Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 28  |  Issue : 3  |  Page : 725-733

Immunohistochemical expression of Twist in colorectal carcinoma


Department of Pathology, Faculty of Medicine, Menoufia University, Shebin El Kom, Egypt

Date of Submission05-Feb-2015
Date of Acceptance15-Mar-2015
Date of Web Publication22-Oct-2015

Correspondence Address:
Aiat S Hemida
Department of Pathology, Faculty of Medicine, Menoufia University, 32814 Shebin El Kom
Egypt
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.165816

Rights and Permissions
  Abstract 

Objectives
The aim of this study was to explore the relationship between immunohistochemical expression of Twist and the relevant clinicopathological features of colorectal carcinoma (CRC) in Egyptian patients.
Background
In Egypt, there is an increasing incidence of CRC, especially among patients of 40 years of age or less. Worldwide, many efforts have been made to find biomarkers to predict the behavior of CRC. Epithelial-mesenchymal transition is one of the central mechanisms that induces invasion and metastasis of tumors. Twist has been shown to induce epithelial-mesenchymal transition and play a critical role in cancer metastasis. In addition, Twist proteins display oncogenic properties by preventing senescence and apoptosis.
Materials and methods
Using the standard immunohistochemical technique, we assessed Twist expression in 67 colorectal specimens, including 10 specimens from normal colonic mucosa, eight colonic adenoma, and 49 CRC cases, and correlated our results with the available clinicopathological parameters.
Results
Negative Twist cytoplasmic immunoreactivity was detected in all the normal colonic mucosa specimens, whereas 75% of adenomas and 85.7% of CRC showed positive Twist cytoplasmic expression. Negative Twist nuclear immunoreactivity was detected in all the normal colonic mucosa and adenoma specimens, whereas 44.9% of CRC showed positive nuclear Twist expression. Nucleocytoplasmic Twist expression was significantly associated with high-grade tumors, mucinous adenocarcinoma, and advanced Dukes' stage, and showed a high tendency to be associated with vascular invasion.
Conclusion
The negativity of Twist in normal colonic mucosa confirm Twist as an embryonic transcription factor that remains largely undetectable in healthy adult tissues and involved in oncogenesis and malignant transformation in CRC. Being negative in adenoma and expressed only in CRC, Twist nuclear translocation may be a late event in carcinogenesis. Nucleocytoplasmic Twist expression is associated with poor prognostic factors in CRC.

Keywords: Colorectal carcinoma, epithelial-mesenchymal transition, immunohistochemical, Twist


How to cite this article:
Mohammed AS, Kandil MA, Asaad NY, Aiad HA, El Tahmoudy MA, Hemida AS. Immunohistochemical expression of Twist in colorectal carcinoma. Menoufia Med J 2015;28:725-33

How to cite this URL:
Mohammed AS, Kandil MA, Asaad NY, Aiad HA, El Tahmoudy MA, Hemida AS. Immunohistochemical expression of Twist in colorectal carcinoma. Menoufia Med J [serial online] 2015 [cited 2020 Mar 30];28:725-33. Available from: http://www.mmj.eg.net/text.asp?2015/28/3/725/165816


  Introduction Top


In western countries, colorectal carcinoma (CRC) is the third most commonly diagnosed cancer and the third cause of cancer deaths, according to the last registry of the National Cancer Institute, Surveillance Epidemiology, and End results [1]. The incidence according to results of the National Population-Based Cancer Registry Program, Egypt, reaches 3.57% [2].

Invasion is the first step of the cascade of events leading to the development of metastasis. The basic biological regulation of invasion and metastasis remains poorly understood [3]. Epithelial-mesenchymal transition (EMT), one of the central mechanisms that induces invasion and metastasis of tumors, is a process by which epithelial cells lose their polarity and are converted to mesenchymal phenotypes [4].

EMT is controlled by a group of transcriptional repressors (Zeb-1, Zeb-2, Twist, Snail, and Slug) that recruit histone deacetylases to E-box elements that are located within the E-cadherin promoter and a variety of other genes [5]. In the present study, we focused on Twist because it is considered as one of the master regulators of EMT through indirect (Twist) suppression of E-cadherin (CDH1) [6]. It is considered to be important for metastasis in several cancer types [7]. In addition, the aberrant expression of Twist is frequently reported in CRC [8],[9].


