Microsatellite instability in colorectal cancer is associated with local lymphocyte infiltration and low frequency of distant metastases

Abstract

Colorectal carcinomas (CRCs) with high microsatellite instability (MSI-H) share clinicopathological features distinctly different from their microsatellite stable (MSS) counterparts. Unlike MSS cancers, MSI-H CRCs occur predominantly in the right-sided colon and are often characterised by a strong lymphocyte infiltration. A poor differentiation pattern is found in most MSI-H CRCs, even though patients with MSI-H carcinomas seem to have a significantly longer survival after surgical resection. To clarify which factors contribute to the obvious paradoxon of a more favourable prognosis of MSI tumours, several clinical and histopathological features as well as the microsatellite status were evaluated in 120 colorectal cancer cases fulfilling clinical criteria (Bethesda) indicative for familial colorectal cancer. Microsatellite instability status and lymphocyte infiltration were related to tumour stage and patients' follow-up. Statistical analysis confirmed well-known relations, such as enhanced lymphocyte infiltration accompanied by Crohn's like reaction (CLR) in MSI-H cancers (CLR+ in 27 out of 47 MSI-H vs 14 out of 71 MSS CRCs, P<0.001). However, after stratification for depth of local invasion and penetration of the primary tumour, T3 tumours displaying MSI had a significantly lower rate of distant metastases (M1 in four out of 35 MSI-H vs 20 out of 41 MSS CRCs, P<0.001). A similar tendency was observed for CLR-positive CRCs (M1 in six out of 29 CLR+ vs 17 out of 45 CLR- CRCs, P=0.13). In a logistic regression model, the MSI-H phenotype and the presence of CLR were independent predictors of a low UICC stage (P=0.006 and 0.04, respectively). These data, together with the recent definition of highly immunogenic neo-antigens expressed in MSI-H tumour cells, suggest that MSI-H CRCs elicit a protective host response that may prevent metastasis formation.

Figure 1

Histological evaluation of Crohn's like reaction. HE-stained sections of MSI-H tumours with marked lymphocyte infiltration. (A) Exemplary illustration of Crohn's like lesions (black arrows) with apparent germinal centres surrounding the invasion front of the tumour (× 100 magnification). (B) Peritumoural lymphocytes surrounding the penetration border of the primary tumour like a cap (× 50). Note the pronounced Crohn's like lymphoid reaction. Germinal centres that were not mandatory for the diagnosis of CLR are clearly detectable in both tumour sections.

Figure 2

Kaplan–Meier estimates of overall survival. (A and B) Patients of all tumour stages stratified by microsatellite status (A) and presence of Crohn's like reaction (CLR, B). (C and D) Overall survival of patients with T3 stage colon cancer depending on microsatellite status (C) and CLR (D). P-values shown were calculated using the log-rank test for survival differences.