Cancer Management and Research

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Clinicopathologic Factors Associated with

Mismatch Repair Status Among Filipino Patients
with Young-Onset Colorectal Cancer

Dennis Lee Sacdalan, Reynaldo L Garcia, Michele H Diwa & Danielle Benedict
Sacdalan

To cite this article: Dennis Lee Sacdalan, Reynaldo L Garcia, Michele H Diwa & Danielle
Benedict Sacdalan (2021) Clinicopathologic Factors Associated with Mismatch Repair Status
Among Filipino Patients with Young-Onset Colorectal Cancer, Cancer Management and
Research, , 2105-2115, DOI: 10.2147/CMAR.S286618

To link to this article: https://doi.org/10.2147/CMAR.S286618

© 2021 Sacdalan et al.

Published online: 01 Mar 2021.

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ORIGINAL RESEARCH

Clinicopathologic Factors Associated with

Mismatch Repair Status Among Filipino Patients
with Young-Onset Colorectal Cancer
This article was published in the following Dove Press journal:
Cancer Management and Research

Dennis Lee Sacdalan 1–3 Introduction: Young-onset colorectal cancer is recognized as a distinct disease that may be
Reynaldo L Garcia 2 sporadic or hereditary in nature. Microsatellite instability testing is recommended as a
Michele H Diwa 4 routine procedure in evaluating colorectal cancer specimens, especially in young-onset
Danielle Benedict Sacdalan 1,5 disease, because of implications in management. Immunohistochemistry of mismatch repair
proteins serves as an inexpensive alternative to microsatellite instability testing with the
1
Division of Medical Oncology,
added advantage of monitoring protein expression levels that may suggest underlying genetic
Department of Medicine, University of
the Philippines, Manila, Philippines; or epigenetic alterations. This descriptive study aimed to determine the frequencies of
2
National Institute of Molecular Biology proficient and deficient mismatch repair status among Filipino young-onset colorectal cancer
and Biotechnology, University of the
Philippines, Diliman, Quezon City, patients, and to investigate their clinicopathologic profile.
Philippines; 3Augusto P. Sarmiento Methods: Tumor tissues were prospectively collected from patients from two tertiary
Cancer Institute, The Medical City, Pasig hospitals in the Philippines. Patients of age ≤45 years with resected adenocarcinoma of the
City, Philippines; 4Department of
Pathology, University of the Philippines, colon or rectum were recruited.
Manila, Philippines; 5Department of Results: Seventy-seven out of 124 patients had tumor samples sent for immunohistochemistry.
Pharmacology and Toxicology, University
Of these, 61 samples (79%) were found to have proficient status while 16 samples (21%) had
of the Philippines, Manila, Philippines
deficient status. Mismatch repair protein deficiencies, when present, more commonly involved
MSH2 and MSH6 (9%) rather than MLH1 and PMS2 (5%). The deficient group had a mean age
of 37.1 years and a female preponderance (56.25%), presenting as locally advanced ascending or
descending colon tumors with mucinous histology in half of the population. The mismatch repair
proficient group presented as locally advanced rectal and sigmoid tumors but with fewer
mucinous adenocarcinomas (26.2%) compared to the deficient group. In both the mismatch
repair proficient and deficient patients with family history reports, most did not have any known
relative with cancer (75.4% and 68.75%, respectively).
Conclusion: This is the first attempt to perform mismatch repair testing among young-onset
colorectal cancer patients in the Philippines and to gather data on their clinicopathologic
characteristics. However, the limited sample size precludes conclusive results for the asso­
ciations of mismatch repair with clinicopathologic features.
Keywords: biomarkers, early-onset colorectal cancer, immunohistochemistry, microsatellite
instability

Introduction
Correspondence: Dennis Lee Sacdalan Colorectal cancer (CRC) ranks third among all incident cancers.1 In the Philippines, the
Division of Medical Oncology, Department number of new CRC cases has escalated from 5787 in 2010 to 9625 in 2015.2,3 Among
of Medicine, University of the Philippines-
Philippine General Hospital, Taft Avenue, individuals <40 years of age, new cases of CRC comprise 17–24%.4,5 The increasing
Manila, 1000, Philippines incidence of this disease among young Filipinos mirrors recent findings reported in the
Tel/Fax +63 285263775
Email [email protected] United States.6

