CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2005;3:370 375 Is a Protective Factor for Survival in Patients With Colorectal Carcinoma? ALESSANDRO CAPORALE,* ANNA RITA VESTRI, EUGENIO BENVENUTO,* MAURO MARIOTTI, UMILE MICHELE COSENZA,* MASSIMO SCARPINI,* ANDREA GIULIANI,* PIETRO MINGAZZINI, and FRANCESCO ANGELICO *Department of Surgery Pietro Valdoni, Rome, Italy; and Department of Experimental Medicine and Pathology, University La Sapienza, Rome, Italy Background & Aims: The role of desmoplasia in colorectal carcinoma progression is unclear and the presence of collagen stroma may represent a barrier against cancer diffusion and vascular invasion or a stroma to build up and support the tumor. The aim of this study was to evaluate the effect of desmoplastic response on long-term survival of patients who underwent radical resection for colorectal carcinoma. Methods: The study included 429 patients who underwent radical colorectal resection for cancer with a median follow-up period of 72.8 months. Results: At univariate analysis significant associations were observed between desmoplasia and histologic type, parietal infiltration, growth pattern, and staging. No associations were found between desmoplasia and the other clinical and histologic parameters. The multivariate analysis stratified for tumor stage revealed that the factor showing the most favorable influence on time to death was desmoplasia. The presence of desmoplasia was likely to decrease the failure rate to a third of the rate experienced by patients without desmoplasia. Parietal infiltration was associated with an increased risk for a shortened time to death. Conclusions: Our results favor the view that desmoplasia is a protective factor for survival in patients with colorectal carcinoma. This finding is consistent with the hypothesis that desmoplasia may prevent cancer invasiveness by building a barrier against tumor diffusion. It has been observed that cancer invasion may stimulate host reactions within and around tumor tissue as a response to tumor progression. Cancer invasion may induce local inflammatory cell accumulation, angiogenesis, immune reactions, and extracellular matrix production. is a process of extracellular matrix production and degradation frequently observed during cancer invasion. This remodeling process is induced by activation of fibroblasts with increased production of matrix proteins and matrix degrading enzymes. It has been postulated that desmoplasia might be one of the factors determining the biological behavior of a malignant tumor, although its role in the development and progression of human malignancies so far has not been well elucidated. In fact, the presence of collagen stroma may altogether represent a barrier against cancer diffusion and vascular invasion or a stroma to build up and support the tumor. According to recent studies, desmoplasia may be regarded as a factor promoting tumor invasion in breast, 1 pancreas, 2 lung, 3 prostate, 4 esophagus, 5 and stomach, 6 although its role in colorectal cancer still is debated. 4,7 13 The aim of this study was to evaluate the effect of desmoplasia on the 5-year survival in a cohort of patients who underwent radical resection for colorectal cancer. Materials and Methods This study included patients who underwent radical colorectal resection for carcinoma from 1987 to 1996 at the Pietro Valdoni Department of Surgery of the University La Sapienza in Rome. Patients had to fulfill the following criteria: radical surgical intervention, no postoperative death, no liver metastases, description of desmoplasia, TNM classification reported by the same pathologist, and a minimum of 5 years after surgery. The clinical end point of the study was death from colorectal cancer; deaths from other causes were excluded. Survival status was assessed by telephone interviews performed by the same clinician. Cause of death was assessed by medical records and death certificates. Of the 1152 treated patients, 484 fulfilled the inclusion criteria, 55 patients were missing at end of follow-up evaluation or dead from causes different from colorectal cancer and were censored in the analyses at the time of death or when they were lost to follow-up evaluation, and 429 patients were eligible for the study (248 men, 181 women; average age 64.3 11.2 y; median, 65.5 y; range, 21 87 y). 2005 by the American Gastroenterological Association 1542-3565/05/$30.00 PII: 10.1053/S1542-3565(04)00674-3
