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Table 2 lists the number of adenocarcinomas according to the intensity of the EGFR reactivity and the percentage of reactive cells. EGFR reactivity was not uniform throughout the cases of colon adenocarcinoma Table 4. In general, a greater percentage of neoplastic cells stained with a greater intensity in the deepest region of the adenocarcinoma beyond the muscularis propria compared with adenocarcinoma occurring in the mucosa and superficial submucosa Figs.

A Superficial, luminal region of adenocarcinoma. B Deep region of adenocarcinoma, beyond the muscularis propria. A Superficial luminal region of adenocarcinoma. B Middle region of the adenocarcinoma, within the muscularis propria, subjacent to the adenocarcinoma shown in Panel A. C Deep region of adenocarcinoma, beyond the muscularis propria, subjacent to the adenocarcinoma shown in Panel B.

However, there were marked differences within the subsets of neoplasms. There were no statistically significant associations between the mean percentage of EGFR reactive cells per case in the overall tumor and morphologic features of the adenocarcinomas and patient age. One was small solid clusters or buds that emerged from the base or lateral edge of malignant glands and that frequently were angulated, producing a structure shaped similar to a hockey stick.

The second was undifferentiated cells, which were comprised of discontinuous, isolated single or small clusters of malignant cells in the stroma. Although some cells had less EGFR reactivity along one portion of the cell membrane, no preferential reactivity of intraluminal or basolateral regions of neoplastic cells was observed. Heterogenous epidermal growth factor receptor EGFR reactivity. EGFR reactivity was similar in lymph node and liver metastases and the primary adenocarcinoma.

The 47 cases of liver metastases demonstrated a similar significant correlation between the EGFR reactivity in the metastases and the tumor Tables 4 and 5. The benign hepatic parenchyma adjacent to the metastases had strong membranous reactivity in 16 of 38 cases in which there was adequate tissue. EGFR reactivity in benign hepatocytes appeared to have no relation with the presence and intensity of EGFR reactivity in the adjacent metastasis. Four separate multivariate analyses modelling for decreased length of survival were performed, with a different EGFR parameter substituted each time Table 7.

Factors included in the analyses were patient age at the time of surgery, tumor location, tumor grade, lymph node status, number of PTDs, extramural vascular invasion, and perineural invasion. Quantitative immunohistochemical detection systems that evaluate a cellular constituent that is linked directly to a corresponding anticonstituent monoclonal therapy are a recent development in diagnostic surgical pathology.

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Many issues surrounding the accuracy, utility, and grading scheme of this system have engendered debate. Chimeric monoclonal antibody therapy against EGFR is an investigational chemotherapeutic agent for patients with metastatic colorectal adenocarcinoma. Although the final cutpoints will be based on patient response to EGFR monoclonal therapy, many background issues gleaned from past experience with a similar detection system require further study, the findings of which undoubtedly will impact the final grading system.

We found that Strongly reactive cells were present in much fewer neoplasms; A comparison of the prevalence of EGFR reactivity in colon adenocarcinoma in the current study and other studies is hampered by differences in EGFR detection techniques, fixation methods of tested tissue, and EGFR antibody.

In the current study, no difference was found in EGFR reactivity between adenocarcinomas arising in different regions of the colon, a discovery that was similar to that of a previous study, 26 but which differed from the findings of another study in which sigmoid adenocarcinomas were found to express EGFR more often compared with rectal adenocarcinomas. EGFR expression within colon adenocarcinomas is not uniform.

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There may be marked regional differences. It was our impression that EGFR expression was not arbitrary or random. We examined EGFR reactivity within three regions of invasive colon carcinoma: the luminal, middle, and deep beyond the muscularis propria regions. The results of the current study suggest that the optimal EGFR scoring system may be restricted to the evaluation of reactivity in adenocarcinomas located in the deepest regions of invasion, rather than as an overall tumor score.

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This also may facilitate interobserver variation by reducing the area of tumor in which reactivity is evaluated. The current study found no statistical association between tumor grade and EGFR reactivity. To our knowledge, the majority of studies published to date also have reported no association; 25 , 32 , 37 - 39 , 41 , 43 only one group of authors to date have reported an association between increased EGFR reactivity and tumor grade. Although the lack of a significant association between tumor grade and EGFR reactivity reported in the current study is similar to the findings of most previously published reports, it is our opinion that we and other authors arrived at this conclusion using two divergent approaches to tumor grading.

