`
`OncogeneExpressioninGastroenteropancreatic
`NeuroendocrineTumors
`ImplicationsforPathogenesis
`
`Da-GongWang, M.D.,Ph.D.
`ColinF.Johnston,
`Ph.D.
`KeithD.Buchanan, M.D.,Ph.D.
`
`DivisionofMetabolismandEndocrinology,
`SchoolofClinicalMedicine,TheQueen’sUni-
`versityofBelfast,Belfast,UnitedKingdom.
`
`Partofthisstudy(informationononcogeneex-
`pressioninpancreaticneuroendocrinetumors)
`waspresentedat ajointmeetingoftheMedical
`ResearchSocietyandtheEuropeanSocietyof
`ClinicalInvestigationattheUniversityofCam-
`bridge,Cambridge,UnitedKingdom,April2–
`5,1995.
`
`TheNorthernIrelandNeuroendocrineTumor
`RegisterissupportedbygrantsfromtheUlster
`CancerFoundation.
`
`Addressforreprints:Da-GongWang,M.D.,
`Ph.D.,c/oColinF.Johnston,Ph.D.,Department
`ofMedicine,InstituteofClinicalScience,Well-
`comeResearchLaboratories,GrosvenorRoad,
`BelfastBT126BJ,UnitedKingdom.
`
`ReceivedNovember25,1996;revisionreceived
`March13,1997;acceptedApril23,1997.
`
`q1997AmericanCancerSociety
`
`BACKGROUND. Neuroendocrinetumorsofthegastroenteropancreaticsystemin-
`cludepancreaticisletcellandcarcinoidtumors.Thesetumorscomprise afunction-
`allyandbiologicallyheterogeneousgroupofneoplasmsthatrarelyshowreliable
`histopathologicsignsofmalignancy.Noetiologicfactorsareproventobeassoci-
`atedwiththem,andtheirexactontogenyandcarcinogenesisremainunknown.
`METHODS. Monoclonalantibodieswereemployed,alongwithmicrowaveantigen
`retrievalandtheavidin-biotinimmunohistochemicalmethod,toinvestigatethe
`expressionofc-myc,bcl-2,c-erbB-2,c-erbB-3,c-jun,andproliferatingcellnuclear
`antigen(PCNA)in aretrospectiveseriesof116primarygastroenteropancreatic
`neuroendocrinetumors(GPNTs).Theauthorsattemptedtocorrelatethisexpres-
`sionwiththeclinicopathologicoutcomeofthedisease.
`RESULTS. Immunoreactivitiesforc-myc,bcl-2,c-erbB-2,c-erbB-3,andc-junwere
`detectedin100%,45%,24%,7%,and24%ofpancreaticneuroendocrinetumors
`(PNTs),respectively.Incarcinoidtumors,immunoreactivitiesweredetectedforc-
`myc(63%),bcl-2(28%),c- erbB-2(31%),c-erbB-3(6%),andc-jun(23%).Therewere
`significantlyhigherincidencesofc-myc,bcl-2,andc-
`erbB-2immunoreactivitiesin
`carcinoidtumorsoftherectumthaninthoseoftheappendix,andsignificantly
`higherincidencesofbcl-2andc-junimmunoreactivitiesincarcinoidtumorsof
`thebronchusthaninthoseoftheappendix.IncidenceofPCNAimmunoreactivity
`wassignificantlyhigherinmalignantthaninbenignPNTsandalsosignificantly
`higherincarcinoidtumorsofthejejunumandileumthaninthoseoftheappendix.
`CONCLUSIONS. Theoncogenesc-myc,bcl-2,c-erbB-2,andc-junarefrequently
`expressedinhumanGPNTs.Theexpressionoftheseoncogenesmayrepresent
`pathogeniceventsinthegeneration,malignanttransformation,andprogression
`ofGPNTs.TheimmunohistochemicalevaluationofcellkineticsinGPNTsbyPCNA
`mightbeausefuladjuncttoconventionaldiagnosticprocedures.Cancer
`1997;80:668–75.q1997AmericanCancerSociety.
`
`KEYWORDS:oncoprotein,isletcelltumor,carcinoid,pathogenesis.