  Materials and methods Top


This work included 67 colorectal specimens from Egyptian patients obtained from Pathology Department, Faculty of Medicine, Menoufia University, from 2007 to 2014. They were randomly selected, based on the availability of paraffin-embedded blocks for serial cutting and examination. Demographic and clinical features for these patients were collected from the patients' medical records. In terms of age, the age of malignant cases was classified into two subgroups by using 45 years as the cutoff point [10]. In terms of tumor size, using median of the tumor size (5 cm) of the studied cases were classified into two categories [11]. The site of the malignant tumor, whether right colon, left colon or rectal tumors, was assessed. In addition, the gross appearance of tumor either fungating, ulcerative or annular infiltrating was assessed. This study was approved by the ethical committee of our institute.

Histopathological assessment

The hematoxylin and eosin (H&E)-stained sections were evaluated for histological type, according to Hamilton et al. [12]. Tumor grading was assessed based on gland formation, either low grade (΃50% gland formation) or high grade (<50% gland formation) [13]. The mitotic tumor cells were counted in 10 randomly selected high-power fields [14]. Similarly, apoptosis was counted in 10 high-power fields [15]. Lymphovascular invasion was assessed [16]. Pathologic staging of the tumor was performed according to TNM American Joint Committee on Cancer-Union International Center [17], as well as according to modified Dukes' staging system [18].

Immunohistochemical staining

Immunohistochemical (IHC) staining was performed on formalin-fixed, paraffin-embedded material that was sectioned at 4 μm thickness and placed onto positive-charged slides. The primary antibody was a rabbit polyclonal antibody against Twist (anti-Twist antibody ab50581, dilution, 1 : 100; overnight at 4°C) (Abcam Biotechnology, Cambridge, UK). Negative control slide was included in each run by omitting the primary antibody. Positive control slide (normal liver) for each run was also included. IHC staining was performed using the universal Dakocytomation-labeled stretavidin-biotin-2 system, horseradish peroxidase (LSAB-2 System, HRP Kit, Catalogue No. k0679) (Lab Vision, Fremont, California, USA). All slides were de-paraffinized using xylene and then rehydrated in decreasing concentrations of ethanol. Inhibition of endogenous peroxidase activity, using 3% hydrogen peroxidase for 15 min, was carried out. Antigen retrieval was carried out using microwave heating (20 min; 10 mmol/citrate buffer, pH 6.0). The primary antibody was applied to the slides. The slides were incubated overnight with the primary antibody at room temperature, and washed by using PBS, and then incubated with secondary antibody for 15 min followed by PBS wash. Finally, the detection of bound antibody was accomplished using a modified labeled avidin-biotin reagent for 20 min, and then PBS wash was carried out. A 0.1% solution of diaminobenzidine was used for 5 min as a chromogen. Slides were counterstained with Mayer's hematoxylin for 5-10 min.

Interpretation of immunohistochemical staining

Assessment of results was determined using visual approach. Unintentional bias was prevented by coding patients' slides. The entire slide was scanned for immunostaining evaluation in the tumorous and adjacent nontumorous areas. Evaluation was carried out using an Olympus CH2 light microscope (Olympus Corporation, Shinjuku, Tokyo, Japan), with a wide angle (field size of 0.274 mm 2 and field diameter of 0.59 mm 2 ). The cases were assigned as positive for Twist expression when more than 10% of tumor cells showed brown staining either cytoplasmic or nucleocytoplasmic localization regardless of intensity [19],[20].

Statistical analysis

Data were collected, tabulated, and statistically analyzed by using SPSS 'Statistical Package for the Social Science' program for Windows, version 16 (SPSS Inc., Chicago, Illinois, USA). To test whether these variables differed according to clinicopathological parameters and biological markers, the Fisher's exact test, χ΂-test, and Mann-Whitney test were used. All P-values were two-sided; P-values of 0.05 or less were considered statistically significant, and highly significant when P-value of 0.01 or less [21],[22].


