Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
2818 Vol. 10, 2818 –2823, April 15, 2004 Clinical Cancer Research Clinical Significance of Dysadherin Expression in Gastric Cancer Patients Yutaka Shimada,1 Seiji Yamasaki,1 Yosuke Hashimoto,1 Tetsuo Ito,1 Jun-ichiro Kawamura1 Toshiya Soma,1 Yoshinori Ino,2 Yukihiro Nakanishi,2 Michiie Sakamoto,3 Setsuo Hirohashi,2 and Masayuki Imamura1 1 Department of Surgery and Surgical Basic Science, Graduate School of Medicine, Kyoto University, Kyoto, Japan; 2Pathology Division, National Cancer Center Research Institute, Tokyo, Japan; and 3 Department of Pathology, Keio University, Tokyo, Japan ABSTRACT Purpose: Dysadherin, a cancer-associated cell membrane glycoprotein, has been reported to down-regulate Ecadherin expression and promote metastasis. To evaluate the role of dysadherin in gastric cancer, we examined dysadherin and E-cadherin expression in gastric cancer patients. Experimental Design: Dysadherin and E-cadherin expression were evaluated in 276 gastric cancer patients by immunohistochemistry, and the results were compared with the clinicopathological findings of the subjects. Results: Dysadherin was not expressed in normal gastric epithelium. Both dysadherin and E-cadherin were localized to the cell membrane. Dysadherin expression was sometimes largely localized to infiltrating tumor cells or cells dissociating. Ninety gastric cancer patients (32.6%) were positive for dysadherin, and 151 patients (54.7%) showed preservation of E-cadherin expression. Expression of dysadherin was associated with moderately differentiated carcinoma and hematogenous metastasis, whereas reduced expression of E-cadherin showed an association with poorly differentiated carcinoma and peritoneal dissemination. As a result, dysadherin positivity and reduced E-cadherin expression were associated with a poor prognosis. In addition, patients with both dysadherin positivity and reduced Ecadherin had the worst prognosis. Multivariate analysis re- Received 4/25/03; revised 1/23/04; accepted 1/27/04. Grant support: This work was supported in part by a grant-in-aid from the Japanese Ministry of Education, Culture, Sports, Science, and Technology (Grant 14370385). The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked advertisement in accordance with 18 U.S.C. Section 1734 solely to indicate this fact. Requests for reprints: Yutaka Shimada, Department of Surgery and Surgical Basic Science, Graduate School of Medicine, Kyoto University, Kawaracho 54, Shogoin Sakyo-ku, Kyoto, 606-8507 Japan. Phone: 81-75-751-3626; Fax: 81-75-751-4390; E-mail: [email protected]. vealed that reduced E-cadherin expression was an independent prognostic factor, but dysadherin expression was not. Conclusion: Combined analysis of dysadherin and Ecadherin expression may help to predict the prognosis and the mode of metastasis in gastric cancer patients. Patients with dysadherin positivity have a higher risk of hematogenous metastasis, whereas patients with reduced E-cadherin expression have an increased risk of peritoneal dissemination. INTRODUCTION The cadherins are a family of intercellular adhesion molecules that are essential for the formation of tight junctions between cells (1), and E-cadherin is the most important among them. It has been suggested that inactivation of cadherin-mediated intercellular adhesion plays a role in the initial steps of tumor invasion and metastasis (2, 3). Several mechanisms that lead to irreversible and reversible inactivation of the E-cadherin/ catenin complex in human tumors have been reported (4), and the most recent studies have indicated that a cell membrane glycoprotein known as “dysadherin” down-regulates E-cadherin expression and promotes metastasis (5). Transfection of the dysadherin gene was shown to decrease E-cadherin protein expression and function without affecting its mRNA expression in an experimental model. In addition, a prognostic influence of dysadherin has already been suggested in patients with breast, pancreatic, and colorectal cancer (5–7). Gastric cancer is one of the most aggressive tumors and tends to be associated with hematogenous metastasis, peritoneal dissemination, and lymph node metastasis. Several studies have shown that down-regulation of the E-cadherin/catenin complex is associated with a poor prognosis of gastric cancer (8 –12). Reduced E-cadherin expression had been