`
`N
`
`euroendocrinetumorsofthegastroenteropancreaticsystemin-
`cludetwomaingroups,isletcelltumorsofthepancreasand
`carcinoidtumors.Thesetumorssecreteactivehormonesandmaybe
`associatedwithdistinctiveclinicalsyndromes.Pancreaticneuroendo-
`crinetumors(PNTs)arerare,withanannualincidenceof0.2in
`100,000,1 andareeitherinheritedaspartofthemultipleendocrine
`neoplasiatype1(MEN1)syndromeor,morefrequently,aresporadic.
`2 fivemainsyndromeshave
`SincethefirstreportbyNicholsin1902,
`beenassociatedwithPNTs:thehypoglycemicorinsulinomasyn-
`drome;theZollinger–Ellisonorgastrinomasyndrome;theVerner–
`Morrison,waterydiarrheahypokalemiaachlorhydria(WDHA),orva-
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`soactiveintestinalpolypeptide(VIP)omasyndrome;
`
`syndrome.Aboutone-thirdofPNTsfailtoproduce
`
`scribedasnonfunctioning. 1 Carcinoidtumorsarethe
`
`beenintensivelystudied.Onlyafewstudies,withlim-
`8,23 Inthistheglucagonomasyndrome;andthesomatostatinoma
`itednumbersofcases,havebeenreported.
`study,wehaveanalyzed,byimmunohistochemistry
`usingmonoclonalantibodies,theexpressionoffiveanyhormone-relatedsyndromeandarethereforede-
`dominantoncogenes—c- myc,bcl-2,c- erbB-2,c- erb
`B-3,andc-jun—inaretrospectiveseriesof116pri-mostcommonofthegastrointestinaltract(GI)neuro-
`endocrineneoplasmsandaccountfor55–86%ofall maryhumanGPNTs,includingisletcelltumorsofthe
`3,4 Accordingtothesiteoforigin,carci-
`pancreasandcarcinoidsofforegut,midgut,andhind-suchtumors.
`gutorigin,andwehaveattemptedtocorrelatethis
`noidtumorshavebeenclassifiedastumorsofthefore-
`expressionwiththeclinicopathologicoutcomeofthegut(bronchus,pancreas,stomach,andproximalduo-
`disease.Additionally,asmeasurementofcellprolifera-
`tionmayprovideusefulinformationconcerningtu-appendix,proximalcolon,andovary),andhindgut
`5 Thehistochemicalcharac- morprognosisandmayaidindiagnosis,weexamined
`thecorrelationbetweenthefractionofproliferatingteristics,biochemicalproperties,andclinicalmanifes-
`cellnuclearantigen(PCNA)positivenucleiinthetu-
`morandtheoutcomeinthisseriesofGPNTpatients.bryonicorigin.Thesetumorscomprise afunctionally
`
`denum),midgut(distalduodenum,jejunum,ileum,
`
`(distalcolonandrectum).
`
`tationsofcarcinoidtumorsvaryaccordingtotheirem-
`
`andbiologicallyheterogeneousgroupofneoplasms
`thatrarelyshowreliablehistopathologicsignsofma-
`lignancy.Despiterecentadvancesinthediagnosis,
`localization,andtreatmentofthesetumors,noetio-
`
`andtheirexactontogenyandcarcinogenesisremain
`
`Thepastdecadehasseenmajoradvancesinthe
`
`andmanyoftheseadvanceshavestemmedfromstud-
`
`thedevelopmentofspecifichumantumors.Forexam-
`
`genewasfoundtobeassociatedwithBurkitt’s
`
`MATERIALSANDMETHODS
`Patients
`AllcasesofprimaryGPNTsfromtheperiod1986–1995
`inthearchivalfilesoftheNorthernIrelandNeuroen-logicfactorsareproventobeassociatedwiththem,
`docrineTumorRegister,includingPNTs(n(cid:129)29)and
`carcinoidtumors(n(cid:129)87),werereviewedretrospec-unknown.
`tively.Thistumorregisterwasestablishedin1978by
`theDepartmentofMedicine,theQueen’sUniversityunderstandingofthemoleculargeneticsofcancer,
`1 Detailedclinicopathologicdataonpatients
`ofBelfast.
`(includingage,gender,symptoms,tumorlocation,tu-iesofcellularoncogenesandtumor-suppressorgenes.
