tumor cells, which seem to be

resistant to 5-FU, generally, tumor resistance to drugs

is multifactorial36 and includes protection from apo-

ptosis and mutational status of regulators of apopto-

sis.37,38 The allelic loss of chromosome 18q might act

through these mechanisms.In reviewing the literature for other markers that

could predict the response to adjuvant chemotherapy,

we found that high thymidilate synthase expression

and p53 overexpression were associated with high

recurrence rate39 and that these markers predict the

resistance to 5-FU treatment.4042 However, DCC ex-

pression by immunohistochemistry seems to be a bet-

ter predictor for chemotherapy efficacy; the antigen is

commercially available, and the examination can be

easily performed in every pathology department.

As for the treatment of rectal cancer patients, in our

study, there was no difference between colon and

rectal tumors. 5-FU-levamisole and x-ray therapy

proved to be a useful treatment for DCC+ patients,

resulting in 100 percent cure rate. Therefore, it is pos-

sible that DCC expression could predict which patient

would be a better candidate for sphincter preserva-

tion operation with postoperative chemotherapy.43

These issues should be further investigated in a larger

cohort of patients and in a prospective study.

Patients with DCC tumors did not benefit from

5-FU-levamisole treatment, therefore, the search for

better therapeutic modalities should focus on thisgroup of patients. One candidate for an alternative

treatment is the combination of 5-FU + leucovorin

and CPT11, a topoisomerase inhibitor that has shown

consistent activity in carcinoma refractory to 5-FU.44,45

Another possibility is the combination of 5-FU with

oxaliplatin, which has a proven efficacy in meta-

static colon cancer.46 Other combinations of drugs,

especially those that are known to be effective in

multidrug-resistant tumors, also should be investi-

gated.47

CONCLUSIONS

DCC protein expression is not only a prognostic

factor but also can predict the response to adjuvant

chemotherapy. Therefore, we suggest that DCC im-

munohistochemistry should be performed routinely

in colorectal cancers. 5-FU-based adjuvant treatment

should be administered, if possible, to all DCC+ pa-

tients, irrespective of the stage, because they have the

potential for prolonging survival and DFS. In our

study, the five-year survival and DFS rates were 100

percent. As for DCC patients, although we did not

find statistical benefit for adjuvant therapy, a larger

cohort of patients should be examined before chang-

ing the therapeutic recommendations for this group.

However, clinical trials of new drug combinations

should focus on DCC patients.

ACKNOWLEDGMENTS

The authors thank Hannah Gertzman for the excel-

lent technical assistance, and Miriam Kleiner and

Yossi Sadovnic for photographs.

REFERENCES

1. Moertel CG, Fleming TR, Macdonald JS, et al. Levami-

sole and fluorouracil for adjuvant therapy of resectedcolon carcinoma. N Engl J Med 1990;322:3528.

2. Moertel CG, Fleming TR, Macdonald JS, et al. Levami-

sole and fluorouracil for adjuvant therapy of resected

colon carcinoma. N Engl J Med 1990;322:3528.

3. Nauta R, Stablein DM, Holyoke ED. Survival of patients

with stage B2 colon carcinoma. The gastrointestinal tu-

mor study group experience. Arch Surg 1989;124:1802.

4. Moertel CG, Fleming TR, Macdonald JS, et al. Inter-

group study of fluorouracil plus levamisole as adjuvant

therapy for stage II/DukesB2 colon cancer. J Clin On-

col 1995;13:293643.

5. Mortel CG. Chemotherapy for colorectal cancer. N Engl

J Med 1994;330:113642.

6. Witzig TE, Loprinzi CL, Gonchoroff NJ, et al. DNA

ploidy and cell kinetic measurements as predictors of

recurrence and survival in stage B2 colorectal adeno-

carcinoma. Cancer 1991;68:87988.

7. Fearon ER, Cho KR, Nigro JM, et al. Identification of a

chromosome 18q gene that is altered in colorectal can-

cer. Science 1990;247:4956.

8. Jen J, Kim H, Piantadosi S,et al. Allelic loss of chromo-

some 18q and prognosis in colorectal cancer. N Engl J

Med 1994;331:21321.

