Survivin expression and its potential clinical significance in gastrointestinal
Meltem Baykaraa, Murat Akkusa, Ramazan Yildiza, Ipek Isik Gonulb, Ayse Dursunb, Ugur Coskuna,
Mustafa Beneklia, Alper Sevincc, Faysal Daned, Suleyman Buyukberbera,⁎
aGazi University Medical Faculty, Department Of Medical Oncology, Ankara, Turkey
bGazi University Medical Faculty, Department Of Pathology, Ankara, Turkey
cGaziantep University Medical Faculty, Department Of Medical Oncology, Gaziantep, Turkey
dMarmara University Medical Faculty, Department Of Medical Oncology, Istanbul, Turkey
a b s t r a c ta r t i c l ei n f o
Received 28 January 2011
Received in revised form 2 October 2011
Accepted 3 October 2011
Available online 20 October 2011
Inhibitors of apoptosis proteins
Gastrointestinal stromal sarcoma
This study was designed to determine the level of survivin expression and its clinical significance as a prog-
nostic factor in gastrointestinal stromal sarcoma (GIST). Twenty patients (12 males and 8 females) ranging in
age from 25 to 72, with a median age of 53 were evaluated. Failure of TKI treatment was higher in the survi-
vin-positive group (p=0.06). The rate of metastasis was significantly higher in the survivin positive group vs.
the negative group (80% vs. 30%, p=0.18). The median overall survival (OS) time was 114 (range 29–199)
months, and the median disease-free survival (DFS) time was 88 (range 40–135) months. The median pro-
gression-free survival (PFS) time was 40 (range 24–55) months. Further, a comparison of patients with sur-
vivin positive versus negative tumors, revealed no significant difference for OS, DFS, and PFS (p=0.45,
p=0.19, p=0.55, respectively), number of mitoses in 50 HPF (p=0.14), and tumor size (p=0.94).
In conclusion, survivin was highly expressed in GISTs, although we found no correlation between survivin ex-
pression and PFS, DFS and OS, survivin may be a predictive marker in GISTs for disease progression. We be-
lieve that additional studies are warranted to determine the clinical significance of survivin expression as a
prognostic or predictive marker in patients with GIST.
Crown Copyright © 2011 Published by Elsevier B.V. All rights reserved.
Gastrointestinal stromal tumors (GISTs) are rare, responsible for
only 0.13% of all gastrointestinal malignancies, and constitute 80% of
the gastrointestinal mesenchymal tumors [1,2]. They are generally
observed in middle to older age individuals with median age of 60
at diagnosis. There is also no significant difference in sex distribu-
tions. In nearly 95% of cases, the primary tumor site is the gastrointes-
tinal tract including the stomach (50–60%), small intestine (20–30%),
large intestine (10%), esophagus (5%), and the mesentery, omentum,
and retroperitoneum in b10% of cases . GISTs exhibit a wide spec-
trum of clinical attributes and outcomes. While some GIST lesions
progress rapidly, with 15% to 50% being metastatic at the time of diag-
nosis, others are asymptomatic and remain stable for many years
being diagnosed only incidentally [4,5]. In addition, despite surgical
resection, 40% to 80% of GISTs recur locally, or metastasize to the peri-
toneum and/or liver. The 5-year overall survival (OS) rate is approxi-
mately 50% after radical resection, and the median survival time was
estimated to be 9 to 20 months for unresectable or metastatic GISTs
prior to imatinib therapy . Regional lymph node metastasis and
extra-abdominal metastases are rare . Approximately 90% to 95%
of GISTs express the Kit protein, a trans-membrane receptor for
stem cell factor with the intracytoplasmic portion functioning as a ty-
rosine kinase [8,9]. GISTs are characterized by gain-of-function
mutations in the Kit proto-oncogene, most commonly involving the
exon 11, but in other cases involving exon 9, 13, or 17 . Develop-
ment of platelet-derived growth factor receptor (PDGFRa) mutations