April 2005 ROLE OF DESMOPLASIA IN COLORECTAL CARCINOMA 371 Figure 1. Advancing edge of the tumor. Muscularis propria infiltration with absence of a desmoplastic reaction. Van Gieson 200. The tumors were categorized by site (right colon, left colon, rectosigmoid junction, rectum), parietal infiltration, histologic type, growth pattern according to Ming s classification, 14 lymphonodal involvement, staging (TNM classification), and grading. The presence of inflammatory cell accumulation was scored semiquantitatively as mild, moderate, and severe. The presence or absence of desmoplasia was determined on the detection of the extracellular matrix production at the tumor-advancing edge (Figures 1 and 2). Histologic scoring was performed by the same pathologist throughout the recruitment period. A standard H&E stain was performed in all samples and the presence of collagen was confirmed by Van Gieson stain in representative samples with different amounts of collagen stroma. Univariate analysis of significance of the available parameters was performed using the Kaplan Meier method and the Mantel Cox statistics (log-rank test). Proportions and categoric variables were tested by the 2 test. The Cox proportional hazard method was used in an exploratory manner to identify a subset of variables associated with survival time. The covariates were as follows: desmoplastic reaction, parietal infiltration, staging, histologic type, and tumor site. Two-sided P values less than.05 were considered statistically significant. All statistics were performed with SPSS 10 statistical software (Release 10.0.1, 1999; SPSS, Chicago, IL). Results Patients underwent the following interventions: right hemicolectomy in 21.9%, left hemicolectomy in 11.4%, anterior rectocolic resection in 54.3%, abdominoperineal resection in 11.0%, and total colectomy in 1.4%. Twenty-four percent of tumors were in the right colon, 36% were in the left colon, 9% were in the rectosigmoid junction, and 32% were in the rectum. The mean number of resected lymphonodes was 19.5 14.6; the mean number of involved lymphonodes was 2.8 6.7. Adenocarcinomas were 74%, mucinous-type adenocarcinomas were 24%, signet ring-cell adenocarcinoma were 2%. Sixty-nine percent of tumors were expanding and 31% were infiltrative, according to Ming s 14 classification. Inflammatory cell reaction was absent in 6%, mild in 38%, moderate in 42%, and marked in 13%. Desmoplastic reaction was absent in 29.1% and present in 70.9%. Tumor grading was G1 in 9.6%, G2 in 73.9%, and G3 in 16.6%. According to 1997 TNM International Union Against Cancer classification of staging, patients were classified as follows: 0.2%, I 20.0%, II 38.9%, III 35.0%, and IV 5.8%. The mean follow-up period was 71.6 54.8 months (median, 72.8 mo). The association between desmoplastic reaction and the clinical and histologic characteristics is shown in Table 1. Significant associations were observed between desmoplasia and histologic type (P.0001), parietal infiltration (P.0001), growth pattern (P.002), and staging (P.004). No associations were found between desmoplasia and the other clinical and histologic parameters. Five-year survival was 35.1% and 60.2% for absence and presence of desmoplasia, respectively. One-, 3-, and 5-year survivals according to tumor stage, desmoplasia, and type of adenocarcinoma are shown in Table 2. Multivariate analysis (Cox regression), stratified for stage (Table 3), shows that the factor with the most favorable influence on time to death was desmoplasia. The coefficient decreases the value of hazard function and indicates that the presence of desmoplasia is likely to decrease the failure rate to a third of that experienced by Figure 2. Advancing edge of the tumor. Muscularis propria infiltration with presence of a desmoplastic reaction. Van Gieson 200.