reported to show a positive association with peritoneal dissemination of gastric cancer (8, 11) but not with hematogenous metastasis (13). In fact, Shino et al. (8) indicated that preserved E-cadherin expression was associated with hematogenous metastasis, whereas multiple liver metastases of gastric cancer uniformly show strong E-cadherin expression (10). Therefore, the role of Ecadherin in hematogenous metastasis still remains controversial. In the present study, we examined the expression of dysadherin and E-cadherin in patients with gastric carcinoma and evaluated the prognostic influence of these parameters as well as the relationship with various clinicopathological factors. MATERIALS AND METHODS Patients Two hundred and seventy-six patients with gastric carcinoma who underwent gastrectomy at the Department of Surgery and Surgical Basic Science of Kyoto University from 1990 through 1997 were studied. All patients had a pathological diagnosis of adenocarcinoma (tumor-node-metastasis grade 1 to Downloaded from clincancerres.aacrjournals.org on June 18, 2017. © 2004 American Association for Cancer Research. Clinical Cancer Research 2819 Table 1 Clinicopathological characteristics of the subjects The mean age and standard deviation was 63.1 ⫾ 10.9 yrs. Variable pTNM stage 1a 1b 2 3a 3b 4 Gender Male Female Postoperative chemotherapy a No. 53 41 37 42 18 85 183 93 124 pTNM, pathological tumor-node-metastasis. grade 3). Each patient was classified according to the pathological tumor-node-metastasis system (International Union Against Cancer 1997, 5th edition; Table 1), and patients with Tis tumors were excluded from this study. There were no operative deaths. Standard D2 lymph node dissection was performed, with reconstruction of the stomach being done as follows: Roux-en-Y reconstruction was used for total gastrectomy, jejunal interposition was done for proximal gastrectomy, and gastroduodenostomy or gastrojejunostomy was performed for distal gastrectomy. Patients who received preoperative chemotherapy were excluded from this study, and postoperative chemotherapy was not performed routinely. However, 77 of 145 patients in stages 3a, 3b, and 4 received postoperative i.v. chemotherapy (cisplatin- and 5-fluorouracil-based), whereas 45 patients received oral uracil-tegafur. For the investigation of hematogenous metastasis and peritoneal dissemination, data on the preoperative and postoperative occurrence of metastasis were combined. Written informed consent was obtained from the patients regarding the performance of surgery and the use of resected samples for research. (The approval numbers of Kyoto University Institutional Review Board were 232 and G48, respectively.) Immunohistochemical Staining Immunohistochemical analysis was done retrospectively. Resected gastric specimens, which included both tumor and normal mucosa, were fixed in 10% formaldehyde solution and embedded in paraffin. Sections (4 m) were cut and mounted on aminopropyltriethoxysilane-coated glass slides, and immunohistochemical staining was performed using the avidin-biotin method, as described previously (14). NCC-M53 (diluted 1:5) was used for the detection of dysadherin expression (6) and HECD1 (diluted 1:20) was used for the detection of E-cadherin (a kind gift from Professor Takeichi, Kyoto University). Unmasking of antigens was performed by incubation in citrate buffer (pH 6.0) at 121°C for 20 min in autoclave. Then the sections were incubated overnight at 4°C with each antibody in PBS containing 5% horse serum and counterstained with Mayer’s hematoxylin. As a negative control, the primary antibody was replaced by normal mouse IgG. Evaluation of Immunohistochemical Staining The intensity of immunostaining was evaluated in five areas of each section for correlation and confirmation of the tissue analysis. E-Cadherin. After cell membranes were stained by HECD1, the pattern of E-cadherin immunostaining in cancer tissue was compared with that in normal gastric epithelium. The percent staining was scored as follows: 0 –9%, 0; 10 – 49%, 1; 50 – 89%, 2; 90 –100%, 3). When over 50% of the tumor cells were positive, the tumor was classified as showing “preserved E-cadherin expression,” whereas tumors were evaluated as showing “reduced E-cadherin expression” when fewer than 50% of the cells were positive (15). Dysadherin. After cell membranes were stained by NCC-M53, the