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Published in: BMC Cancer 1/2008

Open Access 01-12-2008 | Research article

A novel diffuse gastric cancer susceptibility variant in E-cadherin (CDH1) intron 2: A case control study in an Italian population

Authors: Soroush Nasri, Helen More, Francesco Graziano, Annamaria Ruzzo, Emily Wilson, Anita Dunbier, Cushla McKinney, Tony Merriman, Parry Guilford, Mauro Magnani, Bostjan Humar

Published in: BMC Cancer | Issue 1/2008

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Abstract

Background

Inherited genetic factors such as E-cadherin (CDH1) promoter variants are believed to influence the risk towards sporadic diffuse gastric cancer (DGC). Recently, a new regulatory region essential for CDH1 transcription has been identified in CDH1 intron 2.

Methods

We genotyped all known polymorphisms located within conserved sequences of CDH1 intron 2 (rs10673765, rs9932686, rs1125557, rs9282650, rs9931853) in an Italian population consisting of 134 DGC cases and 100 healthy controls (55 patient relatives and 45 unrelated, matched individuals). The influence of individual variants on DGC risk was assessed using χ2-tests and logistic regression. The relative contribution of alleles was estimated by haplotype analysis.

Results

We observed a significant (p < 0.0004) association of the CDH1 163+37235G>A variant (rs1125557) with DGC risk. Odds ratios were 4.55 (95%CI = 2.09–9.93) and 1.38 (95%CI = 0.75–2.55) for AA and GA carriers, respectively. When adjusted for age, sex, smoking status, alcohol intake and H. pylori infection, the risk estimates remained largely significant for AA carriers. Haplotype analysis suggested the 163+37235A-allele contributes to disease risk independently of the other variants studied.