The authors of other studies reported that the majority of adenocarcinomas studied, including those associated with liver metastases, were moderately differentiated. To our knowledge, none of the studies listed the morphologic criteria or provided references regarding which tumor grade was assigned. Statistical bias, caused by too small of a study group, is the probable reason for why we were unable to find any association between tumor grade and EGFR reactivity.

A larger study that includes sufficient numbers of patients with moderately and well differentiated adenocarcinomas is needed to address this question appropriately. The morphology of poorly differentiated adenocarcinoma demonstrates tumor buds and undifferentiated single cells and small groups of neoplastic cells. These morphologic patterns have been reported to be associated strongly with lymph node metastases in T1 adenocarcinomas, 18 and in general are an unfavorable morphologic pattern. This observation may explain in part the link between tumor budding and undifferentiated single cell morphologies and a more aggressive clinical course.

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There is a growing body of evidence from cell line cultures and comparisons of cell cultures derived from primary colon and liver metastases that increased EGFR immunohistochemical reactivity and EGFR mRNA transcripts are related directly to the metastatic potential of colorectal adenocarcinoma. The cells in this region are the result of increasing replications and progressive growth. The underlying causes of increased EGFR expression in some neoplasms is unclear. A fluorescent in situ hybridization study, using probes against the EGFR gene region of chromosome 7, demonstrated that EGFR gene overexpression was present in colon adenocarcinoma cell cultures with a high propensity to produce metastases compared with cell lines with less propensity to produce metastases.

The authors concluded that EGFR mRNA in the former group of cell cultures might be in part due to an increase in the copy number of chromosome 7.

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The results of the current study provide additional evidence that the optimal EGFR grading system may restrict the evaluation of EGFR staining to the neoplastic cells in the deepest, most invasive tumor regions, specifically those in which there are numerous tumor buds and undifferentiated cells in the stroma.

The authors of one study observed a redistribution of EGFR from the basolateral to apical regions of cultured colon adenocarcinoma cells. We examined EGFR reactivity in the primary neoplasm and metastases to establish whether there were differences between the sites that potentially could affect an EGFR scoring system. Genomic alterations in metastases can differ from those found in the primary neoplasm, and it was possible that metastatic adenocarcinoma would have increased EGFR expression compared with the primary neoplasm.

No case had an EGFR reactive metastasis and nonreactive primary colon adenocarcinoma. We believe these results support the findings of a study in which cell lines from liver metastases had more EGFR immunohistochemical reactivity than cell lines from the primary colon tumor.

An increasing percentage of EGFR reactive cells was found to be correlated with decreased length of survival. The strength of this correlation varied depending on the intensity and location of the neoplastic cells. This relation was present when the overall tumor and deep region scores were used.

Overall tumor EGFR reactivity failed to demonstrate an independent association. These results provide additional evidence that the deepest, most invasive adenocarcinoma may be the optimal region that reflects the most aggressive growth and metastatic growth potential of the adenocarcinoma. The results of the current study are loosely similar to studies that also found that EGFR was a negative prognostic marker. Depending on the patient group examined and the factor used as the prognostication endpoint marker, EGFR has been associated with decreased prognosis, 2 decreased length of survival, 40 increasing Dukes stage, or mesenteric lymph node metastases.

Nearly as many studies have reported no association between length of survival 61 and Dukes stage. All sections of normal colonic mucosa had cytoplasmic reactivity of the surface epithelial cell layer. Previous studies also have reported EGFR expression by colonocytes in nearly all cases studied. EGFR immunoreactivity in the deepest region of the neoplasms, rather than overall tumor reactivity, was found to have the strongest correlation with EGFR expression in lymph node and liver metastases, and was found to be associated independently with length of survival.

A definitive EGFR scoring system, and the determination of cutpoints for a positive result, will be based on the results of the clinical response of patients with colon adenocarcinoma to EGFR monoclonal chemotherapy. We have no doubt there will be some latitude regarding how and where EGFR reactivity should be evaluated within the context of this clinical response umbrella. Da Jakob. Te lucis ante terminum. A Pelayo que desmayo. Te Deum in G Tom Jolly's nose. Surge, propera amica mea Vidi speciosam.

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Cappellari, A: Sciur Padrun da li beli braghi bianchi. Cappellari, A: Shalom! Cappellari, A: Shi su kana. Cappellari, A: Sirtos. Caraba, P: Predominante.