pattern of dysadherin immunostaining in cancer tissue was compared with that observed in endothelial cells and lymphocytes. The percent staining was scored in the same manner as for E-cadherin. Tumors were classified as positive for dysadherin when ⬎50% of the cells were stained (6, 7). E-cadherin and dysadherin expression were evaluated by two authors (Y. S. and Y. H.), and the mean of the two scores assigned was calculated. If different scores were assigned, final agreement was obtained after discussion between the two researchers. Scoring of the Results Positive staining was assigned a score of “1,” and negative staining was scored as “0.” In addition, pT, pN, pM, histological grade, age, and gender were scored as follows: pT1, pT2 versus pT3, pT4: 1; pN0 versus pN1, pN2, pN3: 1; pM0 versus pM1; G1, G2 versus G3; R0 versus R1, ⬍64 years old versus ⱖ64 years old; Female versus Male. With regard to postoperative treatment, the two categories used were not done (0) or done (1). Statistical Analysis The ages of the patients were compared by the t test. Survival curves were calculated by the Kaplan-Meier method, and differences were analyzed by the log-rank test and Wilcoxon test. Multivariate analysis was performed using Cox’s proportional hazard model (16). The correlation between dysadherin and E-cadherin expression was statistically evaluated using Spearman’s correlation coefficients. Correlations between the expression of these adhesion molecules and each clinicopathological factor were evaluated using Fisher’s exact test and the 2 test. All tests of statistical significance were two-sided and JMP version 5 software for Macintosh (SAS Institute Inc., Cary, NC) was used. RESULTS Dysadherin staining was observed on the membranes of cancer cells, lymphocytes, and endothelial cells, as reported previously (5). E-cadherin was expressed in normal gastric epithelium, whereas dysadherin was not. Dysadherin expression by tumor cells was heterogenous, and it was concentrated in infiltrating tumor cells or cells dissociating in 24.7% of the patients (66 of 267; Fig. 1). Contrary to our expectation, dysadherin expression was not associated with E-cadherin expression (Fig. 2). Downloaded from clincancerres.aacrjournals.org on June 18, 2017. © 2004 American Association for Cancer Research. 2820 E-Cadherin/Dysadherin Expression in Gastric Cancer Fig. 1 Dysadherin and E-cadherin expression. Dysadherin and Ecadherin expression were both localized to the cell membrane. Dysadherin expression was observed in cancer cells (Fig. 1A), infiltrating lymphocytes, and endothelial cells but not in the normal gastric epithelium (Fig. 1B). On the other hand, E-cadherin was expressed by the normal gastric epithelium and also by cancer cells (Fig. 1C). Dysadherin expression was heterogenous in tumor cell nests (Fig. 1D), and its expression was predominantly observed in infiltrating tumor cells or cells dissociating in some cases (Fig. 1E). The arrows indicated the cancer cells (original magnification: 1, A-C at ⫻400; 1, D and E at ⫻200). The background characteristics of the patients and their immunostaining profiles for dysadherin and E-cadherin are summarized in Tables 2 and 3. Dysadherin staining was positive in 32.6% (90 of 276) and E-cadherin staining was preserved in 54.7% (151 of 276). Expression of dysadherin was associated with the patient’s age, moderately differentiated carcinoma (grade 2), M factor (tumor-node-metastasis classification), hematogenous metastasis, and residual tumor. On the other hand, reduced of E-cadherin expression showed an association with the poorly differentiated carcinoma (grade 3) and peritoneal dissemination. When the N factor (tumor-node-metastasis classification) was divided into N negative and N positive, dysadherin expression was also associated with N factor status (P ⫽ 0.023), but E-cadhedrin expression was not. Calculation of survival by the Kaplan-Meier method revealed that dysadherin positivity and reduced E-cadherin expression were both significant prognostic factors (Figs. 3 and 4). Combined analysis of E-cadherin and dysadherin staining re- Downloaded from clincancerres.aacrjournals.org on June 18, 2017. © 2004 American Association for Cancer Research. Clinical Cancer Research 2821 ported to show an association with distant metastasis of pancreatic cancer or colorectal cancer (6, 7). Therefore, our findings regarding