in GISTs without Kit mutations seems to be another alternative onco-
genic mechanism . Prior to the development of imatinib, the pri-
mary treatment for GIST was surgery, but in these patients
recurrence was common and survival was poor [1,3]. Since the devel-
opment of TKIs, such as imatinib, sunitinib, and nilotinib, outcomes
have improved significantly, and studies are ongoing which may
help to determine  the role of TKIs in adjuvant and neoadjuvant
settings. It is hoped that these future studies will help in the develop-
ment new agents for successful therapies against drug-resistant GISTs
. In recent years, research has helped us to understand the mecha-
nisms of cancer development. One mechanism under study is apopto-
sis [10,11], which is regulated by numerous genes [12,13], including
survivin, which is an anti-apoptotic protein that suppresses apoptosis
by the inhibition of caspase-3 and caspase-7 activity. Survivin is
International Immunopharmacology 11 (2011) 2227–2231
⁎ Corresponding author at: Gazi University Medical Faculty, Department of Medical
Oncology Besevler, 06500 Ankara, Turkey. Tel.: +90 312 2025830; fax: +90 312
E-mail address: firstname.lastname@example.org (S. Buyukberber).
1567-5769/$ – see front matter. Crown Copyright © 2011 Published by Elsevier B.V. All rights reserved.
Contents lists available at SciVerse ScienceDirect
journal homepage: www.elsevier.com/locate/intimp
also cell-cycle regulated and expressed in the G2/M phase of the
cell cycle, interacting with mitotic spindle tubules and increased
caspase-3 activity. In addition, over-expression of survivin has onco-
genic potential as it may overcome the G2/M phase checkpoint to
enforce cell progression through mitosis, and initiate development
of neoplastic clones [14,15]. In most normal adult tissues, survivin
is undetectable, but is detectable in fetal tissue from a variety of
human cancer tissues . In some studies, the over expression of
survivin has been correlated with more aggressive clinical behavior,
including liver, colorectal, breast, lung, esophageal, and gastric can-
cers [17-24]. Defects in apoptotic mechanisms also play a crucial
role in resistance to chemotherapy and radiotherapy and it is here
that survivin may serve as a diagnostic marker and potential drug tar-
get [18,25,26]. In this study, we determined the expression of survivin
in tumor tissue from GIST patients and examined the prognostic and
significance importance of this marker.
2. Materials and method
This study included a retrospectiveanalysis of 20 patients (12 males
and 8 females) who were diagnosed with GIST at Gazi University Med-
tion, presence of metastasis and region, risk groups according to tumor
size, and number of mitoses. The project was approved by the hospital
Immunohistochemical (IHC) staining was performed on 4 μm
sections of the parafine-embedded tissue blocks. The antigen was
retrieved with 0.01 M citrate buffer (pH 6.0) by heating the sample
in a microwave oven at a controlled final temperature of 600 C for
20 min. Endogenous peroxidase activity was blocked by incubating
the slides in 3% hydrogen peroxide. The sections were then incubated
for2 hand20 minatroomtemperaturewithprimaryantibodysurvivin
Ab-5 (rabbit polyclonal antibody-Ig G, Lab Vision) and then secondary
antibody (Multi-species Ultra Streptavidin detection system-HRP;
Signet, Massachusetts, USA), respectively. Bound antibodies were visu-
alized using a streptavidinbiotin-peroxidase complex-binding tech-
nique and AEC (3 Amino-9 Ethylcarbazol) was used as the chromogen
was performed on normal gastric mucosa tissue. Cells were considered
positive for survivin when immunoreactivity was clearly observed in
their cytoplasm or nuclei. The cases with positive cells less than 5%
were considered as negative and those with positive cells≥5% were
considered as positive.
2.2. Statistical analysis
Statistical analyses were performed using SPSS 15.0 software.