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CRC can develop through various mechanisms such as The dMMR/MSI-H status of CRC tumors has prognos­
microsatellite instability (MSI), chromosomal instability, tic significance in several clinical scenarios. Young-onset
and aberrant methylation of CpG islands (CIMP) in the CRC that is MSI-H is associated with more aggressive
promoter regions of tumor suppressor genes. Notably, features such as mucinous and signet ring histology.20 In
overlap between these mechanisms may also occur.7–10 stage II disease, MSI-H tumors have excellent prognosis
The development of CRC in the young may be asso­ and do not benefit from adjuvant chemotherapy with 5-
ciated with hereditary conditions. Hereditary non-polypo­ fluorouracil.10 In contrast, MSI-H tumors in stage IV dis­
sis colorectal cancer (HNPCC) is the most common ease carry a poor prognosis but may show remarkable and
inherited cause of susceptibility to CRC. HNPCC is asso­ durable responses to immune checkpoint inhibitors likely
ciated with germline mutations in DNA mismatch repair due to the rich immune response present within these
(MMR) genes, namely: MLH1, MSH2, MSH6, PMS2 and tumors.21,22 These observations highlight the importance
EPCAM. MMR-deficient (dMMR) tumors display high of the early detection of dMMR/MSI-H CRCs.
levels of microsatellite instability (MSI-H) in more than Notably, 16% of young-onset CRC cases carry germ­
97% of the time.11–13 line cancer susceptibility genes, thus the remaining popu­
Microsatellites are segments of DNA that contain tandem lation may be sporadic cases. The question then is whether
repeats, one to six bases long, that occur within the genome. young-onset CRC is an inherited or a sporadic disease.
Their numbers are ideally conserved within every human This issue is complicated by still poorly understood envir­
cell. Replication errors and defective mismatch repair result onmental risk exposures and by unidentified susceptibility
in MSI. For MSI to become detectable by conventional genes or epigenetic mechanisms.23 Regardless of the
techniques, a significant number of cells, as in tumors, need underlying mechanism involved, it is vital to determine if
to carry these abnormal microsatellites. Importantly, both a young-onset CRC tumor carries a dMMR/MSI-H phe­
hereditary and sporadic CRC can display MSI.12 notype because of the possible implications on
An alternative to PCR-based testing is immunohisto­ management.
chemistry (IHC). The four-antibody panel involving Due to the absence of local data, this study aims to
MLH1, MSH2, MSH6 and PMS2 is used to determine determine the frequency of dMMR and MMR-proficient
MMR protein expression. Loss of at least one of these (pMMR) tumors among the recruited Filipino patients
proteins, as demonstrated by lack of nuclear staining, with young-onset CRC from two tertiary hospitals based
indicates dMMR/MSI-H status.9 on IHC. This technique is more advantageous compared to
In the repair of DNA mismatches, MSH2 binds to MSH6 to PCR-testing because of several reasons. First, IHC costs
form the heterodimer MutSα, which is responsible for mis­ comparatively less than MSI testing. Second, it is more
match recognition and initiation of repair.14 After binding to convenient since it necessitates resources that are already
available in most pathology laboratories. Third, IHC can
DNA carrying a base mismatch, MutSα recruits the heterodi­
pinpoint MMR genes likely to be mutated.12
mer MutLα composed of MLH1 and PMS2 in order to carry
A second objective of the study is to compare the
out the repair. Both MSH2 and MLH1 are obligatory partners
clinicopathologic profiles of dMMR and pMMR tumors
that stabilize MSH6 and PMS2, respectively, from proteolytic
from young CRC patients. This can provide a better under­
degradation.15 Hence, in dMMR/MSI-H status, loss of MSH2
standing of the nature of young-onset CRC among
is expected to be accompanied by loss of MSH6 while loss of
Filipinos.
MLH1 comes with loss of PMS2. However, deficiency in
MSH6 or PMS2 may occur even if MSH2 or MLH1 is intact
due to compensatory binding of other MMR proteins to MSH2 Methods
or MLH1. Study Design and Patient Recruitment
Pathologic findings that are predictive of MSI-H include: This study was performed on patients who were diagnosed
increased numbers of tumor infiltrating lymphocytes, lack of with adenocarcinoma of the colon or rectum at age ≤45 at
dirty necrosis and note of a Crohn’s-like lymphoid reaction in the Philippine General Hospital (PGH) and The Medical
the tumor tissue, any mucinous differentiation of the tumor, City. Patients were enrolled regardless of stage of disease
and age <50 at onset.16,17 There is controversy regarding the for as long as they were able to provide formalin-fixed,
“sidedness” of these tumors.17–19 paraffin-embedded (FFPE) specimens adequate for IHC.