dysadherin expression in gastric cancer were consistent with such previous reports. There are several steps and factors that are already known to contribute to the establishment of hematogenous metastasis (17–22), and dysadherin may also have a role in the establishment of such metastasis arising from gastric cancer. In patients with breast, pancreatic, and colorectal cancer, dysadherin positivity is associated with a worse prognosis than dysadherin negativity (5, 6, 7). The present study also suggested that dysadherin expression may predict the survival of gastric cancer patients. Dysadherin expression was also associated with age, moderately differentiated carcinoma (grade 2), and the M factor. The reason for the association between dysadherin ex- Fig. 2 Relationship between dysadherin and E-cadherin expression. The Y axis represents expression of dysadherin (%) and the X axis represents expression of E-cadherin (%). There was no association between the expression of these two molecules (r ⫽ 0.098; P ⫽ 0.105). Table 2 Clinicopathological characteristics of the patients stratified by dysadherin expression Variables vealed that patients with preservation of E-cadherin and no dysadherin expression had the best survival, whereas patients with reduced E-cadherin expression plus dysadherin positivity had the worst survival (Fig. 5). Those with abnormal expression of either dysadherin or E-cadherin showed intermediate survival (Fig. 5). Cox’s multivariate analysis revealed that pT, pN, pM, histological grade, residual tumor, and reduced E-cadherin expression were independent prognostic factors, but dysadherin expression was not (Table 4). DISCUSSION The cadherins are a family of transmembrane glycoproteins involved in homotypic calcium-dependent intercellular adhesion and are crucial facilitators of mutual association between vertebrate cells (1). More than 10 subclasses of cadherins have been identified, including E-cadherin. Reduced expression of Ecadherin is frequently observed in tumors with aggressive histopathological characteristics (8 –12). In several studies, Ecadherin has been found to be a significant prognostic factor for gastric cancer, because of an association with lymph node metastasis, poorly differentiated carcinoma, and peritoneal dissemination (8, 11, 12). In this study, we also found a significant association of E-cadherin expression with survival and with the above-mentioned tumor characteristics, although there was no association with lymph node metastasis. With regard to hematogenous metastasis, several reports suggested that reduced E-cadherin expression is not associated with this mode of tumor spread (8, 13). Interestingly, one study even suggested that preservation of E-cadherin expression was associated with hematogenous metastasis (8). Like these reports, our study also showed that E-cadherin expression was not associated with hematogenous metastasis. However, we also found that dysadherin was a significant prognostic factor for hematogenous metastasis of gastric cancer. Overexpression of dysaherin was originally reported to promote liver metastasis in an animal model (5), and dysadherin expression was also re- Dysadherin(⫺)a Dysadherin (⫹)b (n ⫽ 186) (n ⫽ 90) Age Mean SD Gender Male Female T pT1 pT2 pT3 pT4 N pN0 pN1 pN2 pN3 M pM0 pM1 Grade 1 2 3 R R0 R1 Operation DGc PG TG Postoperative chemotherapy No Yes Hematogenous metastasisd No Yes Peritoneal disseminationd No Yes P 0.019 62.1 11.3 65.3 9.9 0.148 118 68 65 25 45 98 34 9 13 53 17 7 77 55 31 23 24 32 18 16 150 36 58 32 15 52 119 11 45 34 151 35 60 30 103 1 82 46 2 42 102 84 50 40 171 15 68 22 134 52 64 26 0.252 0.115 0.003 2E-04 0.008 0.391 0.911 2E-04 0.872 a Negative. Positive. DG, distal gastrectomy; PG, proximal gastrectomy; pT, pathological tumor; pN, pathological node; pM, pathological metastasis; TG, total gastrectomy; R, residual tumor. d Including postoperative metastasis b c Downloaded from clincancerres.aacrjournals.org on June 18, 2017. © 2004 American Association for Cancer Research. 