The study variants were analyzed on the basis of the One-Sample
Kolmogorov–Smirnow test according to normal distribution. The
data conforming to normal distribution are given with their arithmetic
means and standard deviations, and the nonconforming data are
provided with their median values. The X2, Fischer–Exact, and Mann–
Whitney U tests were used in the statistical evaluation. The impact of
survivin status on survival was investigated by log rank test. Kaplan–
ly accepted as significant.
Among the 20 GIST patients in this series, symptoms and findings
included abdominal pain (n=10, 50%), melena (n=8, 40%), and
drowsiness (n=2, 10%). Tumor sites included the small intestine
(n=11, 55%), stomach (n=7, 35%), and the mesentery (n=2, 10%).
At the time of diagnosis, 5 patients had metastatic disease, and 5
patients who did not exhibit metastatic disease developed liver metas-
tasesby thetimeoffollow-up. The mostcommonsiteofmetastasiswas
the liver (90%). Only one patient had peritoneal metastasis. All patients
were treated surgically, 18 (85%) of whom had their tumors resected
with curative intent and 2 of whom received debulking surgery.
Four patients (20%) had positive surgical margins and during surgery,
8 patients (40%) had lymph nodes removed, although only one lymph
ed spindle-cell GISTs in 15 patients, and mixed-cell GISTs in 5 patients.
There were no epithelioid GISTs observed. The median tumor size was
9.96 cm (range 4–30 cm) that had a median 6.2 (range 0–22) mitosis
per 50 high-power microscopic fields (HPF). A risk assessment was
undertaken based on tumor size and the number of mitosis, with 9 pa-
3 (15%) in the low risk group. The tumors in all patients were positive
for the stem cell factor receptor (CD 117) and cytoplasmic, but not nu-
clear expression of survivin observed in the tumors of 10 patients,
(Fig. 1). The clinical and pathological characteristics of survivin-
positive and negative cases are shown in Table 1.
After surgical intervention, 11 patients received imatinib due to
relapse and/or progressive disease, 5 patients who developed pro-
gressive disease following imatinib treatment were given sunitinib,
and 2 patients were given nilotinib because of progressive disease fol-
lowing sunitinib treatment. Five patients who had progressive dis-
ease despite treatment with TKIs were all survivin positive. The TKI
treatment (imatinib) rate of failure was higher in the survivin-
positive group (p=0.06), although this was not a statistically signif-
icant observation (Fig. 2). Five patients developed metastasis at
follow-up who did not have metastasis at diagnosis, and all but one
were survivin positive. Seven of the 10 patients with metastatic dis-
ease were survivin positive, and the rate of metastasis was higher in
the survivin positive group compared to the survivin negative group
(80% vs. 30%, p=0.18) (Fig. 3).
Four patients dieddue todisease progression,and 1 patient waslost
during the follow-up phase. The median OS time was 114 (%95 CI,
29–199) months, the median DFS time was 88 (%95 CI, 40.0–135)
months, and the median PFS was 62 (%95 CI, 30.9–93)months. There
was no significant difference for OS (Fig. 4), DFS (Fig. 5), PFS (Fig. 6)
(p=0.45, p=0.26, p=0.19, respectively), number of mitoses in 50
HPFs (p=0.14), and tumor size (p=0.94) between survivin positive
and negative patients, likely due to the small patient population.
GISTs are the most common type of sarcoma in the gastrointestinal
tract, and surgery is the primary treatment, although, many patients
still develop recurrences and/or metastasis . While some lesions
progress rapidly, and 15% to 50% of GISTs have metastases at the time
of diagnosis, others are asymptomatic remaining stable for many
years and are diagnosed only incidentally [4,5]. Treatment with the
ever, theemergence ofdrug-resistant tumors has limitedthe long-term
benefit of these drugs in most patients [27,28].