Conclusion

The CDH1 163+37235G>A polymorphism may represent a novel susceptibility variant for sporadic DGC if confirmed in other populations. Considering the broad expression of E-cadherin in epithelia, this exploratory study encourages further evaluation of the 163+37235A-allele as a susceptibility variant in other carcinomas.
Literature
1.
go back to reference Ushijima T, Sasako M: Focus on gastric cancer. Cancer Cell. 2004, 5: 121-125. 10.1016/S1535-6108(04)00033-9.CrossRefPubMed Ushijima T, Sasako M: Focus on gastric cancer. Cancer Cell. 2004, 5: 121-125. 10.1016/S1535-6108(04)00033-9.CrossRefPubMed
2.
go back to reference Lauren PA, Nevalainen TJ: Epidemiology of intestinal and diffuse types of gastric carcinoma. A time-trend study in Finland with comparison between studies from high- and low-risk areas. Cancer. 1993, 71: 2926-2933. 10.1002/1097-0142(19930515)71:10<2926::AID-CNCR2820711007>3.0.CO;2-X.CrossRefPubMed Lauren PA, Nevalainen TJ: Epidemiology of intestinal and diffuse types of gastric carcinoma. A time-trend study in Finland with comparison between studies from high- and low-risk areas. Cancer. 1993, 71: 2926-2933. 10.1002/1097-0142(19930515)71:10<2926::AID-CNCR2820711007>3.0.CO;2-X.CrossRefPubMed
3.
go back to reference Humar B, Fukuzawa R, Blair V, Dunbier A, More H, Charlton A, Yang HK, Kim WH, Reeve AE, Martin I, Guilford P: Destabilized adhesion in the gastric proliferative zone and c-Src kinase activation mark the development of early diffuse gastric cancer. Cancer Res. 2007, 67: 2480-2489. 10.1158/0008-5472.CAN-06-3021.CrossRefPubMed Humar B, Fukuzawa R, Blair V, Dunbier A, More H, Charlton A, Yang HK, Kim WH, Reeve AE, Martin I, Guilford P: Destabilized adhesion in the gastric proliferative zone and c-Src kinase activation mark the development of early diffuse gastric cancer. Cancer Res. 2007, 67: 2480-2489. 10.1158/0008-5472.CAN-06-3021.CrossRefPubMed
4.
go back to reference Karayiannakis AJ, Syrigos KN, Chatzigianni E, Papanikolaou S, Karatzas G: E-cadherin expression as a differentiation marker in gastric cancer. Hepatogastroenterology. 1998, 45: 2437-2442.PubMed Karayiannakis AJ, Syrigos KN, Chatzigianni E, Papanikolaou S, Karatzas G: E-cadherin expression as a differentiation marker in gastric cancer. Hepatogastroenterology. 1998, 45: 2437-2442.PubMed
5.
go back to reference Larue L, Ohsugi M, Hirchenhain J, Kemler R: E-cadherin null mutant embryos fail to form a trophectoderm epithelium. Proc Natl Acad Sci USA. 1994, 91: 8263-8267. 10.1073/pnas.91.17.8263.CrossRefPubMedPubMedCentral Larue L, Ohsugi M, Hirchenhain J, Kemler R: E-cadherin null mutant embryos fail to form a trophectoderm epithelium. Proc Natl Acad Sci USA. 1994, 91: 8263-8267. 10.1073/pnas.91.17.8263.CrossRefPubMedPubMedCentral
6.
go back to reference Berx G, Becker KF, Hofler H, van Roy F: Mutations of the human E-cadherin (CDH1) gene. Hum Mut. 1998, 12: 226-237. 10.1002/(SICI)1098-1004(1998)12:4<226::AID-HUMU2>3.0.CO;2-D.CrossRefPubMed Berx G, Becker KF, Hofler H, van Roy F: Mutations of the human E-cadherin (CDH1) gene. Hum Mut. 1998, 12: 226-237. 10.1002/(SICI)1098-1004(1998)12:4<226::AID-HUMU2>3.0.CO;2-D.CrossRefPubMed
7.
go back to reference Tamura G, Yin J, Wang S, Fleisher AS, Zou T, Abraham JM, Kong D, Smolinski KN, Wilson KT, James SP, Silverberg SG, Nishizuka S, Terashima M, Motoyama T, Meltzer SJ: E-Cadherin gene promoter hypermethylation in primary human gastric carcinomas. J Natl Cancer Inst. 2000, 92: 569-573. 10.1093/jnci/92.7.569.CrossRefPubMed Tamura G, Yin J, Wang S, Fleisher AS, Zou T, Abraham JM, Kong D, Smolinski KN, Wilson KT, James SP, Silverberg SG, Nishizuka S, Terashima M, Motoyama T, Meltzer SJ: E-Cadherin gene promoter hypermethylation in primary human gastric carcinomas. J Natl Cancer Inst. 2000, 92: 569-573. 10.1093/jnci/92.7.569.CrossRefPubMed