2822 E-Cadherin/Dysadherin Expression in Gastric Cancer Table 3 Clinicopathological characteristics of the patients stratified by E-cadherin expression Variables E-Cadherin (⫺)a E-Cadherin (⫹)b (n ⫽ 125) (n ⫽ 151) Age Mean SD Gender Male Female T pT1 pT2 pT3 pT4 N pN0 pN1 pN2 pN3 M pM0 pM1 Grade 1 2 3 R R0 R1 Operation DGc PG TG Postoperative chemotherapy No Yes Hematogenous metastasisd No Yes Peritoneal disseminationd No Yes P 0.382 63.8 11.6 62.6 10.3 0.461 80 45 103 48 18 74 24 9 40 77 27 7 39 42 22 22 62 45 27 17 89 36 119 32 7 39 79 19 58 74 91 34 120 31 62 1 62 87 2 62 63 62 89 62 106 19 113 18 78 47 120 31 0.092 0.253 pression and age is unclear, but more differentiated carcinoma of the stomach was reported to be associated with hematogenous metastasis (23), and our results may help to explain this association. Contrary to our expectation, dysadherin expression showed no relationship with E-cadherin expression by the tumor cells. In pancreatic cancer and colon cancer, there was also no significant association between dysadherin expression and E-cadherin expression (6, 7), so our data are consistent with these previous reports. In conclusion, our findings suggested that combined analysis of dysadherin and E-cadherin expression may help to predict the prognosis and mode of metastasis in gastric cancer patients, thus providing useful information for the follow-up of patients to detect recurrence. 0.144 0.03 0.194 0.35 0.156 0.426 0.002 a Reduced. Preserved. c DG, distal gastrectomy; PG, proximal gastrectomy; pT, pathological tumor; pN, pathological node; pM, pathological metastasis; TG, total gastrectomy; R, residual tumor. d Including postoperative metastasis. Fig. 3 Survival of patients with and without dysadherin positivity. The survival of patients with dysadherin expression was worse than that of patients without dysadherin expression. Dysadherin (⫹), dysadherin positivity; dysadherin (⫺), dysadherin negativity. b Table 4 Results of Cox multivariate analysis Variables Risk ratio 95% CIa P Age (⬎64) Gender (male) pT (⬎T2) pN pM Grade (⬎G2) R Postoperative chemotherapy E-Cadherin preserved Dysadherin positive 1.5 1.29 2.67 5.16 3.35 1.6 1.98 0.86 0.59 1.16 0.79–1.7 0.85–2.00 1.80–3.95 2.81–10.26 1.83–6.09 1.06–2.43 1.07–3.70 0.56–1.37 0.41–0.85 0.78–1.72 0.454 0.232 ⬍0.0001 ⬍0.0001 0.0001 0.025 0.03 0.49 0.004 0.458 a CI, confidence interval; pT, pathological tumor; pN, pathological node; pM, pathological metastasis; R, residual tumor. Fig. 4 Survival in relation to E-cadherin expression. The survival of patients with reduced E-cadherin expression was worse than that of patients with preserved E-cadherin expression. E-cadherin (⫹), preserved E-cadherin expression; E-cadherin (⫺), reduced E-cadherin expression. Downloaded from clincancerres.aacrjournals.org on June 18, 2017. © 2004 American Association for Cancer Research. Clinical Cancer Research 2823 Fig. 5 Survival in relation to the combined E-cadherin/dysadherin status. Patients with preserved E-cadherin expression and negative dysadherin expression had the best survival, whereas patients with reduced E-cadherin expression plus dysadherin positivity had the worst survival. E-Cad (⫹), preserved E-cadherin expression; E-Cad (⫺), reduced Ecadherin expression; dysad (⫹), dysadherin positivity; dysad (⫺), dysadherin negativity. ACKNOWLEDGMENTS We thank Sakiko Shimada for technical assistance with immunohistochemistry; Toby Cavanaugh for support in proofreading the manuscript; and Shunzou Maetani, MD, PhD (Vice President of Tenri Hospital Research Center) for excellent advice on statistical analysis. REFERENCES 1. Takeichi M. Cadherin cell adhesion receptors as a morphogenetic regulator. Science (Wash D C) 1991;251:1451–5. 2. Vleminckx K, Vakaet L Jr, Mareel M, Fiers W, van Roy F. Genetic manipulation of E-cadherin expression by epithelial tumor cells reveals an invasion suppressor role. Cell 1991;66:107–19. 3. Frixen UH, Behrens J, Sachs M, et al. E-cadherin-mediated cell-cell adhesion prevents invasiveness of human carcinoma cells. J Cell Biol 1991;113:173– 85. 4. Hirohashi S. Inactivation of the E-cadherin-mediated cell adhesion system in human cancers. Am J Pathol 1998;153:333–9. 5. Ino Y, Gotoh M, Sakamoto M, Tsukagoshi K, Hirohashi S. Dysadherin, a cancer-associated cell membrane glycoprotein, down-regulates E-cadherin and promotes metastasis. Proc Natl Acad Sci USA 2002;99: 365–70. 6. Shimamura T, Sakamoto M, Ino Y, et al. Dysadherin overexpression in pancreatic ductal adenocarcinoma reflects tumor aggressiveness: relationship to E-cadherin expression. J Clin Oncol 2003;21:659 – 67. 7. Aoki S, Shimamura T, Shibata T, et al. Prognostic significance of dysadherin expression in advanced colorectal carcinoma. Br J Cancer 2003;88:726 –32. 