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Dovepress Sacdalan et al

Excluded were patients diagnosed with polyposis and regression was done to generate adjusted odds ratios. All
inflammatory bowel disease due to alternative mechanisms estimates were done at 95% confidence level.
involved in the pathogenesis of CRC.

Ethical Considerations
Specimen Collection and Preparation for The study was conducted in accordance with the Declaration
IHC of Helsinki. The protocol was approved by the University of
Specimens were obtained from surgically resected primary the Philippines Manila Research Ethics Board and The
or metastatic tumors. Standard procedures for FFPE speci­ Medical City Institutional Review Board. All subjects gave
men preparation were done in the Surgical Pathology their informed consent for inclusion before they participated
laboratory in PGH. Histological confirmation of the diag­ in the study. Specifically, consent to retrieve tumor tissue
nosis of adenocarcinoma was performed by a pathologist specimens, extract demographical and clinicopathologic
on the hematoxylin-eosin stained sections. From the par­ data, and follow-up survival status was obtained.
affin block, 3μm-thick slices of tissue were cut and
mounted on Dako silanized slides for IHC. The tissue
was then incubated in a 60°C oven for one hour. Target
Results
A total of 124 patients aged 22 to 45 years old were recruited
retrieval solution (pH 9.0) was then added at 97°C for
between May 2016 and August 2019. From these patients, 98
fifteen minutes and then rinsed with wash buffer for five
were able to turn over one FFPE sample each. Twenty-six
minutes.
patients with unretrieved samples were mainly those who
underwent surgery in hospitals other than PGH or TMC, and
Immunohistochemical Staining for MMR those whose surgeries were deferred in favor of systemic
Proteins chemotherapy due to disease progression. Out of the 98
Staining was performed on the four MMR proteins: MLH1, tissue blocks retrieved, IHC for MMR protein expression
MSH2, MSH6 and PMS2. The IHC process was performed was performed in 77 samples. IHC was not performed on
using the Dako Autostainer Link 48 and was carried out 47 samples for various reasons concerning quality and quan­
according to the manufacturer’s guidelines. After staining, tity. Two were found to be second primary tumors and were
the slides were viewed under light microscopy. Brownish thus excluded from the study. Complete pathologic response
nuclear staining of weak to strong intensity in any number was noted in 7 resected specimens subjected to neoadjuvant
of tumor cells was considered a positive result.
chemoradiation. Twelve samples were deemed inadequate
for IHC (Figure 1).
Validation Studies for IHC
Prior to IHC staining of the subject specimens, validation
studies were made to ensure the assay would perform as
intended. Selected archival specimens of five known cases
of sporadic colorectal adenocarcinoma were processed for
IHC. Positive controls were derived from the validation
slides and used for comparison with subject specimens.
These positive controls demonstrated strong brown nuclear
staining for all four antibodies against MMR proteins.

Statistical Analysis
Absolute and relative frequencies of dMMR and pMMR
tumors were presented. Crude odds ratios were estimated
to determine association between MMR status and clini­
copathologic features including age, sex, number of rela­
Figure 1 Flowchart of patient recruitment and tissue sample retrieval.
tives with cancer, disease stage, location of primary tumor, Abbreviations: FFPE, formalin-fixed paraffin-embedded; IHC, immunohistochem­
tumor grade, and histologic variants. Multiple logistic istry; CRC, colorectal cancer; pCR, pathologic complete response.

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Clinicopathologic Profile of Young-Onset Table 1 Demographic and Clinicopathologic Data of Patients