  Results Top


Clinical characteristics of the studied CRC cases were demonstrated in [Table 1]. Fifty-nine percent of CRC cases were females with 0.7/1 M/F ratio. Regarding age, 65.3% of the selected patients were older than 45 years. Tumors measured more than 5 cm in maximum diameter constitutes 49% of cases. CRC cases located in right side of colon represent 44.9% of the studied cases.
Table 1: Clinical data of the studied colorectal carcinoma cases (n = 49)

Click here to view


Pathological characteristics of the studied CRC cases were demonstrated in [Table 2]. On gross examination, 63.3% of the studied cases were of the fungating type. Of the studied cases, 22% were diagnosed as mucoid adenocarcinoma. High-grade tumors represent 26.5%. Vascular invasion was detected in 20.4% of cases. Considering nodal status, 57.1% showed nodal positivity. According to TNM staging system, most of the cases belonged to stage T3 that represented 49%, followed by stage T4 that reached 30.6%. In terms of nodal staging, 42.9% were N0, 40.8% were N1, and 16.3% were N2. Of 49 cases, 16 (32.6%) showed distant metastasis (M1). According to the Dukes' staging system, most cases were stages B2 and C2, representing 26.5 and 24.5%, respectively. The mean ± SD of mitotic index in CRC cases was 2.83 ± 2.89, and for apoptotic index it was 2.20 ± 1.34.
Table 2: Pathological data of the studied colorectal carcinoma cases (n = 49)

Click here to view


Immunostaining results

Twist IHC staining was observed as cytoplasmic or nuclear expression.

Normal colonic mucosa

All the normal colonic mucosa cases were negative for both cytoplasmic as well as nuclear Twist expression [Table 3].
Table 3: Cytoplasmic expression of Twist in normal colonic mucosa, adjacent normal mucosa, adenoma, and colorectal carcinoma cases (%)

Click here to view


The studied adenoma cases

All the studied adenoma cases (100%) were negative for nuclear expression of Twist; however, six (75%) of the eight studied adenoma cases showed positive cytoplasmic expression of Twist [Figure 1] [Table 3].
Figure 1: Adenomatous polyp with Twist cytoplasmic expression (immunohistochemical staining ×10 0).

Click here to view


Normal mucosa adjacent to tumor

All the adjacent normal mucosa that appeared in 17 Twist-positive CRC cases showed positive cytoplasmic Twist immunostaining similar to their nearby tumor. No nuclear Twist expression was detected in any of them [Figure 2] [Table 3].
Figure 2: Adjacent normal mucosa showing Twist cytoplasmic expression, note lymphocyte-expressing Twist protein (immunohistochemical staining ×40 0).

Click here to view


Colorectal carcinoma cases

Of the 49 cases with CRC, 42 (85.7%) showed positive cytoplasmic expression of Twist [Figure 3]. There was no statistical significant association between pure cytoplasmic expression of Twist in CRC and the available clinicopathological data [Table 4].
Figure 3: Twist cytoplasmic expression in moderately differentiated adenocarcinoma scattered lymphocytes showing Twist expression were also noted (immunohistochemical staining ×4 00).

Click here to view
Table 4: Relation between cytoplasmic expression of Twist and clinicopathologic factors in colorectal carcinoma cases

Click here to view


Of the 49 cases with CRC, 29 (44.9%) showed positive nuclear expression of Twist, which was always associated with cytoplasmic expression (nucleocytoplasmic expression) [Figure 4]. Nucleocytoplasmic Twist expression was significantly associated with high-grade tumors (P = 0.04), mucinous adenocarcinoma (P = 0.005), and advanced Dukes' stage, (P = 0.03) and showed a high tendency to be associated with vascular invasion (P = 0.07) [Table 5].
Figure 4: Twist combined nuclear and cytoplasmic expression in a case of moderately differentiated adenocarcinoma. Note scattered lymphocytes positivity (immunohistochemical staining ×4 00).

Click here to view
Table 5: Relation between nucleocytoplasmic expression of Twist and clinicopathologic factors in colorectal carcinoma cases

Click here to view


Adjacent stroma

Most of the background lymphocytes were positive for nuclear Twist, and all the Twist positive adenoma and CRC cases showed positivity in the adjacent tumor stroma [Figure 1],[Figure 2],[Figure 3] and [Figure 4].


  Discussion Top


CRC is common with an estimated 1.23 million new cases globally during 2008. It is the second most common cause of cancer mortality in the developed countries and remains associated with a high mortality rate [23]. In Egypt, there is an increasing incidence of CRC, especially among patients of 40 years of age or below [24].

Metastases are the end result of tumor progression and are the most common cause of death in cancer patients. EMT, one of the main mechanisms that induces invasion and metastasis of tumors, is controlled by several genes that are key players in embryonic development, and are related to some steps in oncogenesis [25].