8.
go back to reference Guilford P, Hopkins J, Harraway J, McLeod M, McLeod N, Harawira P, Taite H, Scoular R, Miller A, Reeve AE: E-cadherin germline mutations in familial gastric cancer. Nature. 1998, 392: 402-405. 10.1038/32918.CrossRefPubMed Guilford P, Hopkins J, Harraway J, McLeod M, McLeod N, Harawira P, Taite H, Scoular R, Miller A, Reeve AE: E-cadherin germline mutations in familial gastric cancer. Nature. 1998, 392: 402-405. 10.1038/32918.CrossRefPubMed
10.
go back to reference Humar B, Graziano F, Cascinu S, Catalano V, Ruzzo AM, Magnani M, Toro T, Burchill T, Futschik ME, Merriman T, Guilford P: Association of CDH1 haplotypes with susceptibility to sporadic diffuse gastric cancer. Oncogene. 2002, 21: 8192-8195. 10.1038/sj.onc.1205921.CrossRefPubMed Humar B, Graziano F, Cascinu S, Catalano V, Ruzzo AM, Magnani M, Toro T, Burchill T, Futschik ME, Merriman T, Guilford P: Association of CDH1 haplotypes with susceptibility to sporadic diffuse gastric cancer. Oncogene. 2002, 21: 8192-8195. 10.1038/sj.onc.1205921.CrossRefPubMed
11.
go back to reference Cattaneo F, Venesio T, Molatore S, Russo A, Fiocca R, Frattini M, Scovassi AI, Ottini L, Bertario L, Ranzani GN: Functional analysis and case-control study of -160C/A polymorphism in the E-cadherin gene promoter: association with cancer risk. Anticancer research. 2006, 26: 4627-4632.PubMed Cattaneo F, Venesio T, Molatore S, Russo A, Fiocca R, Frattini M, Scovassi AI, Ottini L, Bertario L, Ranzani GN: Functional analysis and case-control study of -160C/A polymorphism in the E-cadherin gene promoter: association with cancer risk. Anticancer research. 2006, 26: 4627-4632.PubMed
12.
go back to reference Medina-Franco H, Ramos-De la Medina A, Vizcaino G, Medina-Franco JL: Single nucleotide polymorphisms in the promoter region of the E-cadherin gene in gastric cancer: case-control study in a young Mexican population. Ann Surg Oncol. 2007, 14: 2246-2249. 10.1245/s10434-006-9054-4.CrossRefPubMed Medina-Franco H, Ramos-De la Medina A, Vizcaino G, Medina-Franco JL: Single nucleotide polymorphisms in the promoter region of the E-cadherin gene in gastric cancer: case-control study in a young Mexican population. Ann Surg Oncol. 2007, 14: 2246-2249. 10.1245/s10434-006-9054-4.CrossRefPubMed
13.
go back to reference Yamada H, Shinmura K, Ikeda S, Tao H, Otani T, Hanaoka T, Tsuneyoshi T, Tsugane S, Sugimura H: Association between CDH1 haplotypes and gastric cancer risk in a Japanese population. Scand J Gastroenterol. 2007, 42: 1479-1485. 10.1080/00365520701478436.CrossRefPubMed Yamada H, Shinmura K, Ikeda S, Tao H, Otani T, Hanaoka T, Tsuneyoshi T, Tsugane S, Sugimura H: Association between CDH1 haplotypes and gastric cancer risk in a Japanese population. Scand J Gastroenterol. 2007, 42: 1479-1485. 10.1080/00365520701478436.CrossRefPubMed
14.
go back to reference Stemmler MP, Hecht A, Kemler R: E-cadherin intron 2 contains cis-regulatory elements essential for gene expression. Development. 2005, 132 (5): 965-976. 10.1242/dev.01662.CrossRefPubMed Stemmler MP, Hecht A, Kemler R: E-cadherin intron 2 contains cis-regulatory elements essential for gene expression. Development. 2005, 132 (5): 965-976. 10.1242/dev.01662.CrossRefPubMed
18.