with Young-Onset Colorectal Cancer
CRC
Number Percentage
There were slightly more males than females (52.4% vs
(n=124)
47.6%, respectively). The mean age was 37.1 years; the
youngest was 22 years old while the oldest was 45 years Age
0–29 21 16.9
old. More patients (46.8%) presented with locally
30–39 45 36.3
advanced disease (stage III). Seventy six percent of
40–45 58 46.8
patients had left-sided tumors (descending colon, sigmoid
colon and rectum), most of which were in the rectum Sex
Female 59 47.6
(45.2%). There was one patient who presented with two
Male 65 52.4
primary tumors that were synchronously identified in the
ascending colon and in the rectum. A large proportion of Number of family members with
cancer
histopathologic reports (36.3%) did not specify the degree
>2 9 7.3
of differentiation of their respective tumors. Among those 1–2 24 19.4
whose histologic grades were specified, 37.9% of tumors 0 89 71.8
were well differentiated while only 6.5% were poorly Not reported 2 1.6
differentiated. Histologic variants associated with aggres­
Clinical stage
sive features were noted in 39 samples, mostly of the I 3 2.4
mucinous type (Table 1). II 20 16.1
III 58 46.8
IV 41 33.1
Determination of Mismatch Repair Status Unknown 2 1.6
Tumors proficient in MMR proteins were identified by
diffuse brownish nuclear staining with all the four anti­ Tumor location
Ascending colon 24 19.4
bodies against MLH1, MSH2, MSH6 and PMS2 observed
Transverse colon 2 1.6
under light microscopy (Figure 2). The complete absence Descending colon 11 8.9
of nuclear staining with at least one of the four MMR Sigmoid colon 27 21.8
proteins demonstrated dMMR status (Figures 3 and 4). Rectum 56 45.2
Of the 77 tissues that underwent IHC staining, 61 Multiple sites* 1 0.8
samples (79%) had pMMR status while 16 samples Unknown 3 2.4

(21%) were found to have dMMR status. Among the 16 Degree of differentiation
dMMR tumors identified by IHC, seven were due to Well-differentiated 47 37.9
deficiency in both MSH2 and MSH6 while four were Moderately differentiated 24 19.4
Poorly differentiated 8 6.5
due to deficiency in both MLH1 and PMS2. Three tissue
Not specified 45 36.3
samples demonstrated the loss of PMS2 only. There were
2 unexpected cases of isolated loss of MSH2 with intact Histologic variants
Mucinous 31 25.0
MSH6 (Figure 5). A summary of the frequencies of these
Signet ring 7 5.6
staining patterns is illustrated in Figure 6.
Neuroendocrine 1 0.8
Not specified 85 68.5
Features of pMMR and dMMR Tumors in Note: *One patient had two synchronous primary tumors (ascending colon and
rectum).
Young CRC Patients
Clinicopathologic features of the tumors with pMMR and
dMMR tumors were compared (Table 2). The dMMR 43.75%). There were more patients with stage III disease
group had a mean age of 37.1 years, while the pMMR in both pMMR and dMMR groups (47.5% and 43.75%,
group had a mean age of 37.8 years. Sex distribution was respectively) compared to other stages. Deficient MMR
relatively equal among males and females in the pMMR tumors were most frequently located in the ascending
group (49.2% vs 50.8%), but there were almost 1.3 times colon, comprising 40% of cases. However, collectively,
more females than males in the dMMR group (56.25% vs there were still more left-sided tumors compared to right-

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Figure 2 IHC of pMMR tumor showing cells that form glandular structures with positive nuclear staining for antibodies against MLH1, MSH2, MSH6, and PMS2 (400X
magnification).

Figure 3 IHC of dMMR tumor deficient in MLH1 and PMS2. Photomicrographs show non-reactivity to MLH1 and PMS2 antibodies, faint nuclear staining with MSH2
antibodies, and intense staining with MSH6 antibodies (100X magnification).

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Figure 4 IHC of dMMR tumor deficient in MSH2 and MSH6. Photomicrographs show nuclear staining with MLH1 and PMS2 antibodies, and non-reactivity to MSH2 and
MSH6 antibodies (100X magnification).

Figure 5 IHC of dMMR tumor deficient in MSH2 only. Photomicrographs demonstrate strong nuclear staining with MLH1 and PMS2, and weak staining with MSH6 in a few
tumor cells in the absence of MSH2 staining (100X magnification).

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Figure 6 Mismatch repair status of colorectal tumors and types of mismatch repair deficiencies based on IHC.
Abbreviations: pMMR, proficient mismatch repair; dMMR, deficient mismatch repair; IHC, immunohistochemistry.