9. Martinez-Lopez E, Abad A, Font A,et al. Allelic loss on

chromosome 18q as a prognostic marker in stage IIcolorectal cancer. Gastroenterology 1998;114:11807.

10. Jernvall P, Makinen MJ, Karttunen TJ, Makela J, Vihko P.

Loss of heterozygosity of 18q21 is indicative of recur-

rence and therefore poor prognosis in a subset of co-

lorectal cancers. Br J Cancer 1999;79:9038.

11. Kato M, Ito Y, Kobayashi S, Isono K. Detection of DCC

and Ki-ras gene alteration in colorectal carcinoma tissue

as prognostic markers for liver metastatic recurrence.

Cancer 1996;77:172935.



8/9

12. Shibata D, Reale MA, Lavin P, et al. The DCC protein

and prognosis in colorectal cancer. N Engl J Med 1996;

335:172732.

13. Saito M, Yamaguchi A, Goi T,et al. Expression of DCC

protein in colorectal tumors and its relation to tumor

progression and metastases. Oncology 1999;56:134

41.

14. Reymond MA, Dworak O, Remke S, Hohenberger W,Kirchner T, Kockerling F. DCC protein as a predictor of

distant metastases after curative surgery for rectal can-

cer. Dis Colon Rectum 1998;41:75560.

15. Schmitt CA, Thaler KR, Witting BM, Kaulen H, Buschen-

felde KH, Dippold WG. Detection of the DCC gene

product in normal and malignant colorectal tissues and

its relation to codon 201 mutation. Br J Cancer 1998;77:

58894.

16. Shibata D, Rieger RM, Hess D, Summerhayes JC, Steele

G. Disruption of DCC expression results in the acquisi-

tion of metastatic cell behavior. Surg Forum 1995;46:

5267.

17. Jessup JM, Loda M. Prognostic markers in rectal carci-noma. Semin Surg Oncol 1998;15:13140.

18. Sobin LH, Wittekind CH. TNM classification of malig-

nant tumors. 5th ed. New York: Wiley-Liss, 1997:66

73.

19. Kaplan EL, Meier P. Nonparametric estimation from in-

complete observation. J Am Stat Assoc 1958;53:457

81.

20. Cox DR. Regression models and life-tables. J R Stat Soc

1972;34:187220.

21. Vogelstein B, Fearon ER, Hamilton SR, et al. Genetic

alterations during colorectal tumor development. N

Engl J Med 1988;319:52532.

22. Horstmann MA, Posl M, Scholz RB, et al. Frequent re-

duction or loss of DCC gene expression in human os-

teosarcoma. Br J Cancer 1997;75:130917.

23. Kong XT, Choi SH, Inoue A, et al. Alterations of the

tumor suppressor gene DCC in neuroblastoma. Eur J

Cancer 1997;33:19625.

24. Yoshida Y, Itoh F, Endo T, Hinoda Y, Imai K. Decreased

DCC mRNA expression in human gastric cancer is clini-

copathologically significant. Int J Cancer 1998;79:634

40.

25. Saegusa M, Hashimura M, Hara A, Okayasu I. Loss of

expression of the gene deleted in colon carcinoma

(DCC) is closely related to histologic differentiation andlymph node metastasis in endometrial carcinoma. Can-

cer 1999;85:45364.

26. Wakita K, Kohno N, Sakoda Y, Ishikawa Y, Sakaue M.

Decreased expression of the DCC gene in human breast

carcinoma. Surg Today 1996;26:9003.

27. Carthers JM, Hawn MT, Greenson JK, Hitchcock CL,

Boland CR. Prognosis of allelic loss at chromosome

18q21 for stage II colorectal cancer. Gastroenterology

1998;114:118895.

28. Laurent-Puig P, Olschwang S, Delattre O,et al. Survival

and acquired genetic alterations in colorectal cancer.

Gastroenterology 1992;102:113641.

29. Banerjee AK. DCC expression and prognosis in colo-

rectal cancer. Lancet 1997;349:968.