`Severaloncogeneshavebeenwellstudiedoverthe morsize,andoccurrenceofmetastases)wereavail-
`able,andeachpatient’sclinicalprogresshadbeenyearsandcharacterizedwithregardtotheirrolesin
`followedandrecordedsinceinitialdiagnosis.Thetu-
`moridentitywasconfirmedineachcasebythediag-ple,in1980, atranslocationinvolvingthec-myconco-
`nosticpathologyserviceoftheRoyalGroupofHospi-
`tals,Belfast,NorthernIreland.Theconfirmationswerelymphoma,andthisoncogenewassubsequentlyim-
`plicatedinthedevelopmentofmanyothertypesof madebyhistologicmethods,electronmicroscopy,and
`erbB-2isa
`immunohistochemistryforgeneralneuroendocrinehumantumors.Theproto-oncogenec-
`memberofthetype 1growthfactorfamily,whichalso markersandspecificregulatorypeptides.
`includesc- erbB-3andepidermalgrowthfactorrecep-
`TumorSamples
`tor(EGFR). 6 Thec-junproto-oncogeneisamember
`SamplesofGPNTswerecollected,andtumortissueoftheearlyresponsegenefamily.c-
`junappearsto
`hadbeenfixedinmodifiedSusaandprocessedtopar-
`occupy acentralroleintheregulationofproliferation
`7 Am-
`24 Inaddi-andisinvolvedinsignaltransductionprocesses.
`affinwaxaccordingtoaconstantprotocol.
`tion,samplesoftwonormalpancreatawereobtained
`andprocessedidentically.havebeenimplicatedinexperimentalcellulartrans-
`
`plificationandoverexpressionoftheseoncogenes
`
`formationandtumorigenesisinawiderangeofhu-
`Immunohistochemistry
`mancancers,includingneuroendocrinetumorsand
`8–17 bcl-2appears
`Oncoproteinexpressionwasdetectedwithcommer-neuroendocrine-differentiatedcells.
`toconstituteamemberofanewcategoryofonco-
`ciallypreparedmonoclonalantibodiesspecificfor
`18
`eachprotein.Thesewereanti-c- myc,clone9E11,atagenes,namely,regulatorsofprogrammedcelldeath.
`dilutionof1:150;anti-c-
`erbB-2,cloneCB11,1:50;anti-
`19,20
`c-erbB-3,cloneRTJ1,1:50;anti-c-jun,cloneDK4,1:50;andotherhumantumorcelllinesofneuralorigin
`anti-PCNA,clonePC10,1:100(allfromNovocastra,
`NewcastleuponTyne,UK);andanti-
`bcl-2,clone124,However,theexpressionandrolesofoncogenes
`1:50(Dakopatts,Glostrup,Denmark).
`Immunohistochemicalstudieswereperformedpancreaticneuroendocrinetumors(GPNTs)havenot
`
`inthepathogenesisandprogressionofgastroentero-
`
`andimplicatedinthetumorigenesisofGItumors.
`
`21,22
`
`Recently,bcl-2hasbeendescribedinneuroblastoma
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`dogenousperoxidaseactivitywasblockedbytreat-
`
`treatedwith20%normalrabbitserumfor30minutes
`
`maryantibodies(c- myc,bcl-2,c-erbB-2,c-erbB-3,
`
`7of29PNTsinwhichmorethan10%oftumorcells
`bytheavidin-biotincomplex(ABC)methodasde-
`25 Briefly,sections4
`reactedpositively(Fig.1C).Immunoreactivityforc-scribedpreviously.
`mmthick
`erbB-3occurredinonlyoneinsulinomainwhichless
`weredewaxedandsubjectedtomicrowaveantigen
`than10%ofcellswerepositiveandinoneglucago-retrievalbyimmersionincitratebufferpH6.0.En-
`nomainwhich10–50%ofcellswerepositive,and
`thiswaslocalizedexclusivelytothecytoplasm.Inthementwith3%hydrogenperoxide.Theslideswere
`normalpancreas,c-
`erbB-2immunoreactivityoc-
`curredinthecytoplasmofsomeacinarcellsandinatroomtemperature,thenincubatedwiththepri-
`thecellmembraneofductalcells,whereasweakcyto-
`plasmicc- erbB-3wasonlydetectedincellsoftheandPCNA)for1houratroomtemperatureandwith
`isletsofLangerhans.