sided ones (9 vs 6) within the dMMR group. Of note, the diagnosed ≤40 years old. Of these, 32 had colon cancer
only patient with two synchronous primary tumors had while 41 had rectal cancer. Most patients had poorly
dMMR status. differentiated tumors. Clinical stage II and III disease
There were only 3 poorly differentiated tumors seen in were equally most prevalent in this population.5 Another
the pMMR group while only one was seen among dMMR study by Uy et al reported a mean age of 30.7 years for
tumors. Well-differentiated tumors were more common in their retrospective cohort of thirty-five patients. Most of
the pMMR and dMMR groups (44.3% and 40.0%, respec­ these patients presented with mucinous histology. Locally
tively). Although patients from the 2 groups both pre­ advanced disease was seen in 74.3% of this population.
sented with aggressive histologic variants, there was a This study performed IHC staining to determine MMR
greater proportion of these variants in the dMMR group, status based only on MLH1 and MSH2 expression and
led by tumors with mucinous features (50.0%). found that 22.9% of young CRC cases were dMMR.24 A
With respect to family history, most patients from more recent unpublished study by Resoco et al done at the
pMMR and dMMR groups denied having relatives with PGH reviewed the records of 270 patients with CRC
cancer (75.41% and 68.75%, respectively). Logistic diagnosed ≤40 years. The mean age of patients was 35.4
regression analysis of the clinicopathologic features years with slightly more females than males diagnosed.
showed that older age (≥30 years), male sex, and having The rectum was the more common primary site in 56% of
metastatic disease decreased the chances of having a the patients studied. Left-sided tumors were seen in 79%
dMMR tumor. On the other hand, having more relatives of patients. Adenocarcinoma was reported to be the diag­
with cancer, presence of right-sided tumors (ascending and nosis in 211 cases and regardless of histology, 185 tumors
transverse colon), and having aggressive histologic fea­ were well differentiated. Eighty-five percent of patients
tures increased the risk of a dMMR tumor. However, presented with more advanced disease.
none of these associations were statistically significant These findings were consistent with our results con­
due to the limited samples (Table 3). cerning age and site of primary tumor (left-predominant).
It must be mentioned that there were fewer stage IV cases
Discussion in our study because most patients who presented with
Several single-center Philippine studies have attempted to metastatic disease no longer underwent curative surgical
profile young CRC patients. A study by Chang et al resection precluding retrieval of adequate tissue for
reviewed a retrospective cohort of 73 patients with CRC testing.

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Table 2 Clinicopathologic Features of Young-Onset CRC Patients with pMMR and dMMR Status
Number of Patients with pMMR Status Number of Patients with dMMR Status
(%) (%)
n = 61 n = 16

Age
0–29 7 (11.48) 3 (18.75)
30–39 23 (37.70) 6 (37.50)
40–49 31 (50.82) 7 (43.75)

Sex
Female 31 (50.82) 9 (56.25)
Male 30 (49.18) 7 (43.75)

Number of family members with cancer

>2 3 (4.92) 2 (12.50)
1–2 12 (19.67) 3 (18.75)
0 46 (75.41) 11 (68.75)

Clinical stage
I 1 (1.64) 2 (12.50)
II 10 (16.39) 5 (31.25)
III 29 (47.54) 7 (43.75)
IV 20 (32.79) 1 (6.25)
Unknown 1 (1.64) 1 (6.25)

Location of primary tumor

Right-sided
Ascending colon 8 (13.11) 6 (37.50)
Transverse colon 1 (1.64) 1 (6.25)
Left-sided
Descending colon 3 (4.92) 5 (31.25)
Sigmoid 22 (36.07) 1 (6.25)
Rectum 26 (42.62) 2 (12.50)
Multiple sites* 0 (0.00) 1 (6.25)
Unknown 1 (1.64) 0 (0.00)

Degree of differentiation (histologic

grade)
Well differentiated 27 (44.26) 6 (37.50)
Moderately differentiated 13 (21.31) 3 (18.75)
Poorly differentiated 3 (4.92) 1 (6.25)
Not specified 18 (29.51) 6 (37.50)

Histologic variants
Mucinous 16 (26.23) 8 (50.00)
Signet ring 4 (6.56) 0 (0.00)
Neuroendocrine 0 (0.00) 1 (6.25)
Not specified 41 (67.21) 7 (43.75)
Note: *One patient had 2 synchronous primary tumors (ascending colon and rectum).

