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Erschienen in: Annals of Surgical Oncology 4/2014

01.12.2014 | Translational Research and Biomarkers

Chromosomal Instability Associated with Global DNA Hypomethylation is Associated with the Initiation and Progression of Esophageal Squamous Cell Carcinoma

verfasst von: Hiroyuki Kawano, MD, Hiroshi Saeki, MD, PhD, Hiroyuki Kitao, PhD, Yasuo Tsuda, MD, Hajime Otsu, MD, Koji Ando, MD, PhD, Shuhei Ito, MD, PhD, Akinori Egashira, MD, PhD, Eiji Oki, MD, PhD, Masaru Morita, MD, PhD, Yoshinao Oda, MD, PhD, Yoshihiko Maehara, MD, PhD

Erschienen in: Annals of Surgical Oncology | Sonderheft 4/2014

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Abstract

Background

Global DNA hypomethylation is associated with increased chromosomal instability and plays an important role in tumorigenesis. The methylation status of the long interspersed nuclear element-1 (LINE-1) element is a useful surrogate marker for global DNA methylation. Although LINE-1 hypomethylation is recognized as a poor prognostic marker, the correlation of LINE-1 methylation level with tumor suppressor gene mutation, chromosomal instability, and clinical significance in esophageal squamous cell carcinoma (ESCC) remains unclear.

Methods

Using resected tumor tissues and the corresponding normal esophageal mucosa from 105 patients with ESCC, bisulfite pyrosequencing analysis was performed to quantify the LINE-1 methylation levels. p53 mutations in exons two to ten were detected by polymerase chain reaction direct sequencing. Chromosomal instability was assessed by single nucleotide polymorphism array comparative genomic hybridization analysis.

Results

The LINE-1 methylation level of ESCC was significantly lower than matched normal mucosa. LINE-1 methylation levels of normal mucosa from the esophagus had a significant inverse correlation with both cigarette smoking and alcohol consumption of the study subjects. LINE-1 hypomethylation of ESCC was significantly associated with lymph node metastasis, lymphovascular invasion, the frequency of p53 mutation and poor survivability. The LINE-1 methylation levels in ESCC had a significant inverse association with the percentage of copy number alterations in the whole genome, mirroring chromosomal instability.