go back to reference Humar B, Toro T, Graziano F, Muller H, Dobbie Z, Kwang-Yang H, Eng C, Hampel H, Gilbert D, Winship I, Parry S, Ward R, Findlay M, Christian A, Tucker M, Tucker K, Merriman T, Guilford P: Novel germline CDH1 mutations in hereditary diffuse gastric cancer families. Hum Mut. 2002, 19: 518-525. 10.1002/humu.10067.CrossRefPubMed Humar B, Toro T, Graziano F, Muller H, Dobbie Z, Kwang-Yang H, Eng C, Hampel H, Gilbert D, Winship I, Parry S, Ward R, Findlay M, Christian A, Tucker M, Tucker K, Merriman T, Guilford P: Novel germline CDH1 mutations in hereditary diffuse gastric cancer families. Hum Mut. 2002, 19: 518-525. 10.1002/humu.10067.CrossRefPubMed
20.
go back to reference Shi YY, He L: SHEsis, a powerful software platform for analyses of linkage disequilibrium, haplotype construction, and genetic association at polymorphism loci. Cell Res. 2005, 15: 97-98. 10.1038/sj.cr.7290286.CrossRefPubMed Shi YY, He L: SHEsis, a powerful software platform for analyses of linkage disequilibrium, haplotype construction, and genetic association at polymorphism loci. Cell Res. 2005, 15: 97-98. 10.1038/sj.cr.7290286.CrossRefPubMed
22.
go back to reference Driller K, Pagenstecher A, Uhl M, Omran H, Berlis A, Grunder A, Sippel AE: Nuclear factor I X deficiency causes brain malformation and severe skeletal defects. Mol Cell Biol. 2007, 27: 3855-3867. 10.1128/MCB.02293-06.CrossRefPubMedPubMedCentral Driller K, Pagenstecher A, Uhl M, Omran H, Berlis A, Grunder A, Sippel AE: Nuclear factor I X deficiency causes brain malformation and severe skeletal defects. Mol Cell Biol. 2007, 27: 3855-3867. 10.1128/MCB.02293-06.CrossRefPubMedPubMedCentral
23.
go back to reference Chaudhry AZ, Lyons GE, Gronostajski RM: Expression patterns of the four nuclear factor I genes during mouse embryogenesis indicate a potential role in development. Dev Dyn. 1997, 208: 313-325. 10.1002/(SICI)1097-0177(199703)208:3<313::AID-AJA3>3.0.CO;2-L.CrossRefPubMed Chaudhry AZ, Lyons GE, Gronostajski RM: Expression patterns of the four nuclear factor I genes during mouse embryogenesis indicate a potential role in development. Dev Dyn. 1997, 208: 313-325. 10.1002/(SICI)1097-0177(199703)208:3<313::AID-AJA3>3.0.CO;2-L.CrossRefPubMed
24.
go back to reference Rafty LA, Santiago FS, Khachigian LM: NF1/X represses PDGF A-chain transcription by interacting with Sp1 and antagonizing Sp1 occupancy of the promoter. EMBO J. 2002, 21: 334-343. 10.1093/emboj/21.3.334.CrossRefPubMedPubMedCentral Rafty LA, Santiago FS, Khachigian LM: NF1/X represses PDGF A-chain transcription by interacting with Sp1 and antagonizing Sp1 occupancy of the promoter. EMBO J. 2002, 21: 334-343. 10.1093/emboj/21.3.334.CrossRefPubMedPubMedCentral
25.
go back to reference Ouellet S, Vigneault F, Lessard M, Leclerc S, Drouin R, Guerin SL: Transcriptional regulation of the cyclin-dependent kinase inhibitor 1A (p21) gene by NFI in proliferating human cells. Nucleic Acids Res. 2006, 34: 6472-6487. 10.1093/nar/gkl861.CrossRefPubMedPubMedCentral Ouellet S, Vigneault F, Lessard M, Leclerc S, Drouin R, Guerin SL: Transcriptional regulation of the cyclin-dependent kinase inhibitor 1A (p21) gene by NFI in proliferating human cells. Nucleic Acids Res. 2006, 34: 6472-6487. 10.1093/nar/gkl861.CrossRefPubMedPubMedCentral
26.
go back to reference Luciakova K, Barath P, Poliakova D, Persson A, Nelson BD: Repression of the human adenine nucleotide translocase-2 gene in growth-arrested human diploid cells: the role of nuclear factor-1. J Biol Chem. 2003, 278: 30624-30633. 10.1074/jbc.M303530200.CrossRefPubMed Luciakova K, Barath P, Poliakova D, Persson A, Nelson BD: Repression of the human adenine nucleotide translocase-2 gene in growth-arrested human diploid cells: the role of nuclear factor-1. J Biol Chem. 2003, 278: 30624-30633. 10.1074/jbc.M303530200.CrossRefPubMed
27.