Data from our study contrasts with results from the frequently diagnosed than rectal cancer. Compared to
US Nurse’s Health Study (NHS) II that prospectively our study, this large cohort included only women.6 Our
evaluated 89,278 individuals and identified 118 cases of results resonate with those of NHS II and other US data
young-onset CRC. The median age at diagnosis was 45 that describe more advanced disease being found at
years (interquartile range: 41–47), which was older than diagnosis among young CRC patients regardless of
that observed in our study. Here, colon cancer was more MMR status.25

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Table 3 Crude Odds Ratios and Adjusted Odds Ratios for Clinicopathologic Features in Relation to dMMR Status of Young
Colorectal Cancer Patients
Clinicopathologic Features Crude OR 95% CI Adjusted OR 95% CI

Age
0–29* – –
30–39 0.51 0.10–2.67 0.33 0.05–2.19
40–49 0.47 0.09–2.34 0.30 0.05–1.91

Sex
Female* –
Male 0.59 0.18–1.98 0.48 0.10–2.39

Number of family members with cancer

>2 1.50 0.14–15.96 2.08 0.14–29.88
1–2 1.12 0.27–4.74 0.88 0.12–6.46
0*

Clinical Stage
Non-metastatic (stages I–III)* -
Metastatic (stage IV) 0.17 0.02–1.37 0.20 0.02–2.10

Location of primary tumor

Right-sided (ascending and transverse) 3.47 0.71–15.38 2.86 0.60–13.48
Left-sided (descending, sigmoid and rectum)* -

Histologic variants
Non-aggressive* -
Aggressive 4.20 1.23–14.29 2.70 0.62–11.86
Note: *Reference category.

Sargent et al estimated the frequency of dMMR tumors Although pathologists may report histopathologic fea­
to be roughly 17% among patients with stage II/III based on tures that suggest a MSI-H phenotype, these alone are
the multinational ACCENT Group database.26 We report a unreliable in identifying MSI-H tumors.20 Our findings
frequency of dMMR tumors at 21% for stage II/III and 20% show a significantly larger proportion of dMMR ascending
across all stages, but our data is limited to young-onset CRC colon tumors compared to pMMR tumors, which corrobo­
among Filipinos. rates reports that point to right-sided tumors being asso­
Family history clues-in the presence of a hereditary ciated with MSI-H.19 This supports the results of other
condition such as HNPCC; but the inability to elicit a studies on Filipinos.5,24 In contrast, a study by Lee et al
family history of cancer does not rule out HNPCC. For conducted on Asian, mainly Chinese, immigrants to the
example, 68.75% of patients with dMMR tumors report US has shown that among HNPCC patients, left-sided
having no relatives with cancer despite the expected asso­ tumors predominated. These observations warrant further
ciation between dMMR and hereditary cancers. It is worth investigation.
pointing out that our study showed that a stronger family Loss of MLH1 and PMS2 expression is the most com­
history of cancer increases the risk for dMMR status mon dMMR IHC pattern.27 In our study, this was found to
although this finding is not statistically significant. The be less frequent than deficiency in both MSH2 and MSH6
effect of recall and reporting bias cannot be discounted although this may not be significant due to the small
as an explanation for this discrepancy. Taking this obser­ sample size. A similar observation was reported by Jung
vation into account, we believe that it is more reliable to et al, surmising that a lower incidence of the MLH1/
test for MSI or MMR status to identify patients with PMS2-deficient IHC pattern was due to false-positive
hereditary CRC. Unfortunately, despite evidence favoring cases. This was attributed to a non-functional missense
testing for MSI or MMR, it is not routinely performed in mutation in the MLH1 gene that resulted in an antigeni­
the Philippines. cally reactive protein.28