`junimmunoreactivitycordingtothemanufacture’sinstructions.Thesec-
`Cytoplasmicandnuclearc-
`wasobservedin7of29tumorsamples(Fig.1D).No
`c-junimmunoreactivitywasdetectedinnormalpan-ylatedsecondaryantibody(Dakopatts,Glostrup,
`creatictissues.
`
`c-junfor18hoursat4
`
`7C,in amoistchamberac-
`
`tionswerethenwashedandincubatedwithabiotin-
`
`nABC
`Denmark).After35minutesofincubationi
`(Dakopatts,Glostrup,Denmark),thereactionprod-
`uctwasvisualizedusing3,3-diaminobenzidinetet-
`rahydrochloride(Sigma,Poole,UK).
`Controlsutilizedthroughoutthestainingproce-
`dureincludedstainingofsectionsthatwerepreviously
`determinedaseitherpositiveornegativeforeachon-
`coproteinaswellasincubationanddevelopmentof
`sectionsusingnormalblockingserumwithoutincuba-
`tioninprimaryantibody.
`Theimmunohistochemicalresultswereassessed
`withoutknowledgeoftheclinicaldiagnosisandevalu-
`25
`atedsemiquantitativelyasdescribedpreviously.
`
`OncoproteinImmunoreactivityinCarcinoidTumors
`Ofthe87carcinoidtumorsfromdifferentsitesexam-
`ined,c-mycimmunoreactivitywasfoundin55tumors
`(63%),and24tumorsamples(28%)showedimmuno-
`reactivityforbcl-2(Table2).Themajorityofpositive
`casesdisplayedacytoplasmicstainingpatternofvari-
`ableintensityforbothoncoproteins,andoccasional
`nuclearstainingwasobservedforc- myc(Fig.2A).
`Immunoreactivityforc- erbB-2wasfoundin27
`carcinoidtumors(31%).Stainingwascytoplasmic,
`withnodistinctcellmembranestainingobserved(Fig.
`2B).Onlyoneilealcarcinoidtumorandoneappendi-
`cealcarcinoidtumordisplayedimmunoreactivityfor
`c-erbB-3.
`c-junimmunoreactivitywasdetectedin20of87
`carcinoidtumors.Inmostpositivecases,thestaining
`wascytoplasmicandoccasionallynuclear,withthe
`intensityofstainingvaryingfromcasetocase(Fig.2C,
`2D).
`
`PCNAImmunoreactivityinGPNTs
`NuclearimmunoreactivitytoPCNAwasfoundin17
`of29PNTswithmorethan10%positivecells(Fig.3A).
`Inthenormalpancreas,PCNAimmunoreactivitywas
`detectedinoccasionalacinarcellsalone(Fig.3B).
`PCNAimmunoreactivitywasfoundincarcinoid
`tumorsfromdifferentsites,includingthebronchus
`(86%),stomach(80%),jejunumandileum(90%),ce-
`cum(100%),appendix(60%)andrectum(71%).Un-
`equivocalnuclearstainingwaspresentinallpositive
`cases.
`
`AssociationofOncoproteinExpression
`Consecutivesectionsofalltumorsampleswereusedepithelialcellsshowedbcl-2immunoreactivity,and
`inimmunostainingforoncoproteinsandPCNA.A
`markedassociationwasobservedbetweenthepres-Immunoreactivityforc-
`enceofoncoproteinimmunoreactivity,particularly
`
`StatisticalAnalysis
`Thechi-squaretestwasusedwithYate’scorrectionfor
`thestatisticalanalysisofthedatainwhichspecimens
`containingmorethan10%positivetumorcellswere
`included.StatisticalsignificancewassetatP(cid:155)0.05.
`
`RESULTS
`OncoproteinsandPCNAimmunoreactivityinPNTs
`andcarcinoidtumorsaregiveninTables 1and2,in
`whichonlyspecimenswithmorethan10%oftumor
`cellsstainedareincluded.