Conclusions

Our results suggested that whole genome hypomethylation caused by chronic inflammation could initiate carcinogenesis of esophageal squamous cells through chromosomal instability. In addition, chromosomal instability associated with the global hypomethylation might correlate highly with the progression of ESCC.
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Literatur
1.
Zurück zum Zitat Allum WH, Stenning SP, Bancewicz J, et al. Long-term results of a randomized trial of surgery with or without preoperative chemotherapy in esophageal cancer. J Clin Oncol. 2009;27:5062–7.PubMedCrossRef Allum WH, Stenning SP, Bancewicz J, et al. Long-term results of a randomized trial of surgery with or without preoperative chemotherapy in esophageal cancer. J Clin Oncol. 2009;27:5062–7.PubMedCrossRef
3.
Zurück zum Zitat Morita M, Yoshida R, Ikeda K, et al. Advances in esophageal cancer surgery in Japan: an analysis of 1000 consecutive patients treated at a single institute. Surgery. 2008;143:499–508.PubMedCrossRef Morita M, Yoshida R, Ikeda K, et al. Advances in esophageal cancer surgery in Japan: an analysis of 1000 consecutive patients treated at a single institute. Surgery. 2008;143:499–508.PubMedCrossRef
4.
Zurück zum Zitat Morita M, Kumashiro R, Kubo N, et al. Alcohol drinking, cigarette smoking, and the development of squamous cell carcinoma of the esophagus: epidemiology, clinical findings, and prevention. Int J Clin Oncol. 2010;15:126–34.PubMedCrossRef Morita M, Kumashiro R, Kubo N, et al. Alcohol drinking, cigarette smoking, and the development of squamous cell carcinoma of the esophagus: epidemiology, clinical findings, and prevention. Int J Clin Oncol. 2010;15:126–34.PubMedCrossRef
5.
Zurück zum Zitat Toh Y, Oki E, Ohgaki K, et al. Alcohol drinking, cigarette smoking, and the development of squamous cell carcinoma of the esophagus: molecular mechanisms of carcinogenesis. Int J Clin Oncol. 2010;15:135–44.PubMedCrossRef Toh Y, Oki E, Ohgaki K, et al. Alcohol drinking, cigarette smoking, and the development of squamous cell carcinoma of the esophagus: molecular mechanisms of carcinogenesis. Int J Clin Oncol. 2010;15:135–44.PubMedCrossRef
6.
Zurück zum Zitat Ehrlich M. DNA methylation in cancer: too much, but also too little. Oncogene. 2002;21:5400–13.PubMedCrossRef Ehrlich M. DNA methylation in cancer: too much, but also too little. Oncogene. 2002;21:5400–13.PubMedCrossRef
7.
Zurück zum Zitat Gaudet F, Hodgson JG, Eden A, et al. Induction of tumors in mice by genomic hypomethylation. Science. 2003;300:489–92.PubMedCrossRef Gaudet F, Hodgson JG, Eden A, et al. Induction of tumors in mice by genomic hypomethylation. Science. 2003;300:489–92.PubMedCrossRef
8.
Zurück zum Zitat Holm TM, Jackson-Grusby L, Brambrink T, et al. Global loss of imprinting leads to widespread tumorigenesis in adult mice. Cancer Cell. 2005;8:275–85.PubMedCrossRef Holm TM, Jackson-Grusby L, Brambrink T, et al. Global loss of imprinting leads to widespread tumorigenesis in adult mice. Cancer Cell. 2005;8:275–85.PubMedCrossRef
9.
Zurück zum Zitat Suzuki K, Suzuki I, Leodolter A, et al. Global DNA demethylation in gastrointestinal cancer is age dependent and precedes genomic damage. Cancer Cell. 2006;9:199–207.PubMedCrossRef Suzuki K, Suzuki I, Leodolter A, et al. Global DNA demethylation in gastrointestinal cancer is age dependent and precedes genomic damage. Cancer Cell. 2006;9:199–207.PubMedCrossRef
10.
Zurück zum Zitat Nishida N, Kudo M, Nishimura T, et al. Unique association between global DNA hypomethylation and chromosomal alterations in human hepatocellular carcinoma. PLoS One. 2013;8:e72312.PubMedCentralPubMedCrossRef Nishida N, Kudo M, Nishimura T, et al. Unique association between global DNA hypomethylation and chromosomal alterations in human hepatocellular carcinoma. PLoS One. 2013;8:e72312.PubMedCentralPubMedCrossRef
12.