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Another notable finding regarding dMMR IHC patterns the Philippine Council for Health Research and Development
is the presence of isolated MSH2 deficiency in 2 samples. (grant code FP150025). The authors thank Prof. Cynthia P.
This aberrant pattern has also been observed in three Cordero of the Clinical Epidemiology Unit, University of the
reports which offer no clear explanation for this uncom­ Philippines College of Medicine for her contribution in the
mon result.28–30 Because degradation of MSH6 is expected statistical analysis of the study data.
in the absence of MSH2 expression, it is difficult to
account for this phenomenon. One possible cause may be Disclosure
poor tissue preparation or staining technique that could The authors report no conflicts of interest in this work.
have led to non-specific binding of MSH6 antibodies or
to non-binding of MSH2 antibodies to their target protein.
References
Very faint or patchy IHC staining may also lead to sub­
1. Ferlay J, Soerjomataram I, Ervik M, et al., Cancer Incidence and
jective misinterpretation of the results although the sam­ Mortality Worldwide: IARC CancerBase No. 11. International
ples in this study were thoroughly reviewed by our Agency for Research on Cancer; Lyon, France: 2013. Available
pathologist. from: http://globocan.iarc.fr;. Accessed February 18, 2021.
2. Laudico AV, Medina V, Mirasol-Lumague MR, et al. 2010 Philippine
Our study has several limitations. First, this study Cancer Facts and Estimates. Manila: Philippine Cancer Society, Inc;
involves patients from two hospitals within the National 2010.
3. Laudico AV, Mirasol-Lumague MR, Medina V, Mapua CA,
Capital Region, which may inadequately represent the Valenzuela FG, Pukkala E. 2015 Philippine Cancer Facts and
population of young Filipinos with CRC. Second, varia­ Estimates. Manila: Philippine Cancer Society, Inc; 2015.
bility in the reporting of histopathologic findings between 4. Kaw LL, Punzalan CK, Crisostomo AC, Bowyer MW, Wherry DC.
Surgical pathology of colorectal cancer in Filipinos: implications for
samples in the study due to differences in reporting stan­ clinical practice. J Am Coll Surg. 2002;195:188–195. doi:10.1016/
dards between surgical pathology laboratories hampered S1072-7515(02)01186-9
5. Chang RL, Roxas MF, Asprer JM. Colorectal cancer in the young: a
comparison of pMMR and dMMR tumors using histo­ five-year review of cases. Philipp J Surg Spec. 2003;58(1):32–35.
pathologic features such as degree of differentiation of 6. Nguyen LH, Liu PH, Zheng X, et al. Sedentary behaviors, TV view­
tumor cells. Third, the limited number of specimens ing time, and risk of young-onset colorectal cancer. JNCI Cancer
Spectr. 2019;2:pky073. doi:10.1093/jncics/pky073
obtained from patients due to metastatic disease affected 7. Grady WM. CIMP and colon cancer gets more complicated. Gut.
the estimates of the frequencies reported for MMR status. 2007;56(11):1498–1500. doi:10.1136/gut.2007.125732
8. Ogino S, Goel A. Molecular classification and correlates in colorectal
This also explains why it is difficult to make generaliza­ cancer. J Mol Diagn. 2008;10:13–27. doi:10.2353/jmoldx.200
tions about the larger population of CRC patients based on 8.070082
our findings due to non-significant results on statistical 9. Hashmi AA, Ali R, Hussain ZF, et al. Mismatch repair deficiency
screening in colorectal carcinoma by a four-antibody immunohisto­
analysis. chemical panel in Pakistani population and its correlation with his­
Nevertheless, this is the first study to profile MMR topathological parameters. World J Surg Oncol. 2017;15:116.
doi:10.1186/s12957-017-1158-8
status among young Filipinos with CRC. It is hoped that 10. Kawakami H, Zaanan A, Sinicrope FA. Microsatellite instability
larger prospective studies will profile a broader population testing and its role in the management of colorectal cancer. Curr
of Filipinos in order to better estimate the true prevalence Treat Options Oncol. 2015;16:30. doi:10.1007/s11864-015-0348-2
11. Smith C, Butler JA. Colorectal cancer in patients younger than 40
of dMMR and pMMR among young CRC patients. years of age. Dis Colon Rectum. 1989;32:843–846. doi:10.1007/
BF02554552
12. De la Chapelle A, Hampel H. Clinical relevance of microsatellite
Conclusion instability in colorectal cancer. J Clin Oncol. 2010;28:3380–3387.
This is the first attempt to profile young-onset Filipino doi:10.1200/JCO.2009.27.0652
CRC patients according to MMR status. IHC of tumor 13. Loughrey MB, McGrath J, Coleman HG, et al. Identifying mismatch
repair-deficient colon cancer: near-perfect concordance between immu­
samples can easily identify the MMR status of a patient nohistochemistry and microsatellite instability testing in a large, popu­
and can serve as a substitute for molecular testing to lation-based series. Histopathology. 2020. doi:10.1111/his.14233
14. Li GM. Mechanisms and functions of DNA mismatch repair. Cell
determine MSI status. This inexpensive technique needs Res. 2008;18:85–98. doi:10.1038/cr.2007.115
to be part of standard evaluation of colorectal cancer 15. Hall G, Clarkson A, Shi A, et al. Immunohistochemistry for PMS2
because of its utility in clinical decision-making. and MSH6 alone can replace a four antibody panel for mismatch
repair deficiency screening in colorectal adenocarcinoma. Pathology.
2010;42:409–413.
Acknowledgments 16. Gatalica Z, Vranic S, Xiu J, Swensen J, Reddy S. High microsatellite
instability (MSI-H) colorectal carcinoma: a brief review of predictive
This study was supported by grants from the University of biomarkers in the era of personalized medicine. Fam Cancer.
the Philippines System (OVPAA-EIDR Code 06-008) and 2016;15:405–412. doi:10.1007/s10689-016-9884-6