The Twist proteins, Twist 1 and Twist 2 (formerly Dermo-1), belong to the huge basic Helix Loop Helix (bHLH) transcription factor family. Although they differ in their N-terminus, their C-terminal halves are sequentially very close, encompassing a conserved bHLH motif as well as an interaction domain named 'Twist box'. Through their bHLH motif, the Twist proteins are able to recognize E-box responsive elements (CANNTG) and behave either as transcription repressors or activators, depending on the cellular context [26].

Compelling evidence supports a preponderant and unusual role of Twist proteins in tumor progression. They are capable of simultaneously promoting malignant conversion, cancer cell dissemination, acquisition of self-renewal capabilities, chromosomal instability, neoangiogenesis, and chemoresistance [27]. We aimed to explore the association between the IHC expression of Twist and the relevant clinicopathological features of CRC.

All the normal non-neoplastic colonic epithelium were negative for Twist immunoreactivity. This result agreed with the fact that Twist proteins are embryonic transcription factors that play key roles in embryonic development, although they remain largely undetectable in healthy adult tissues, being restricted to precursor cells including the myogenic, osteoblastic, chondroblastic, odontoblastic, and myelomonocytic lineages, maintaining their undifferentiated state [9]. Moreover, this is also consistent with previous IHC studies [9],[27].

In our study, all the adjacent normal mucosa that appeared in 17 Twist-positive CRC cases showed positive cytoplasmic Twist immunostaining similar to their nearby tumor. This may indicate changes in the surrounding tumor environment that may enhance the subsequent development of tumor cells (Field cancerization).

We found that 75% of the studied adenoma cases showed positive cytoplasmic expression of Twist. These results match with other studies in which Twist was expressed in benign precursor lesions (adenoma) of CRC [8],[28]. But, does this mean that EMT processes driving metastasis are already active in a benign premalignant condition? In the case of CRC progression, one study observed the presence of disseminated epithelial cells in the bone marrow of patients with intraepithelial colorectal neoplasia [29]. The type of mutations in the disseminated cells differ from that present in invasive CRC, suggesting that cell dissemination might be an early event in the development of colorectal neoplasms, as most bone marrow K-ras mutations were found in codon 13, a codon barely mutated in invasive CRC but frequently mutated in aberrant crypt foci [30].

With regard to CRC, in our study, 85.7% showed positive cytoplasmic expression of Twist. Comparable with our results, another study found that Twist-2-positive cytoplasmic expression was observed in 71.0% of the CRC samples [31]. Twist showed lower cytoplasmic expression in other tissues, including endometrial carcinoma (51%), esophageal squamous cell carcinoma (42%), renal cell carcinoma (38.5%), and bladder carcinoma (44.2%) [32-35]. In our study, 44.9% of the CRC cases showed positive nucleocytoplasmic expression of Twist. Similar to our results, nucleocytoplasmic expression of Twist was observed in 40.5% of the CRC samples [27]. Expression in other tissues was variable. Only 26% of the primary hepatocellular carcinoma cases showed positive nucleocytoplasmic expression of Twist [36]. However, higher nucleocytoplasmic expression of Twist was found in 60.7% of the esophageal squamous cell carcinoma tissues [37].

Regulation mechanism of Twist remains to be elucidated. However, in breast cancer, the promoter of the Twist gene was much less frequently methylated in invasive lobular-type than in invasive ductal-type cancer, in which the former type was known to display higher levels of Twist expression [38]. Therefore, promoter methylation of Twist may affect clinical outcome [32]. In addition, it may explain different levels of Twist expression in variable tissues.

In our study, none of the normal colonic mucosa specimens or colorectal adenoma showed Twist nuclear expression, and thus Twist nuclear translocation may be a late event in carcinogenesis. There was no statistical significant difference between adenoma and CRC cases, with regard to cytoplasmic Twist expression. In addition, both colorectal adenoma and CRC cases showed much higher cytoplasmic expression of Twist than normal colorectal mucosa, thus cytoplasmic expression of Twist is involved in oncogenesis and malignant transformation in CRC. The high expression of Twist in both colorectal adenoma and cancer can be explained by that Twist methylation level was higher in colorectal adenoma and cancer than in normal colorectal mucosa, and these results suggest that Twist methylation may be a useful biomarker for screening colorectal tumors [8].