Zurück zum Zitat Yang AS, Estecio MR, Doshi K, et al. A simple method for estimating global DNA methylation using bisulfite PCR of repetitive DNA elements. Nucleic Acids Res. 2004;32:e38.PubMedCentralPubMedCrossRef Yang AS, Estecio MR, Doshi K, et al. A simple method for estimating global DNA methylation using bisulfite PCR of repetitive DNA elements. Nucleic Acids Res. 2004;32:e38.PubMedCentralPubMedCrossRef
13.
Zurück zum Zitat Ikeda K, Shiraishi K, Eguchi A, et al. Long interspersed nucleotide element 1 hypomethylation is associated with poor prognosis of lung adenocarcinoma. Ann Thorac Surg. 2013;96:1790–4.PubMedCrossRef Ikeda K, Shiraishi K, Eguchi A, et al. Long interspersed nucleotide element 1 hypomethylation is associated with poor prognosis of lung adenocarcinoma. Ann Thorac Surg. 2013;96:1790–4.PubMedCrossRef
14.
Zurück zum Zitat Igarashi S, Suzuki H, Niinuma T, et al. A novel correlation between LINE-1 hypomethylation and the malignancy of gastrointestinal stromal tumors. Clin Cancer Res. 2010;16:5114–23.PubMedCrossRef Igarashi S, Suzuki H, Niinuma T, et al. A novel correlation between LINE-1 hypomethylation and the malignancy of gastrointestinal stromal tumors. Clin Cancer Res. 2010;16:5114–23.PubMedCrossRef
15.
Zurück zum Zitat Ogino S, Nosho K, Kirkner GJ, et al. A cohort study of tumoral LINE-1 hypomethylation and prognosis in colon cancer. J Natl Cancer Inst. 2008;100:1734–8.PubMedCentralPubMedCrossRef Ogino S, Nosho K, Kirkner GJ, et al. A cohort study of tumoral LINE-1 hypomethylation and prognosis in colon cancer. J Natl Cancer Inst. 2008;100:1734–8.PubMedCentralPubMedCrossRef
16.
Zurück zum Zitat Iwagami S, Baba Y, Watanabe M, et al. LINE-1 hypomethylation is associated with a poor prognosis among patients with curatively resected esophageal squamous cell carcinoma. Ann Surg. 2013;257:449–55.PubMedCrossRef Iwagami S, Baba Y, Watanabe M, et al. LINE-1 hypomethylation is associated with a poor prognosis among patients with curatively resected esophageal squamous cell carcinoma. Ann Surg. 2013;257:449–55.PubMedCrossRef
17.
Zurück zum Zitat Shigaki H, Baba Y, Watanabe M, et al. LINE-1 hypomethylation in noncancerous esophageal mucosae is associated with smoking history. Ann Surg Oncol. 2012;19:4238–43.PubMedCrossRef Shigaki H, Baba Y, Watanabe M, et al. LINE-1 hypomethylation in noncancerous esophageal mucosae is associated with smoking history. Ann Surg Oncol. 2012;19:4238–43.PubMedCrossRef
18.
20.
Zurück zum Zitat Egashira A, Morita M, Yoshida R, et al. Loss of p53 in esophageal squamous cell carcinoma and the correlation with survival: analyses of gene mutations, protein expression, and loss of heterozygosity in Japanese patients. J Surg Oncol. 2011;104:169–75.PubMedCrossRef Egashira A, Morita M, Yoshida R, et al. Loss of p53 in esophageal squamous cell carcinoma and the correlation with survival: analyses of gene mutations, protein expression, and loss of heterozygosity in Japanese patients. J Surg Oncol. 2011;104:169–75.PubMedCrossRef
21.
Zurück zum Zitat Olive KP, Tuveson DA, Ruhe ZC, et al. Mutant p53 gain of function in two mouse models of Li–Fraumeni syndrome. Cell. 2004;119:847–60.PubMedCrossRef Olive KP, Tuveson DA, Ruhe ZC, et al. Mutant p53 gain of function in two mouse models of Li–Fraumeni syndrome. Cell. 2004;119:847–60.PubMedCrossRef
24.
Zurück zum Zitat Saeki H, Kitao H, Yoshinaga K, et al. Copy-neutral loss of heterozygosity at the p53 locus in carcinogenesis of esophageal squamous cell carcinomas associated with p53 mutations. Clin Cancer Res. 2011;17:1731–40.PubMedCrossRef Saeki H, Kitao H, Yoshinaga K, et al. Copy-neutral loss of heterozygosity at the p53 locus in carcinogenesis of esophageal squamous cell carcinomas associated with p53 mutations. Clin Cancer Res. 2011;17:1731–40.PubMedCrossRef
25.
Zurück zum Zitat Hu N, Clifford RJ, Yang HH, et al. Genome wide analysis of DNA copy number neutral loss of heterozygosity (CNNLOH) and its relation to gene expression in esophageal squamous cell carcinoma. BMC Genomics. 2010;11:576.PubMedCentralPubMedCrossRef Hu N, Clifford RJ, Yang HH, et al. Genome wide analysis of DNA copy number neutral loss of heterozygosity (CNNLOH) and its relation to gene expression in esophageal squamous cell carcinoma. BMC Genomics. 2010;11:576.PubMedCentralPubMedCrossRef