2114 submit your manuscript | www.dovepress.com Cancer Management and Research 2021:13
DovePress
Dovepress Sacdalan et al

17. Greenson JK, Huang SC, Herron C, et al. Pathologic predictors of 25. Dozois EJ, Boardman LA, Suwanthanma W, et al. Young-onset
microsatellite instability in colorectal cancer. Am J Surg Pathol. colorectal cancer in patients with no known genetic predisposition:
2009;33:126–133. doi:10.1097/PAS.0b013e31817ec2b1 can we increase early recognition and improve outcome? Medicine.
18. Lee J, Xiao YY, Sun YY, et al. Prevalence and characteristics of 2008;87:259. doi:10.1097/MD.0b013e3181881354
hereditary non-polyposis colorectal cancer (HNPCC) syndrome in 26. Sargent DJ, Shi Q, Yothers G, et al. Prognostic impact of deficient
immigrant Asian colorectal cancer patients. BMC Cancer. mismatch repair (dMMR) in 7,803 stage II/III colon cancer (CC)
2017;17:843. doi:10.1186/s12885-017-3799-y patients (pts): a pooled individual patient data analysis of 17 adjuvant
19. Baran B, Ozupek NM, Tetik NY, Acar E, Bekcioglu O, Baskin Y. trials in the ACCENT database. J Clin Oncol. 2014;32:5s.
Difference between left-sided and right-sided colorectal cancer: a doi:10.1200/jco.2014.32.15_suppl.3507
focused review of literature. Gastroenterol Res. 2018;11:264–273. 27. Lee CT, Chow NH, Chen YL, et al. Clinicopathological features of
20. Alexander J, Watanabe T, Wu TT, Rashid A, Li S, Hamilton SR. mismatch repair protein expression patterns in colorectal cancer.
Histopathological identification of colon cancer with microsatellite instabil­ Pathol Res Pract. 2020;217:153288. doi:10.1016/j.prp.2020.153288
ity. Am J Pathol. 2001;158:527–535. doi:10.1016/S0002-9440(10)63994-6 28. Jung J, Kang Y, Lee YJ, et al. Comparison of the mismatch repair
21. Overman MJ, Lonardi S, Wong KY, et al. Durable clinical benefit system between primary and metastatic colorectal cancers using
with nivolumab plus ipilimumab in DNA mismatch repair-deficient/ immunohistochemistry. J Pathol Transl Med. 2017;51:129–136.
microsatellite instability-high metastatic colorectal cancer. J Clin doi:10.4132/jptm.2016.12.09
Oncol. 2018;36:773–779. doi:10.1200/JCO.2017.76.9901
29. Pearlman R, Markow M, Knight D, et al. Two-stain immunohistochemical
22. Le DT, Uram JN, Wang H, et al. PD-1 blockade in tumors with
screening for Lynch syndrome in colorectal cancer may fail to detect
mismatch-repair deficiency. N Engl J Med. 2015;372:2509–2520.
mismatch repair deficiency. Mod Pathol. 2018;31:1891–1900.
doi:10.1056/NEJMoa1500596
30. Roth RM, Haraldsdottir S, Hampel H, Arnold CA, Frankel WL.
23. Stigliano V, Sanchez-Mete L, Martayan A, Anti M. Early-onset
Discordant mismatch repair protein immunoreactivity in Lynch syn­
colorectal cancer: a sporadic or inherited disease? World J
drome-associated neoplasms: a recommendation for screening syn­
Gastroenterol. 2014;2014(20):12420. doi:10.3748/wjg.v20.i35.12420
chronous/metachronous neoplasms. Am J Clin Pathol. 2016;146:50–
24. Uy GB, Kaw LL, Punzalan CK, et al. Clinical and molecular biologic
characteristics of early-onset versus late-onset colorectal carcinoma in 56. doi:10.1093/ajcp/aqw067
Filipinos. World J Surg. 2004;28:117–123. doi:10.1007/s00268-003-7281-4

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