go back to reference Schuur ER, Kruse U, Iacovoni JS, Vogt PK: Nuclear factor I interferes with transformation induced by nuclear oncogenes. Cell Growth Differ. 1995, 6: 219-227.PubMed Schuur ER, Kruse U, Iacovoni JS, Vogt PK: Nuclear factor I interferes with transformation induced by nuclear oncogenes. Cell Growth Differ. 1995, 6: 219-227.PubMed
28.
go back to reference Furuya T, Uchiyama T, Adachi A, Chochi Y, Oga A, Kawauchi S, Ishiglo K, Sasaki K: Relation of DNA ploidy to genetic aberrations detected by chromosomal CGH and FISH in gastric adenocarcinomas. Oncol Rep. 2006, 15: 1491-1496.PubMed Furuya T, Uchiyama T, Adachi A, Chochi Y, Oga A, Kawauchi S, Ishiglo K, Sasaki K: Relation of DNA ploidy to genetic aberrations detected by chromosomal CGH and FISH in gastric adenocarcinomas. Oncol Rep. 2006, 15: 1491-1496.PubMed
29.
go back to reference Weiss MM, Kuipers EJ, Postma C, Snijders AM, Pinkel D, Meuwissen SG, Albertson D, Meijer GA: Genomic alterations in primary gastric adenocarcinomas correlate with clinicopathological characteristics and survival. Cell Oncol. 2004, 26: 307-317.PubMedPubMedCentral Weiss MM, Kuipers EJ, Postma C, Snijders AM, Pinkel D, Meuwissen SG, Albertson D, Meijer GA: Genomic alterations in primary gastric adenocarcinomas correlate with clinicopathological characteristics and survival. Cell Oncol. 2004, 26: 307-317.PubMedPubMedCentral
30.
go back to reference Buffart TE, Carvalho B, Hopmans E, Brehm V, Kranenbarg EK, Schaaij-Visser TB, Eijk PP, van Grieken NC, Ylstra B, Velde van de CJ, Meijer GA: Gastric cancers in young and elderly patients show different genomic profiles. J Pathol. 2007, 211: 45-51. 10.1002/path.2085.CrossRefPubMed Buffart TE, Carvalho B, Hopmans E, Brehm V, Kranenbarg EK, Schaaij-Visser TB, Eijk PP, van Grieken NC, Ylstra B, Velde van de CJ, Meijer GA: Gastric cancers in young and elderly patients show different genomic profiles. J Pathol. 2007, 211: 45-51. 10.1002/path.2085.CrossRefPubMed
31.
go back to reference Pharoah PD, Oliveira C, Machado JC, Keller G, Vogelsang H, Laux H, Becker KF, Hahn H, Paproski SM, Brown LA, Caldas C, Huntsman D: CDH1 c-160a promotor polymorphism is not associated with risk of stomach cancer. Int J Cancer. 2002, 101: 196-197. 10.1002/ijc.10590.CrossRefPubMed Pharoah PD, Oliveira C, Machado JC, Keller G, Vogelsang H, Laux H, Becker KF, Hahn H, Paproski SM, Brown LA, Caldas C, Huntsman D: CDH1 c-160a promotor polymorphism is not associated with risk of stomach cancer. Int J Cancer. 2002, 101: 196-197. 10.1002/ijc.10590.CrossRefPubMed
33.
go back to reference Wang GY, Lu CQ, Zhang RM, Hu XH, Luo ZW: The E-cadherin gene polymorphism 160C->A and cancer risk: A HuGE review and meta-analysis of 26 case-control studies. Am J Epidemiol. 2008, 167: 7-14. 10.1093/aje/kwm264.CrossRefPubMed Wang GY, Lu CQ, Zhang RM, Hu XH, Luo ZW: The E-cadherin gene polymorphism 160C->A and cancer risk: A HuGE review and meta-analysis of 26 case-control studies. Am J Epidemiol. 2008, 167: 7-14. 10.1093/aje/kwm264.CrossRefPubMed
34.
go back to reference Verhage BA, van Houwelingen K, Ruijter TE, Kiemeney LA, Schalken JA: Single-nucleotide polymorphism in the E-cadherin gene promoter modifies the risk of prostate cancer. Int J Cancer. 2002, 100: 683-685. 10.1002/ijc.10541.CrossRefPubMed Verhage BA, van Houwelingen K, Ruijter TE, Kiemeney LA, Schalken JA: Single-nucleotide polymorphism in the E-cadherin gene promoter modifies the risk of prostate cancer. Int J Cancer. 2002, 100: 683-685. 10.1002/ijc.10541.CrossRefPubMed
35.