26.
Zurück zum Zitat Egashira A, Morita M, Kakeji Y, et al. p53 gene mutations in esophageal squamous cell carcinoma and their relevance to etiology and pathogenesis: results in Japan and comparisons with other countries. Cancer Sci. 2007;98:1152–6.PubMedCrossRef Egashira A, Morita M, Kakeji Y, et al. p53 gene mutations in esophageal squamous cell carcinoma and their relevance to etiology and pathogenesis: results in Japan and comparisons with other countries. Cancer Sci. 2007;98:1152–6.PubMedCrossRef
27.
Zurück zum Zitat Florea AM. DNA methylation pyrosequencing assay is applicable for the assessment of epigenetic active environmental or clinical relevant chemicals. Biomed Res Int. 2013;2013:486072.PubMedCentralPubMedCrossRef Florea AM. DNA methylation pyrosequencing assay is applicable for the assessment of epigenetic active environmental or clinical relevant chemicals. Biomed Res Int. 2013;2013:486072.PubMedCentralPubMedCrossRef
28.
Zurück zum Zitat Liu Z, Li A, Schulz V, et al. MixHMM: inferring copy number variation and allelic imbalance using SNP arrays and tumor samples mixed with stromal cells. PLoS One. 2010;5:e10909.PubMedCentralPubMedCrossRef Liu Z, Li A, Schulz V, et al. MixHMM: inferring copy number variation and allelic imbalance using SNP arrays and tumor samples mixed with stromal cells. PLoS One. 2010;5:e10909.PubMedCentralPubMedCrossRef
29.
Zurück zum Zitat Gasche JA, Hoffmann J, Boland CR, Goel A. Interleukin-6 promotes tumorigenesis by altering DNA methylation in oral cancer cells. Int J Cancer. 2011;129:1053–63.PubMedCentralPubMedCrossRef Gasche JA, Hoffmann J, Boland CR, Goel A. Interleukin-6 promotes tumorigenesis by altering DNA methylation in oral cancer cells. Int J Cancer. 2011;129:1053–63.PubMedCentralPubMedCrossRef
30.
Zurück zum Zitat Alvarez H, Opalinska J, Zhou L, et al. Widespread hypomethylation occurs early and synergizes with gene amplification during esophageal carcinogenesis. PLoS Genet. 2011;7:e1001356.PubMedCentralPubMedCrossRef Alvarez H, Opalinska J, Zhou L, et al. Widespread hypomethylation occurs early and synergizes with gene amplification during esophageal carcinogenesis. PLoS Genet. 2011;7:e1001356.PubMedCentralPubMedCrossRef
31.
Zurück zum Zitat Saeki H, Kimura Y, Ito S, et al. Biologic and clinical significance of squamous epithelial dysplasia of the esophagus. Surgery. 2002;131:S22–7.PubMedCrossRef Saeki H, Kimura Y, Ito S, et al. Biologic and clinical significance of squamous epithelial dysplasia of the esophagus. Surgery. 2002;131:S22–7.PubMedCrossRef
32.
Zurück zum Zitat Bass AJ, Watanabe H, Mermel CH, et al. SOX2 is an amplified lineage-survival oncogene in lung and esophageal squamous cell carcinomas. Nat Genet. 2009;41:1238–42.PubMedCentralPubMedCrossRef Bass AJ, Watanabe H, Mermel CH, et al. SOX2 is an amplified lineage-survival oncogene in lung and esophageal squamous cell carcinomas. Nat Genet. 2009;41:1238–42.PubMedCentralPubMedCrossRef
33.
Zurück zum Zitat Han X, Fang X, Lou X, et al. Silencing SOX2 induced mesenchymal–epithelial transition and its expression predicts liver and lymph node metastasis of CRC patients. PLoS One. 2012;7:e41335.PubMedCentralPubMedCrossRef Han X, Fang X, Lou X, et al. Silencing SOX2 induced mesenchymal–epithelial transition and its expression predicts liver and lymph node metastasis of CRC patients. PLoS One. 2012;7:e41335.PubMedCentralPubMedCrossRef
34.
35.
Zurück zum Zitat Ramsey MR, Wilson C, Ory B, et al. FGFR2 signaling underlies p63 oncogenic function in squamous cell carcinoma. J Clin Investig. 2013;123:3525–38.PubMedCentralPubMedCrossRef Ramsey MR, Wilson C, Ory B, et al. FGFR2 signaling underlies p63 oncogenic function in squamous cell carcinoma. J Clin Investig. 2013;123:3525–38.PubMedCentralPubMedCrossRef
36.