`
`OncoproteinImmunoreactivityinPNTs
`Strongimmunoreactivityforc- mycwaswidespread,
`generallycytoplasmic,andwithsomenuclearstaining
`identifiedinall29tumorsamples(Fig.1A).Cyto-
`plasmicbcl-2immunoreactivity,heterogeneousinin-
`tensity,waspresentin13samples(Fig.1B).Inthe
`normalpancreata,moderatelyintensec- mycimmu-
`noreactivitywasobservedintheacinarcellcytoplasm,
`andweakimmunoreactivitywasdetectedinthecyto-
`plasmofcellsoftheisletsofLangerhans.Onlyductular
`
`endocrinetissuewasnegative.
`erbB-2occurredinthe
`cytoplasmandoccasionallyinthecellmembranesin
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`TABLE1
`OncoproteinandPCNAImmunoreactivitiesinPancreaticNeuroendocrineTumors
`
`Tumortype
`
`No.oftumors
`
`No.metastatic
`
`c- myc
`
`bcl-2
`
`c-erbB-2
`
`c-erbB-3
`
`c-jun
`
`PCNA
`
`OncogenesinCarcinoidTumors/Wangetal.
`
`671
`
`Insulinoma
`Gastrinoma
`Glucagonoma
`VIPoma
`Nonfunctioning
`Total
`Totalbenign
`Totalmalignant
`Normalpancreas
`
`11
`6
`4
`3
`5
`29
`18
`11
`2
`
`0
`3
`2
`2
`4
`11
`0
`11
`0
`
`PCNA:proliferatingcellnuclearantigen.
`a P(cid:129)0.018versusbenignpancreaticneuroendocrinetumors.
`
`11(100%)
`6(100%)
`4(100%)
`3(100%)
`5(100%)
`29(100%)
`18(100%)
`11(100%)
`2(100%)
`
`4(36%)
`3(50%)
`3(75%)
`2(67%)
`1(20%)
`13(45%)
`9(50%)
`4(36%)
`0(0%)
`
`2(18%)
`1(17%)
`3(75%)
`1(33%)
`0(0%)
`7(24%)
`2(11%)
`5(45%)
`0(0%)
`
`0(0%)
`0(0%)
`1(25%)
`0(0%)
`0(0%)
`2(7%)
`1(6%)
`0(0%)
`2(100%)
`
`1(9%)
`2(33%)
`1(25%)
`2(67%)
`1(20%)
`7(24%)
`3(17%)
`4(36%)
`0(0%)
`
`3(27%)
`5(83%)
`2(50%)
`3(100%)
`4(80%)
`17(59%)
`7(39%)
`10(91%)
`2(100%)
`
`a
`
`TABLE2
`OncoproteinandPCNAImmunoreactivitiesinCarcinoidTumors
`
`Originalsite
`
`No.oftumors
`
`No.metastatic
`
`c- myc
`
`bcl-2
`
`c-erbB-2
`
`c-erbB-3
`
`c-jun
`
`PCNA
`
`2
`0
`1
`
`18
`1
`0
`
`3
`25
`
`16(73%)
`1(100%)
`5(100%)
`
`10(45%)
`1(100%)
`2(40%)
`
`8(36%)
`1(100%)
`3(60%)
`
`3(17%)
`0(0%)
`0(0%)
`
`7(32%)
`1(100%)
`2(40%)
`
`19(86)
`1(100%)
`4(80%)
`
`15(75%)
`14(46%) a
`2(100%)
`
`3(15%)
`4(13%) b,c
`0(0%)
`
`6(30%)
`4(13%) b
`1(50%)
`
`1(5%)
`1(3%)
`0(0%)
`
`6(30%)
`2(7%) d
`0(0%)
`
`18(90%)
`18(60%) e
`2(100%)
`
`7(100%)
`55(63%)
`
`4(57%)
`24(28%)
`
`4(57%)
`27(31%)
`
`0(0%)
`5(6%)
`
`2(29%)
`20(23%)
`
`5(71%)
`67(77%)
`
`Foregut
`Bronchus
`Mediastinum
`Stomach
`Midgut
`Jejunumandileum
`Appendix
`Cecum
`Hindgut
`Rectum
`Total
`
`22
`1
`5
`
`20
`30
`2
`
`7
`87
`
`PCNA:proliferatingcellnuclearantigen.