Previous studies on CRC carcinoma found a statistical association between cytoplasmic expression of Twist in tumor tissues of CRC and lymph node metastasis [9]. In addition, another study found that nuclear Twist expression in CRC showed a tendency to increase with tumor invasion depth, mucinous adenocarcinoma, poorly differentiated adenocarcinoma, the presence of a lymph node metastasis, and clinical staging [27]. Similarly, Twist overexpression was associated with poor prognostic factors in other tissues such as bladder cancer [31] and esophageal squamous cell carcinoma [33],[37]. In our study, we did not find a significant correlation between cytoplasmic expression of Twist regarding any of the available clinicopathological data. However, nucleocytoplasmic Twist expression was significantly associated with high-grade tumors (P = 0.04), mucinous adenocarcinoma (P = 0.005), and advanced Dukes' stage (P = 0.03), and showed a high tendency to be associated with vascular invasion (P = 0.07). Therefore, nuclear localization of Twist is associated with poor prognostic factors and predicts bad behavior of CRC positive cases.

The tumor stroma is the compartment providing the connective-tissue framework of the tumor. In our study, all the Twist-positive adenoma and CRC cases showed positivity in the adjacent tumor stroma. This indicates changes in the local tissue microenvironment, which shifts to growth-promoting stage owing to local conditions such as chronic inflammation [39]. Moreover, cancer-associated fibroblasts have been shown to be important promoters of tumor growth and progression [40]. In addition, most of the background lymphocytes were positive for nuclear Twist, as, recently, Twist proteins were found to perform important roles in lymphocyte function and maturation. Twist 1 and Twist 2 are key regulators of B-cell activation in an inflammatory environment such as autoimmune disease [41].


  Conclusion Top


Cytoplasmic Twist negativity in normal colonic mucosa and its positivity in both adenoma and CRC confirm that Twist is involved in oncogenesis and malignant transformation in CRC. Nuclear localization of Twist is a late event in colorectal carcinogenesis, which is associated with poor prognostic factors and predicts bad behavior of CRC-positive cases.

.

.



Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Ries LAG, Young JL, Keel GE, Eisner MP, Lin YD, Horner M-J, (editors). SEER survival monograph: cancer survival among adults: US SEER Program, 1988-2001, patient and tumor characteristics. NIH Pub. No. 07-6215. Bethesda, MD: National Cancer Institute; 2007:33-44.  Back to cited text no. 1
    
2.
Ibrahim AS, Khaled HM, Mikhail NN, Baraka H, Kamel H. Cancer incidence in Egypt: results of the national population-based cancer registry program. J Cancer Epidemiol 2014; 2014 :437971.  Back to cited text no. 2
    
3.
Guarino M. Epithelial-mesenchymal transition and tumour invasion. Int J Biochem Cell Biol 2007; 39 :2153-2160.  Back to cited text no. 3
    
4.
Tenesa A, Dunlop MG. New insights into the aetiology of colorectal cancer from genome-wide association studies. Nat Rev Genet 2009; 10 :353-358.  Back to cited text no. 4
    
5.
Peinado H, Olmeda D, Cano A. Snail, Zeb and bHLH factors in tumour progression: an alliance against the epithelial phenotype? Nat Rev Cancer 2007; 7 :415-428.  Back to cited text no. 5
    
6.
Thiery JP, Acloque H, Huang RY, Nieto MA. Epithelial-mesenchymal transitions in development and disease. Cell 2009; 139 :871-890.  Back to cited text no. 6
    
7.
Polyak K, Weinberg RA. Transitions between epithelial and mesenchymal states: acquisition of malignant and stem cell traits. Nat Rev Cancer 2009; 9 :265-273.  Back to cited text no. 7
    
8.
Okada T, Suehiro Y, Ueno K, Mitomori S, Kaneko S, Nishioka M, et al.. TWIST1 hypermethylation is observed frequently in colorectal tumors and its overexpression is associated with unfavorable outcomes in patients with colorectal cancer. Genes Chromosomes Cancer 2010; 49 :452-462.  Back to cited text no. 8
    
9.
Gomez I, Peòa C, Herrera M, Muòoz C, Larriba MJ, Garcia V, et al.. TWIST1 is expressed in colorectal carcinomas and predicts patient survival. PLoS One 2011; 6 :e18023.  Back to cited text no. 9
    