Zurück zum Zitat Takahashi Y, Ishii G, Taira T, et al. Fibrous stroma is associated with poorer prognosis in lung squamous cell carcinoma patients. J Thorac Oncol. 2011;6:1460–7.PubMedCrossRef Takahashi Y, Ishii G, Taira T, et al. Fibrous stroma is associated with poorer prognosis in lung squamous cell carcinoma patients. J Thorac Oncol. 2011;6:1460–7.PubMedCrossRef
37.
Zurück zum Zitat Cai C, Rajaram M, Zhou X, et al. Activation of multiple cancer pathways and tumor maintenance function of the 3q amplified oncogene FNDC3B. Cell Cycle. 2012;11:1773–81.PubMedCentralPubMedCrossRef Cai C, Rajaram M, Zhou X, et al. Activation of multiple cancer pathways and tumor maintenance function of the 3q amplified oncogene FNDC3B. Cell Cycle. 2012;11:1773–81.PubMedCentralPubMedCrossRef
38.
Zurück zum Zitat Wang MT, Chen G, An SJ, et al. Prognostic significance of cyclinD1 amplification and the co-alteration of cyclinD1/pRb/ppRb in patients with esophageal squamous cell carcinoma. Dis Esophagus. 2012;25:664–70.PubMedCrossRef Wang MT, Chen G, An SJ, et al. Prognostic significance of cyclinD1 amplification and the co-alteration of cyclinD1/pRb/ppRb in patients with esophageal squamous cell carcinoma. Dis Esophagus. 2012;25:664–70.PubMedCrossRef
39.
Zurück zum Zitat Miyawaki Y, Kawachi H, Ooi A, et al. Genomic copy-number alterations of MYC and FHIT genes are associated with survival in esophageal squamous-cell carcinoma. Cancer Sci. 2012;103:1558–66.PubMedCrossRef Miyawaki Y, Kawachi H, Ooi A, et al. Genomic copy-number alterations of MYC and FHIT genes are associated with survival in esophageal squamous-cell carcinoma. Cancer Sci. 2012;103:1558–66.PubMedCrossRef
40.
Zurück zum Zitat Hu N, Wang C, Su H, et al. High frequency of CDKN2A alterations in esophageal squamous cell carcinoma from a high-risk Chinese population. Genes Chromosomes Cancer. 2004;39:205–16.PubMedCrossRef Hu N, Wang C, Su H, et al. High frequency of CDKN2A alterations in esophageal squamous cell carcinoma from a high-risk Chinese population. Genes Chromosomes Cancer. 2004;39:205–16.PubMedCrossRef
41.
Zurück zum Zitat Walsh CS, Ogawa S, Scoles DR, et al. Genome-wide loss of heterozygosity and uniparental disomy in BRCA1/2-associated ovarian carcinomas. Clin Cancer Res. 2008;14:7645–51.PubMedCentralPubMedCrossRef Walsh CS, Ogawa S, Scoles DR, et al. Genome-wide loss of heterozygosity and uniparental disomy in BRCA1/2-associated ovarian carcinomas. Clin Cancer Res. 2008;14:7645–51.PubMedCentralPubMedCrossRef
42.
Zurück zum Zitat Plo I, Nakatake M, Malivert L, et al. JAK2 stimulates homologous recombination and genetic instability: potential implication in the heterogeneity of myeloproliferative disorders. Blood. 2008;112:1402–12.PubMedCrossRef Plo I, Nakatake M, Malivert L, et al. JAK2 stimulates homologous recombination and genetic instability: potential implication in the heterogeneity of myeloproliferative disorders. Blood. 2008;112:1402–12.PubMedCrossRef
43.
Zurück zum Zitat Pickering CR, Zhang J, Yoo SY, et al. Integrative genomic characterization of oral squamous cell carcinoma identifies frequent somatic drivers. Cancer Discov. 2013;3:770–81.PubMedCrossRef Pickering CR, Zhang J, Yoo SY, et al. Integrative genomic characterization of oral squamous cell carcinoma identifies frequent somatic drivers. Cancer Discov. 2013;3:770–81.PubMedCrossRef
Metadaten
Titel
Chromosomal Instability Associated with Global DNA Hypomethylation is Associated with the Initiation and Progression of Esophageal Squamous Cell Carcinoma
verfasst von
Hiroyuki Kawano, MD
Hiroshi Saeki, MD, PhD
Hiroyuki Kitao, PhD
Yasuo Tsuda, MD
Hajime Otsu, MD
Koji Ando, MD, PhD
Shuhei Ito, MD, PhD
Akinori Egashira, MD, PhD
Eiji Oki, MD, PhD
Masaru Morita, MD, PhD
Yoshinao Oda, MD, PhD
Yoshihiko Maehara, MD, PhD
Publikationsdatum
01.12.2014
Verlag
Springer US
Erschienen in
Annals of Surgical Oncology / Ausgabe Sonderheft 4/2014
Print ISSN: 1068-9265
Elektronische ISSN: 1534-4681
DOI
https://doi.org/10.1245/s10434-014-3818-z

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