30. Mehlen P, Rabizadeh S, Snipas SJ, Assa-Munt N,

Salvesen GS, Bredesen DE. The DCC gene product in-

duces apoptosis by mechanisms requiring receptor pro-teolysis. Nature 1998;395:8014.

31. Samagura K, Makino M, Shirai H, et al. Enhanced in-

duction of apoptosis in human gastric carcinoma cells

after preoperative treatment with 5-fluorouracil. Cancer

1997;79:1227.

32. Schepotin IB, Soldatenkov V, Buras RR, Nauta RJ,

Shabahang M, Evans SR. Apoptosis of human primary

and metastatic colon adenocarcinoma cell lines in vitro

induced by 5-fluorouracil, verapamil and hyperthermia.

Anticancer Res 1994;14:120731.

33. Koshiji M, Taketani S, Takeuchi K, Hioki K, Ikehara S.

Mechanisms underlying apoptosis induced by combi-

nation of 5-fluorouracil and interferon-gamma. Bio-chem Biophys Res Commun 1997;240:37681.

34. Inada T, Ichikawa A, Kubota T, Ogata Y, Moossa AR,

Hoffman RM. 5-FU-induced apoptosis correlates with

efficacy against human gastric and colon cancer

xenografts in nude mice. Anticancer Res 1997;17:1965

71.

35. Artwohl M, Holzenbein T, Wagner L, Freudenthaler A,

Waldhausl W, Baumgartner-Parzer SM. Levamisole in-

duced apoptosis in cultured vascular endothelial cells.

Br J Pharmacol 2000;131:157783.

36. Mader RM, Muller M, Stenger GG. Resistance to 5-fluo-

rouracil. Gen Pharmacol 1998;31:6616.

37. Greif R, Swallow C, Bapat B, Redsron M, Gallinger S,

Couture L. Molecular biology of colorectal cancer. Curr

Probl Cancer 1997;21:233300.

38. Watanabe T, Wu TT, Catalano PJ,et al. Molecular pre-

dictors of survival after adjuvant chemotherapy for co-

lon cancer. N Engl J Med 2001;344:1196206.

39. Lenz HJ, Daneberg KD, Leichman CG, et al. p53 and

thymidylate syntheses expression in untreated stage II

colon cancer: association with recurrence, survival and

site. Clin Cancer Res 1998;4:122734.

40. Leichman L, Lenz HJ, Leichman CG,et al. Quantitation

of intratumoral thymidylate synthesis expression pre-

dicts for resistance to protracted infusion of 5-fluoro-uracil and weekly leucovorin in disseminated colorectal

cancers: preliminary report from an ongoing trial. Eur J

Cancer 1995;31A:130610.

41. Johnston PG, Lenz HJ, Leichman CG,et al. Thymidilate

syntheses gene and protein expression correlate and

are associated with response to 5-fluorouracil in human

colorectal and gastric tumors. Cancer Res 1995;55:1407

12.

42. Benhatter J, Cerottini JP, Saraga E, Mettez G, Givel JC.



9/9

p53 mutations as possible predictor of response to che-

motherapy in colorectal carcinomas. Int J Cancer 1996;

69:1902.

43. Furham GM, Talamonti MS, Curley SA. Spincter-

preserving extended resection for locally advanced rec-

tosigmoid carcinoma involving the urinary bladder. J

Surg Oncol 1992;50:7780.

44. Saltz LB, Douillard JY, Pirotta N, et al. Irinotecan plusfluorouracil/leucovorin for metastatic colorectal cancer:

a new survival standard. Oncologist 2001;6:8191.

45. Rothenberg ML. Efficacy and toxicity of irinotecan in

patients with colorectal cancer. Semin Oncol 1998;25:

3946.

46. Gerard B, Bleiberg H, VanDaele D, et al. Oxaliplatin

combined to 5-fluorouracil and folinic acid: an effective

therapy in patients with advanced colorectal cancer.

Anticancer Drugs 1998;9:3015.

47. Van Cutsem E. A glimpse of the future. New directionsin the treatment of colorectal cancer. Eur J Cancer 1996;

32A:S237.


Deleted in Colorectal Cancer Protein

Documents

Transcript of Deleted in Colorectal Cancer Protein