`a P(cid:129)0.032.
`b P(cid:129)0.043vs.rectalcarcinoidtumors.
`c P(cid:129)0.024.
`d P(cid:129)0.046vs.lungcarcinoidtumors.
`e P(cid:129)0.046vs.jejunumandileumcarcinoidtumors.
`
`bcl-2andc-mycimmunoreactivities,inPNTsand
`
`2,c-
`
`Ofthe29PNTsstudied,13tumors,whichdis-
`
`jun,andtheclinicopathologicfeaturesofPNT
`patients.Thepresenceoftheseoncoproteinimmuno-bronchialcarcinoidtumors.
`reactivitiesdidnothaveanyindependentinfluence
`mycim-
`onthelengthofsurvivalofthesepatients.Althoughplayedbcl-2immunoreactivity,alsoshowedc-
`therewas atendencyofgastrinoma,glucagonoma,VI-
`munoreactivity(Table1).Of10bcl-2positivecarcinoid
`myc.All
`Poma,andnonfunctioningPNTstoshow ahigherinci-tumorsofthelung, 9werealsopositiveforc-
`denceofpositivitythanthatofinsulinoma,thediffer-
`14bcl-2positiveGIcarcinoidtumorsalsodemon-
`myc,
`enceswerenotproventobestatisticallysignificant.stratedc-mycimmunoreactivity.Inaddition,c-
`However,therewas asignificantdifferenceinon-
`bcl-2,andc-erbB-2immunoreactivitywereallpresent
`coprotienimmunoreactivitiesbetweencarcinoidtu-infourrectalcarcinoidtumors,andamongthesec-
`myc(P(cid:129)
`morsoftheappendixandrectumforc-
`erbB-2( P(cid:129)0.043)
`0.032),bcl-2(P(cid:129)0.043),andc-
`andbetweencarcinoidtumorsoftheappendixand
`bronchusforbcl-2(P(cid:129)0.024)andc-
`jun(P(cid:129)0.046).
`Ahighincidenceofc- myc,bcl-2,andc- erbB-2expres-immunolocalizationpatternsofc-myc,bcl-2,c-erbB-
`
`junimmunoreactivitywasalsofoundintwo.
`
`AssociationwithClinicopathologicFindings
`Nosignificantcorrelationwasobservedbetweenthe
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`(A)c- mycimmunoreactivity in a pancreatic neuroendocrine tumor (PNT) is shown (original magnification 1250). (B) bcl-2 immunoreactivity
`FIGURE1.
`inthesametumorsampleas(A)isshown(originalmagnification1250).(C)c-
`erb B-2 immunoreactivity in a PNT is shown; the arrow indicates
`membranestaining(originalmagnification1250).(D)c-
`junnuclear immunoreactivity in a PNT is shown (original magnification 1250).
`
`sionincarcinoidtumorsfromsitesotherthanthe
`
`didnotreachstatisticalsignificance.Whereasonly7%
`junpositiv-
`itycomparedwith30%ofjejunumandileumcarcinoid
`
`DISCUSSION
`Pancreaticneuroendocrinetumorsareslowlygrowingappendixwasalsoobserved,althoughthedifference
`neoplasmswithmalignantpotential.Approximately
`80–90%ofinsulinomas(whichcomprise70%oftheofappendicealcarcinoidtumorsshowedc-
`functioningendocrinepancreatictumors)arebenign,
`whereasonlyapproximately10–30%ofgastrinomas,tumors,thedifferencewasalsonotproventobestatis-
`3 In
`VIPomas,andnonfunctioningtumorsarebenign.
`thecurrentstudy,c-mycproteinimmunoreactivityElevenof13patientswithmalignantPNTsand
`wasdetectedinalltumorsamples,and amarkedasso-
`ciationwithbcl-2expressionwasobserved.Recently,(including1of5stomach,13of18jejunoileal,and1
`26 demonstratedthatbcl-2prevents
`Iwahashietal.
`apoptosisinducedbycytokinesinpancreaticisletHowever,thepresenceofimmunoreactivitytoanyof
`cells.Despitetheapparentimportanceofc-
`mycinthe
`inductionofcellproliferation,expressionofc- mychastothepresenceofdistantmetastases.