8. Shino Y, Watanabe A, Yamada Y, et al. Clinicopathologic evaluation of immunohistochemical E-cadherin expression in human gastric carcinomas. Cancer (Phila) 1995;76:2193–201. 9. Jawhari A, Jordan S, Poole S, Browne P, Pignatelli M, Farthing MJ. Abnormal immunoreactivity of the E-cadherin-catenin complex in gastric carcinoma: relationship with patient survival. Gastroenterology 1997;112:46 –54. 10. Mayer B, Johnson JP, Leitl F, et al. E-cadherin expression in primary and metastatic gastric cancer: down-regulation correlates with cellular dedifferentiation and glandular disintegration. Cancer Res 1993; 53:1690 –5. 11. Yonemura Y, Endou Y, Kimura K, et al. Inverse expression of S100A4 and E-cadherin is associated with metastatic potential in gastric cancer. Clin Cancer Res 2000;6:4234 – 42. 12. Tanaka M, Kitajima Y, Edakuni G, Sato S, Miyazaki K. Abnormal expression of E-cadherin and -catenin may be a molecular marker of submucosal invasion and lymph node metastasis in early gastric cancer. Br J Surg 2002;89:236 – 44. 13. Ougolkov A, Yamashita K, Bilim V, Takahashi Y, Mai M, Minamoto T. Abnormal expression of E-cadherin, -catenin, and c-erbB-2 in advanced gastric cancer: its association with liver metastasis. Int J Colorectal Dis 2003;18:160 – 6. 14. Uchida S, Shimada Y, Watanabe G, et al. In oesophageal squamous carcinoma vascular endothelial growth factor is associated with p53 mutation, advanced stage and poor prognosis. Br J Cancer 1998;77: 1704 –9. 15. Sato F, Shimada Y, Watanabe G, Uchida S, Makino T, Imamura M. Expression of vascular endothelial growth factor, matrix metalloproteinase-9 and E-cadherin in the process of lymph node metastasis in oesophageal cancer. Br J Cancer 1999;80:1366 –72. 16. Cox DR. Regression models and life tables. J R Stat Soc B 1972; 34:187–220. 17. Ikeguchi M, Katano K, Oka A, Tsujitani S, Maeta M, Kaibara N. Relationship between hematogenic metastasis of gastric cancer and the maximum extent of venous invasion by cancer cells in the gastric wall. Hepatogastroenterology 1995;42:660 –5. 18. Alexiou D, Karayiannakis AJ, Syrigos KN, et al. Clinical significance of serum levels of E-selectin, intercellular adhesion molecule-1, and vascular cell adhesion molecule-1 in gastric cancer patients. Am J Gastroenterol 2003;98:478 – 85. 19. Karayiannakis AJ, Syrigos KN, Polychronidis A, et al. Circulating VEGF levels in the serum of gastric cancer patients: correlation with pathological variables, patient survival, and tumor surgery. Ann Surg 2002;236:37– 42. 20. Tang W, Nakamura Y, Tsujimoto M, et al. Heparanase: a key enzyme in invasion and metastasis of gastric carcinoma. Mod Pathol 2002;15:593– 8. 21. Wang C-S, Lin K-H, Hsu Y-C, Hsueh S. Distant metastasis of gastric cancer is associated with elevated expression of the antimetastatic nm23 gene. Cancer Lett 1998;128:23–9. 22. Fidler IJ, Radinsky R. Search for genes that suppress cancer metastasis. J Natl Cancer Inst (Bethesda) 1996;88:1700 –3. 23. Moriguchi S, Kamakura T, Odaka T, et al. Clinical features of the differentiated and undifferentiated types of advanced gastric carcinoma: univariate and multivariate analyses. J Surg Oncol 1991;48:202– 6. Downloaded from clincancerres.aacrjournals.org on June 18, 2017. © 2004 American Association for Cancer Research. Clinical Significance of Dysadherin Expression in Gastric Cancer Patients Yutaka Shimada, Seiji Yamasaki, Yosuke Hashimoto, et al. Clin Cancer Res 2004;10:2818-2823. Updated version Cited articles Citing articles E-mail alerts Reprints and Subscriptions Permissions Access the most recent version of this article at: http://clincancerres.aacrjournals.org/content/10/8/2818 This article cites 21 articles, 6 of which you can access for free at: http://clincancerres.aacrjournals.org/content/10/8/2818.full#ref-list-1 This article has been cited by 6 HighWire-hosted articles. Access the articles at: http://clincancerres.aacrjournals.org/content/10/8/2818.full#related-urls Sign up to receive free email-alerts related to this article or journal. To order reprints of this article or to subscribe to the journal, contact the AACR Publications Department at [email protected]. To request permission to re-use all or part of this article, contact the AACR Publications Department at [email protected]. Downloaded from clincancerres.aacrjournals.org on June 18, 2017. © 2004 American Association for Cancer Research.