10.
Zheng S, Han MY, Xiao ZX, Peng JP, Dong Q. Clinical significance of vascular endothelial growth factor expression and neovascularization in colorectal carcinoma. World J Gastroenterol 2003; 9 :1227-1230.  Back to cited text no. 10
    
11.
Bahnassy AZ, El-Houssini S, El-Shehaby MR, Mahmoud R, Abdallah S, El-Serafi M. Cyclin A and cyclin D1 as significant prognostic markers in Egyptian patients with colorectal carcinoma. J Egypt Cancer Inst 2002; 14 :289-301.  Back to cited text no. 11
    
12.
Hamilton SR, Bosman FT, Boffetta P, Ilyas M, Morreau H, Nakamura SI, et al. Carcinoma of the colon and rectum. In: Bosman FT, Carneiro F, Hruban RH, Theise ND, editors. WHO classification of tumours of the digestive system. 3rd volume. 4th ed. Lyon: IARC Press; 2010: 134-146.  Back to cited text no. 12
    
13.
Washington MK, Berlin J, Branton P, Burgart LJ, Carter DK, Fitzgibbons PL, et al. Protocol for the examination of specimens from patients with primary carcinoma of the colon and rectum. Arch Pathol Lab Med 2009; 133 : 1539-1551.  Back to cited text no. 13
    
14.
Miracco C, de Santi M, Pacenti L, Schurfeld K, Laurini L, Pirtoli L, et al. Telomerase activity, Ki67, cyclin D1 and A expression, and apoptosis in solitary fibrous tumors: additional features of a predictable course? Pathol Res Pract 2001; 197 :475-481.  Back to cited text no. 14
    
15.
Garrity MM, Burgart LJ, Riehle DL, Hill EM, Sebo TJ, Witzig T. Identifying and quantifying apoptosis: navigating technical pitfalls. Mod Pathol 2003; 16 :389-394.  Back to cited text no. 15
    
16.
Chiung NC, Chia TS, Ming TL, King JC. Clinicopathological association of cyclooxyghenase-2expression in gastric adenocarcinoma. Ann Surg 2001; 233 :183-188.  Back to cited text no. 16
    
17.
Sobin LH, Gospodarowicz MK, Wittekind C, editors. TNM classification of malignant tumours. ISBN: 978-1-4443-3241-4. 7th ed. New Jersey: Wiley-Blackwell; 2009.   Back to cited text no. 17
    
18.
Astler VB, Coller FA. The prognostic significance of direct extension of carcinoma of the colon and rectum. Ann Surg 1954; 139 :846-852.  Back to cited text no. 18
[PUBMED]    
19.
Markiewicz A, Ahrends T, We³nicka-Ja?kiewicz M, Seroczyñska MB, Skokowski J, Ja?kiewicz J, et al. Expression of epithelial to mesenchymal transition-related markers in lymph node metastases as a surrogate for primary tumor metastatic potential in breast cancer. J Transl Med 2012; 10 :226.  Back to cited text no. 19
    
20.
Kim K, Park EY, Yoon MS, Suh DS, Kim KH, Lee JH, et al. The role of TWIST in ovarian epithelial cancers. Korean J Pathol 2014; 48 : 283-291.  Back to cited text no. 20
    
21.
Dawson B, Trapp R. Basic and clinical biostatistics: large medical books. Oxford, London. Boston: McGraw Hill; 2001. 270-275.  Back to cited text no. 21
    
22.
RM Samaka, MMA El-Wahed, MA Kandil, E Abdelzaher, MI Shaaban, RA Allah. Immunohistochemical localization of b-catenin in medulloblastoma. Menoufia Med J 2014; 27 :10-15.  Back to cited text no. 22
    
23.
Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. Int J Cancer 2010; 127 :2893-2917.  Back to cited text no. 23
    
24.
Gado A, Ebeid B, Abdelmohsen A, Axon A. Colorectal cancer in Egypt is commoner in young people: is this cause for alarm? Alexandria J Med 2014; 50 :197-201.  Back to cited text no. 24
    
25.
Nguyen DX, Massagué J. Genetic determinants of cancer metastasis. Nat Rev Genet 2007; 8 :341-352.  Back to cited text no. 25
    
26.
Pan D, Fujimoto M, Lopes A, Wang YX. Twist-1 is a PPARdelta-inducible, negative-feedback regulator of PGC-1alpha in brown fat metabolism. Cell 2009; 137 :73-86.  Back to cited text no. 26
    