Survivin is a well-known apoptosis inhibitor and is a bi-functional
protein that suppresses apoptosis and regulates cell division. Over-
expression of survivin has oncogenic potential [14,15] and it is widely
expressed in fetal tissues and human cancers, but generally not in
normal adult tissues except in placentae and thymi. It is also
expressed in cancer cell lines, including some lung, colon, gastric,
breast, prostate, and pancreatic lines, as well as in neuroblastoma
and lymphoma. As a tumor marker, survivin has been a focus for
many scientists ; however, data within the literature concerning
the prognostic significance of survivin is controversial. Some of the
literature reports that an increase in nuclear survivin expression
M. Baykara et al. / International Immunopharmacology 11 (2011) 2227–2231
relates to poor prognostic outcome, others mention improved prog-
nostic outcomes, or a lack of prognostic significance [30,35]. Okada
et al. reported that survivin is found primarily in the cytoplasm, but
in some tumors it may be found mainly in the nuclei and that its
expression in the nuclei could be associated with more favorable out-
comes . Kennedy et al. also reported that survivin is expressed in
the nucleus and that its expression level correlates with outcome in
breast cancer . In our study, we report an association between
survivin expression and the development of metastasis, but found
no other association between survivin expression and OS, DFS and
PFS, due to the small number of patients enrolled in this study. Defin-
itive studies regarding survivin expression as a prognostic factor in
patients with GIST will require larger, more in-depth studies. In addi-
tion, such studies may also help to determine the association between
survivin expression and the occurrence of metastases curative surgery.
Mitotic index and tumor size is known to be a prognostic marker for
recurrence or metastasis of GISTs, but there was no significant differ-
ence in mitosis number in 50 HPFs between the survivin positive and
tic factor, irrelevant to survivin expression.
Survivin expression as a predictive marker for anticancer therapy is
not yet a definitive marker,  although, our data and others support
its potential. Chemotherapy and radiotherapy eradicate cancer cells by
apoptosis, and in cancer cells, the expression of apoptosis inhibitors,
such as survivin, could have a role in the development of resistance to
chemotherapy [18–39]. Asanuma, et al., reported that survivin could
that survivin expression might be a predictive marker for chemothera-
py resistance in esophageal cancer [23,40]. In our study, we observed
that 5 patients, all with progressive disease despite treatment with
TKIs, were all survivin positive. Failure of TKI treatment was higher
Fig. 1. Cytoplasmic staining of survivin by immunohistochemistry. A. A case of high-
grade GIST, which consists of hypercellular spindle cells with moderate cytological aty-
pia, streptavidine-biotin peroxidase X100. B. A case of low-grade GIST, which consists
of pure spindle cells, with no staining of survivin, streptavidine-biotin peroxidase
Clinicopathologic characteristics of patients.
Survivin positive Survivin negative
n  n 
Response to imatinib
48.5 (25–69) 53 (31–72)
Fig. 2. Response to imatinib treatment according to survivin expression. The imatinib
treatment rate of failure was higher in the survivin-positive group (p=0.06), but
this is not a statistically significant due to the small number of patients enrolled in
Fig. 3. The presence of metastases according to survivin expression. The rate of metas-
tasis was higher in the survivin positive group (p=0.18) but this is not a statistically
significant due to the small number of patients enrolled in this study.
M. Baykara et al. / International Immunopharmacology 11 (2011) 2227–2231
within the survivin positive group, but this difference was not statisti-
cally significant. Even so, the treatment failure group did exhibit a
high level of survivin expression. Therefore, we suggest that survivin
may be a potential marker of therapeutic unresponsiveness.
In this study, survivin was highly expressed in GISTs. And, although
we found no correlation between survivin expression and DFS, PFS, or
OS, this increase in survivin expression may be a predictive marker for
TKI resistance, metastatic recurrence during the course of the disease,
and a new target molecule for anticancer therapy. We believe that larg-
er, more in-depth studies should be undertaken to more accurately
determine the clinical significance of survivin expression as a prognos-
tic or predictive marker in GISTs.
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