372 CAPORALE ET AL CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 3, No. 4 Table 1. Prevalence of Some Clinical and Histologic Parameters According to Presence or Absence of patients without desmoplastic reaction (odds ratio,.33, P.0001). Survival functions for patients with adenocarcinomas with different stages are shown in Figures 3 6. The positive coefficient of parietal infiltration increases the value of hazard function and indicates an adverse effect on time to death (odds ratio, 1.5, P.013), therefore increasing the risk for a shortened time to death 1.5-fold (95% confidence interval, 1.1 2.1). Perivisceral infiltration increases the failure rate to nearly 5-fold (odds ratio, 4.891, P.001). Discussion Absent Present P* Age 65 y 28.6 71.4.828 65 y 29.6 70.4 Site Right colon 32.0 68.0 Left colon 28.4 71.6.602 R-S junction 21.1 78.9 Rectum 28.7 71.3 Histological type Adenocarcinoma 23.3 76.7.0001 Mucinous 45.9 54.1 Growth pattern Infiltrative 21.2 78.8.002 Expanding 32.7 67.3 Parietal infiltration Submucosal 52.9 47.1 Muscular 35.6 64.4.0001 Serosal 22.7 77.3 Perivisceral 20.9 79.1 Inflammatory response Mild 28.6 43.8 Moderate 31.3 45.1.774 Marked 23.6 47.3 Staging I 43.1 57.0 II 29.3 70.7.004 III 22.0 78.0 IV 20.0 80.0 Grading 1 39.0 61.0 2 28.4 71.6.329 3 26.8 73.2 NOTE. Data are expressed in percentages. * 2 test. It is still unclear whether a desmoplastic reaction represents a host barrier against a neoplastic invasiveness or, on the contrary, is an expression of tumor invasion. Although in breast, 1 lung, 3 esophagus, 5 stomach, 6 pancreas, 2 and prostate 4 desmoplasia is considered as an aggressive factor, in colorectal cancer its role seems to be protective. In 1987, Martin et al 15 reported a beneficial effect of fibroblastic reaction in colonic cancer in rats and suggested that fibrous encapsulation could have a role in the mechanisms of tumor regression. In support of this result, it has been reported that the L-3,4-dehydroproline induced inhibition of the desmoplastic response may lead to an increase in spontaneous metastasis from experimental murine melanomas. 16 The aim of our study was to evaluate the possible protective role of desmoplasia on long-term survival in patients who underwent radical colorectal carcinoma resection. The clinical end point was death from colorectal carcinoma. The study included 429 patients who received radical surgery and had more than 5 years of follow-up evaluation. Most information about vital status was obtained by phone interviews performed by the same well-trained clinician. The analysis of mean and median survival time of patients stratified according to tumor stage showed that patients with desmoplasia survived longer than those without desmoplasia. In patients with adenocarcinomas, in all stage groups, survival rates were higher in those with desmoplasia as compared with those without desmoplasia. A similar trend was observed in patients with mucinous and ring cell adenocarcinomas, who represent a separate subset of patients carrying a poorer prognosis. The association of desmoplasia and survival assessed by a multivariate analysis including possible confounding clinical and histopathologic variables (ie, parietal infiltration, staging, histologic type, tumor site) showed a strong protective effect of desmoplasia on survival time and a negative correlation of time to death with tumor parietal infiltration. These results were obtained after stratification for staging to make comparisons between patients with the same clinical and pathologic conditions. The positive association between desmoplasia and survival time was highly significant in patients with tumor stages 1 3. In stage 4 patients, the association was less evident as the result of a small number of cases and of a more advanced tumor disease. Our results are in agreement with Hewitt et al 7 who examined intertumoral and intratumoral variation in the desmoplastic response of colorectal carcinoma. The investigators found a decreased invasive activity in the tumor center where desmoplastic response was marked, and a more active invasion at the tumor edge where desmoplasia was absent, thus confirming the hypothesis that desmoplastic response limits tumor invasiveness. Similar conclusions were obtained in a recent study of 69