go back to reference Lindstrom S, Wiklund F, Jonsson BA, Adami HO, Balter K, Brookes AJ, Xu J, Zheng SL, Isaacs WB, Adolfsson J, Gronberg H: Comprehensive genetic evaluation of common E-cadherin sequence variants and prostate cancer risk: strong confirmation of functional promoter SNP. Hum Genet. 2005, 118: 339-347. 10.1007/s00439-005-0060-6.CrossRefPubMed Lindstrom S, Wiklund F, Jonsson BA, Adami HO, Balter K, Brookes AJ, Xu J, Zheng SL, Isaacs WB, Adolfsson J, Gronberg H: Comprehensive genetic evaluation of common E-cadherin sequence variants and prostate cancer risk: strong confirmation of functional promoter SNP. Hum Genet. 2005, 118: 339-347. 10.1007/s00439-005-0060-6.CrossRefPubMed
36.
go back to reference Tsukino H, Kuroda Y, Nakao H, Imai H, Inatomi H, Kohshi K, Osada Y, Katoh T: E-cadherin gene polymorphism and risk of urothelial cancer. Cancer Lett. 2003, 195: 53-58. 10.1016/S0304-3835(03)00130-7.CrossRefPubMed Tsukino H, Kuroda Y, Nakao H, Imai H, Inatomi H, Kohshi K, Osada Y, Katoh T: E-cadherin gene polymorphism and risk of urothelial cancer. Cancer Lett. 2003, 195: 53-58. 10.1016/S0304-3835(03)00130-7.CrossRefPubMed
37.
go back to reference Zhang X, Ma X, Zhu QG, Li LC, Chen Z, Ye ZQ: Association between a C/A single nucleotide polymorphism of the E-cadherin gene promoter and transitional cell carcinoma of the bladder. J Urol. 2003, 170: 1379-1382. 10.1097/01.ju.0000084297.43710.e9.CrossRefPubMed Zhang X, Ma X, Zhu QG, Li LC, Chen Z, Ye ZQ: Association between a C/A single nucleotide polymorphism of the E-cadherin gene promoter and transitional cell carcinoma of the bladder. J Urol. 2003, 170: 1379-1382. 10.1097/01.ju.0000084297.43710.e9.CrossRefPubMed
38.
go back to reference Yu JC, Hsu HM, Chen ST, Hsu GC, Huang CS, Hou MF, Fu YP, Cheng TC, Wu PE, Shen CY: Breast cancer risk associated with genotypic polymorphism of the genes involved in the estrogen-receptor-signaling pathway: a multigenic study on cancer susceptibility. J Biomed Sci. 2006, 13: 419-432. 10.1007/s11373-006-9069-7.CrossRefPubMed Yu JC, Hsu HM, Chen ST, Hsu GC, Huang CS, Hou MF, Fu YP, Cheng TC, Wu PE, Shen CY: Breast cancer risk associated with genotypic polymorphism of the genes involved in the estrogen-receptor-signaling pathway: a multigenic study on cancer susceptibility. J Biomed Sci. 2006, 13: 419-432. 10.1007/s11373-006-9069-7.CrossRefPubMed
39.
go back to reference Shin Y, Kim IJ, Kang HC, Park JH, Park HW, Jang SG, Lee MR, Jeong SY, Chang HJ, Ku JL, Park JG: A functional polymorphism (-347 G-->GA) in the E-cadherin gene is associated with colorectal cancer. Carcinogenesis. 2004, 25: 2173-2176. 10.1093/carcin/bgh223.CrossRefPubMed Shin Y, Kim IJ, Kang HC, Park JH, Park HW, Jang SG, Lee MR, Jeong SY, Chang HJ, Ku JL, Park JG: A functional polymorphism (-347 G-->GA) in the E-cadherin gene is associated with colorectal cancer. Carcinogenesis. 2004, 25: 2173-2176. 10.1093/carcin/bgh223.CrossRefPubMed
41.
go back to reference Cavallaro U, Christofori G: Cell adhesion and signalling by cadherins and Ig-CAMs in cancer. Nat Rev Cancer. 2004, 4 (2): 118-132. 10.1038/nrc1276.CrossRefPubMed Cavallaro U, Christofori G: Cell adhesion and signalling by cadherins and Ig-CAMs in cancer. Nat Rev Cancer. 2004, 4 (2): 118-132. 10.1038/nrc1276.CrossRefPubMed
Metadata
Title
A novel diffuse gastric cancer susceptibility variant in E-cadherin (CDH1) intron 2: A case control study in an Italian population
Authors
Soroush Nasri
Helen More
Francesco Graziano
Annamaria Ruzzo
Emily Wilson
Anita Dunbier
Cushla McKinney
Tony Merriman
Parry Guilford
Mauro Magnani
Bostjan Humar
Publication date
01-12-2008
Publisher
BioMed Central
Published in
BMC Cancer / Issue 1/2008
Electronic ISSN: 1471-2407
DOI
https://doi.org/10.1186/1471-2407-8-138

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