`recentlybeenlinkedtotheinductionofcelldeathin
`differentcells. 27,28 However,apoptoticcelldeathin-immunoreactivityandPNTbehavior.Thirty-nineper-
`centofbenigntumorsshowedimmunoreactivityfor
`ducedbyc-
`mycisinhibitedbybcl-2,whereascellpro-
`liferationenhancedbyderegulatedandoverexpressedPCNA,whereasinmalignantPNTsimmunoreactivity
`P(cid:129)0.018).There
`29,30 Moreover,amarkedsynergy
`c- mycisnotreduced.
`betweenbcl-2andc-mycinc-myc/bcl-2double-wasalso astatisticallysignificantdifferenceintheinci-
`transgenicmiceduringtumorigenesishasbeendem-
`onstrated.31,32 Thepresenceofbothbcl-2andc-myctumorsofthejejunumandileumandthoseofthe
`immunoreactivitiesinPNTswouldindicatethat adis-
`
`ticallysignificant.
`
`15of26patientswithmalignantGIcarcinoidtumors
`
`of3rectalcarcinoidtumors)hadhepaticmetastases.
`
`the5oncogenesexaminedwasnotsignificantlylinked
`
`TherewasabsoluteconcordancebetweenPCNA
`
`toPCNAwaspresentin91%ofcases(
`
`denceofPCNAimmunoreactivitybetweencarcinoid
`appendix(P(cid:129)0.046).
`
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`OncogenesinCarcinoidTumors/Wangetal.
`
`673
`
`(A)c- myc immunoreactivity in a rectal carcinoid tumor is shown (original magnification 1250). (B) c-erb B-2 immunoreactivity in the
`FIGURE2.
`sametumorsampleas(A)isshown(originalmagnification1250).(C)c-
`jun nuclear and cytoplasmic immunoreactivity in an ileal carcinoid tumor is
`juncytoplasmic immunoreactivity in an appendiceal carcinoid tumor is shown (original magnification 1250).
`shown(originalmagnification1250).(D)c-
`
`FIGURE3.
`(A)Proliferatingcellnuclearantigen(PCNA)immunoreactivityin amalignantpancreaticneuroendocrinetumorisshown(originalmagnifica-
`tion1250).(B)PCNAimmunoreactivityin anormalpancreasisshown(originalmagnification1250).
`
`turbanceoftheapoptoticpathwaymaycontributeto
`
`ingtheapoptoticeffectsofderegulatedc-mycexpres-
`
`ouscellgrowth,providesamechanisticbasisforthe
`
`oncogenicsynergybetweenthesetwooncogenesin
`PNTs.thegenerationofthesetumors,andbcl-2,bymitigat-
`Thecurrentstudyhasdemonstratedanincidence
`ofc-erbB-2immunoreactivityin29%ofPNTs,whichissionwithoutaffectingitsabilitytopromotecontinu-
`similartothatdemonstratedinimmunohistochemical
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`674
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`CANCERAugust15,1997 /Volume80 /Number4
`
`11 andchronicpan-
`studiesforpancreaticcarcinoma
`11 andisinkeepingwithapreviousreporton
`insulinomas,8 therebysuggestingthatthisoncogene
`
`andotherpancreaticdiseases.Inthenormalpancreas,
`erbB-3proteinwasfoundtobe
`restrictedtothecellsofisletofLangerhans;inPNTs,
`
`c-erbB-3.Theseobservationswereinkeepingwitha
`14 inwhich90%of
`pancreaticcarcinomasand100%ofcasesofpancreati-
`
`notclearwhythisgeneisdown-regulatedinPNTs,and
`
`c-erbB-3isderegulatedinpancreatitis,pancreaticcar-
`
`Insulinomastendedtoshowalowerincidenceof
`junthanothertypesofPNTs.
`Itmaybethattheexpressionofthisoncogeneisgener-
`
`ratherthenaconsequence,ofincreasedcellularprolif-
`
`tionbetweentheexpressionoftheproliferationindi-
`juninasubsetofnormalpancreata
`
`andPNTs.
`
`tumorthatareclearlyseparatefromothertumorsof
`
`withsluggishbiologicaggressiveness.Ithasbeen
`
`capableofinvadingadjacentorgansandmetastasizing
`
`isoftenunpredictable.Itisknown,forinstance,that
`
`metastaticpotential. 33,34 Thereasonsforthesediffer-
`encesarenotfullyunderstood.