April 2005 ROLE OF DESMOPLASIA IN COLORECTAL CARCINOMA 373 Table 2. Survival According to Time, Stage, and Type of Adenocarcinoma Number (deaths) 1 y 3 y 5 y P value Adenocarcinoma Stage I Absent 37 (12) 94.6% 81.1% 67.6% Present 49 (3) 98.0% 97.9% 93.4%.001 Stage II Absent 49 (33) 89.8% 34.7% 32.7% Present 115 (33) 97.5% 79.7% 71.3%.0001 Stage III Absent 33 (32) 63.6% 15.2% 6.1% Present 114 (70) 85.5% 43.6% 38.6%.001 Stage IV Absent 5 (5) 20% 0 0 Present 20 (18) 45% 10% 10%.6327 Mucinous and ring cell adenocarcinoma Stage I Absent 11 (3) 90.9% 72.7% 72.7% Present 4 (0) 100% 100% 100%.2718 Stage II Absent 19 (9) 89.5% 52.6% 52.6% Present 26 (5) 96.2% 80.8% 80.8%.237 Stage III Absent 16 (15) 43.7% 6.3% 6.3% Present 25 (18) 76.0% 28.0% 28.0%.0627 Stage IV Absent 5 (5) 20.0% 0 0 Present 5 (5) 0 0 0.3675 patients who underwent radical hepatectomy for liver metastases from colorectal cancer. In this study, fibrotic capsular formation around liver metastasis was associated with a lower rate of local recurrence, suggesting that the capsule may serve as a mechanical and chemical barrier to local invasion. 8 By contrast, it has been postulated that fibrous encapsulation might benefit tumor invasiveness by decreasing access by host immune cells. 9 In fact, recently it has been suggested that desmoplasia might promote tumor invasiveness by supplying oxygen, nutrients, and the necessary proteases to lose the matrix during endothelial cell migration and proliferation. 10 This hypothesis has been confirmed by some clinical observations. Jass et al, 11 in a multivariate survival analysis of grade- and stage-related variables performed in 447 specimens of rectal cancer, found that lymphocytic Table 3. Variables in the Model Equation of the Cox Regression 95% confidence interval for odds ratio P value Odds ratio Lower Upper Absent.000 Present.000.33.25.44 Parietal infiltration Submucosal.001 Muscular.633 1.13.67 1.92 Serosal.013 1.52 1.09 2.13 Perivisceral.001 4.89 1.92 12.41 Figure 3. Estimated proportion surviving according to presence or absence of desmoplasia in the group of patients with stage I colorectal adenocarcinoma (P.001).
374 CAPORALE ET AL CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 3, No. 4 Figure 4. Estimated proportion surviving according to presence or absence of desmoplasia in the group of patients with stage II colorectal adenocarcinoma (P.0001). Figure 6. Estimated proportion surviving according to presence or absence of desmoplasia in the group of patients with stage IV colorectal adenocarcinoma (P.6327). infiltration was the only prognostic variable. Moreover, Halvorsen and Seim 4 reported that tumor desmoplasia is an independent prognostic variable that may increase the risk for death by a factor of about 1.5 compared with tumors with little or no fibrosis. Recently, Nakada et al, 12 in a biopsy study of 109 early colorectal carcinomas, found that desmoplastic response is predictive of deep submucosal invasion and suggested performing a surgical resection in the presence of a prominent desmoplastic response and an endoscopic treatment for carcinomas with poor desmoplastic response. Figure 5. Estimated proportion surviving according to presence or absence of desmoplasia in the group of patients with stage III colorectal adenocarcinoma (P.001). Finally, in a 21-month follow-up study of 77 patients with advanced colorectal carcinoma, fibrous reaction significantly increased the relative risk for liver metastasis, although the increase of tumor recurrence was not statistically significant. 