27.
Hong R, Lim SC. Overexpression of Twist in colorectal adenocarcinoma. Basic Appl Pathol 2009; 2 :15-20.  Back to cited text no. 27
    
28.
Kroepil F, Fluegen G, Totikov Z, Baldus SE, Vay C, Schauer M, et al. Down-regulation of CDH1 is associated with expression of SNAI1 in colorectal adenomas. PLoS One 2012; 7 :e46665.  Back to cited text no. 28
    
29.
Steinert R, Vieth M, Hantschick M, Reymond MA. Epithelial cells disseminate into the bone marrow of colorectal adenoma patients. Gut 2005; 54 :1045-1046.  Back to cited text no. 29
[PUBMED]    
30.
Yamashita N, Minamoto T, Ochiai A, Onda M, Esumi H. Frequent and characteristic K-ras activation in aberrant crypt foci of colon. Is there preference among K-ras mutants for malignant progression? Cancer 1995; 75(Suppl) :1527-1533.  Back to cited text no. 30
    
31.
Yu H, Jin GZ, Liu K, Dong H, Yu H, Duan JC, et al. Twist2 is a valuable prognostic biomarker for colorectal cancer. World J Gastroenterol 2013; 19 :2404-2411.  Back to cited text no. 31
[PUBMED]    
32.
Kyo S, Sakaguchi J, Ohno S, Mizumoto Y, Maida Y, Hashimoto M, et al. High Twist expression is involved in infiltrative endometrial cancer and affects patient survival. Hum Pathol 2006; 37 :431-438.  Back to cited text no. 32
    
33.
Sasaki K, Natsugoe S, Ishigami S, Matsumoto M, Okumura H, Setoyama T, et al. Significance of Twist expression and its association with E-cadherin in esophageal squamous cell carcinoma. J Exp Clin Cancer Res 2009; 28 :158,   Back to cited text no. 33
    
34.
Ohba K, Miyata Y, Matsuo T, Asai A, Mitsunari K, Shida Y, et al. High expression of Twist is associated with tumor aggressiveness and poor prognosis in patients with renal cell carcinoma. Int J Clin Exp Pathol 2014; 7 :3158-3165.  Back to cited text no. 34
    
35.
Yu Q, Zhang K, Wang X, Liu X, Zhang Z. Expression of transcription factors snail, slug, and twist in human bladder carcinoma. J Exp Clin Cancer Res 2010; 29 :119.  Back to cited text no. 35
    
36.
Lee TK, Poon RT, Yuen AP, Ling MT, Kwok WK, Wang XH, et al. Twist overexpression correlates with hepatocellular carcinoma metastasis through induction of epithelial-mesenchymal transition. Clin Cancer Res 2006; 12 :5369-5376.  Back to cited text no. 36
    
37.
Gong T, Xue Z, Tang S, Zheng X, Xu G, Gao L, et al. Nuclear expression of Twist promotes lymphatic metastasis in esophageal squamous cell carcinoma. Cancer Biol Ther 2012; 13 :606-613.  Back to cited text no. 37
    
38.
Frackler MJ, McVeigh M, Evron E, Garrett E, Mehrotra J, Polyak K, et al., DNA methylation of RASSFIA, HIN-1, RAR-beta, Cyclin D2 and Twist in in situ and invasive lobular breast carcinoma. Int J Cancer 2003; 107 :970-975.  Back to cited text no. 38
    
39.
Joyce JA, Pollard JW. Microenvironmental regulation of metastasis. Nat Rev Cancer 2009; 9 :239-252.  Back to cited text no. 39
    
40.
Mueller MM, Fusenig NE. Friends or foes - bipolar effects of the tumour stroma in cancer. Nat Rev Cancer 2004; 4 :839-849.  Back to cited text no. 40
    
41.
Doreau A, Belot A, Bastid J, Riche B, Trescol-Biemont MC, Ranchin B, et al. Interleukin 17 acts in synergy with B cell-activating factor to influence B cell biology and the pathophysiology of systemic lupus erythematosus. Nat Immunol 2009; 10 :778-785  Back to cited text no. 41
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Materials and me...
Results
Discussion
Conclusion
Acknowledgements
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed1108    
    Printed8    
    Emailed0    
    PDF Downloaded120    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]