`Inthisstudy,wepresenttheinitialreportofonco-
`geneexpressionin alargeseriesofarchivalparaffin
`embeddedcarcinoidtumors.Ofthefiveoncogenes
`examined,fourwerefoundtobefrequentlyexpressed
`incarcinoidtumors.However,theincidencesoftheir
`immunoreactivitieswerequitedifferentincarcinoid
`tumorsfromdifferentsites.Appendicealcarcinoidtu-
`morsdisplayed alowincidenceofimmunoreactivity
`forc-myc,bcl-2,andc-erbB-2comparedwithcarci-
`noidtumorsfromothersites,andthesedifferences
`betweenappendicealtumorsandrectalandbronchial
`tumorshavebeenproventobestatisticallysignificant.
`Althoughthedifferenceisnotstatisticallysignificant
`forc-jun,thetrendisnotable.Becauseitiswellknown
`thatcarcinoidtumorsoftheappendixaremuchless
`malignantthanthoseoftheileumorrectum,with
`metastasesinlessthan2%ofcasesand a5-yearsur-
`34 itmaybethattheexpressionof
`vivalrateof99%,
`
`theseoncogenesplaysapartintheneoplasticprocess
`ofcarcinoidtumors.creatitis
`Ithasbeensuggestedthatassessmentofthepro-
`portionofPCNApositivecellsmaybeusefulinthemaybeexpressedinasimilarfashioninbothPNTs
`studyofcertaintumorsasanindependentprognostic
`variableandthattheprofilemightreflectthemeta-theexpressionofthec-
`35,36 Thecurrentstudy
`staticbehaviorofthesetumors.
`hasdemonstratedthatthereisstatisticaldifferenceinhowever,onlytwocaseswerefoundtobepositivefor
`PCNAimmunoreactivitybetweenbenignandmalig-
`nantPNTs,inkeepingwithapreviousreport.
`ferencealsowasobservedbetweenappendicealand
`jejunumandileumcarcinoidtumors.Thisobservationtisstudieddisplayedc-erbB-3immunoreacitivity.Itis
`wouldsuggestthatPC10mightbeusefulinpredicting
`malignancyinGPNTs.themolecularmechanismbywhichtheexpressionof
`Carcinogenesisis amultistepprocessthatis
`largelygeneticallydetermined.Previously,wehavecinoma,andPNTsisnotyetknown.
`demonstratedthat,unlikeinmanymorecommontu-
`mortypes,tumorsuppressorgenep53mutationmayimmunoreactivityforc-
`berelativelyunimportantinthegenesisofneuroendo-
`crinetumors. 38 Inthisstudy,weshowthattheonco-allyinvolvedintheneoplasticprocessandisacause,
`genesc-
`myc,bcl-2,c-erbB-2,andc-
`junmayplaya
`roleinthepathogenesisofGPNTs.Obviously,othereration;wesuggestthisbecausewefoundnoassocia-
`oncogenes,andespeciallytumorsuppressorgenes,
`maybeinvolvedinthetumorigenesisoftheGPNT,cator,PCNA,andc-
`becausetumorsuppressorgeneshavealreadybeen
`demonstratedtoplay aprimaryroleinthemultistepGIcarcinoidtumorscomposeadistinctivetypeof
`tumorigenesisofmanytumors.
`Inconclusion,theoncogenesc-myc,bcl-2,c-erbthegut.Theyaregenerallyslow-growingneoplasms
`junarefrequentlyexpressedinGPNTs.The
`B-2,andc-
`expressionoftheseoncogenesmayrepresentpatho-noted,however,thatsomecarcinoidtumorsarequite
`geniceventsinthegeneration,malignanttransforma-
`tion,andprogressionofGPNTs.Theimmunohisto-todistantsites,andthatthebehaviorofthesetumors
`chemicalevaluationofcellkineticsinGPNTsbyPCNA
`mightbe ausefuladjuncttoconventionaldiagnosticvarioussubsetsofGIcarcinoidtumorshavedifferent
`procedures.
`
`37 Adif-previousstudybyLemoineetal.,
`
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