13 However, the investigators concluded that a longer follow-up period and a larger number of cases are necessary to determine the biological significance of fibrous reaction. In conclusion, our results, based on the long-term follow-up evaluation of a large series of radically operated patients, favor the view that desmoplasia is a protective factor for survival in patients with colorectal carcinoma. This finding is consistent with the hypothesis that desmoplasia may prevent cancer invasiveness by building a barrier against tumor diffusion. However, this result is counter to findings in other gastrointestinal cancers in which desmoplasia is a poor prognostic factor. Further biomolecular studies of the components of the extracellular matrix (ie, metalloproteinases and their inhibitors) are needed to elucidate such controversial findings. References 1. Hasebe T, Sasaki S, Imoto S, et al. Prognostic significance of fibrotic focus in invasive ductal carcinoma of the breast: a prospective observational study. Mod Pathol 2002;15:502 516. 2. Iacobuzio-Donahue CA, Ryu B, Hruban RH, et al. Exploring the host desmoplastic response to pancreatic carcinoma: gene expression of stromal and neoplastic cells at the site of primary invasion. Am J Pathol 2002;160:91 99. 3. Shimosato Y, Suzuki A, Hashimoto T, et al. Prognostic implications of fibrotic focus (scar) in small peripheral lung cancers. Am J Surg Pathol 1980;4:365 373. 4. Halvorsen TB, Seim E. Association between invasiveness, inflammatory reaction, desmoplasia and survival in colorectal cancer. J Clin Pathol 1989;42:162 166.
April 2005 ROLE OF DESMOPLASIA IN COLORECTAL CARCINOMA 375 5. Koliopanos A, Friess H, di Mola FF, et al. Connective tissue growth factor gene expression alters tumor progression in esophageal cancer. World J Surg 2002;26:420 427. 6. Caporale A, Cosenza UM, Vestri AR, et al. Has desmoplastic response extent protective action against tumor aggressiveness in gastric carcinoma? J Exp Cancer Res 2001;20:21 24. 7. Hewitt RE, Powe DG, Carter I, et al. and its relevance to colorectal tumour invasion. Int J Cancer 1993;53:62 69. 8. Lunevicius R, Nakanishi H, Ito S, et al. Clinicopathological significance of fibrotic capsule formation around liver metastasis from colorectal cancer. J Cancer Res Clin Oncol 2001;127:193 199. 9. Liotta LA, Rao CN, Barsky SH. Tumor invasion and the extracellular matrix. Lab Invest 1983;49:636 649. 10. Masson R, Lefebvre O, Noel A, et al. In vivo evidence that the stromelysin-3 metalloproteinase contributes in a paracrine manner to epithelial cell malignancy. J Cell Biol 1998;140:1535 1541. 11. Jass JR, Atkin WS, Cuzick J, et al. The grading of rectal cancer: historical perspectives and a multivariate analysis of 447 cases. Histopathology 1986;10:437 459. 12. Nakada I, Tasaki T, Ubukata H, et al. Desmoplastic response in biopsy specimens of early colorectal carcinoma is predictive of deep submucosal invasion. Dis Colon Rectum 1998;41:896 900. 13. Nishimura R, Hasebe T, Tsubono Y, et al. The fibrotic focus in advanced colorectal carcinoma: a hitherto unrecognized histological predictor for liver metastasis. Virchows Arch 1998;433:517 522. 14. Ming SC. Gastric carcinoma. A pathobiological classification. Cancer 1977;39:2475 2485. 15. Martin MS, Caignard A, Hammann A, et al. An immunohistological study of cells infiltrating progressive and regressive tumors induced by the two variant subpopulations of a rat colon cancer cell line. Int J Cancer 1987;40:87 93. 16. Barsky SH, Gopalakrishna R. Increased invasion and spontaneous metastasis of B16 melanoma with inhibition of the desmoplastic response in C57 BL/6 mice. Cancer Res 1987;47:1663 1667. Address requests for reprints to: Francesco Angelico, MD, Via Antonio Nibby 8, 00161 Rome, Italy. e-mail: francesco.angelico@uniroma1.it; fax: (39) 06-4440290.