Elevated Microsatellite Alterations at Selected Tetranucleotides (EMAST) in Colorectal Cancer is Associated with an Elderly, Frail Phenotype and Improved Recurrence-Free Survival

  • Martin M. Watson
  • Arezo Kanani
  • Dordi Lea
  • Ramesh B. Khajavi
  • Jon Arne Søreide
  • Hartwig Kørner
  • Hanne R. Hagland
  • Kjetil SøreideEmail author
Translational Research and Biomarkers



Elevated microsatellite alterations at selected tetranucleotides (EMAST) is a poorly investigated form of microsatellite instability (MSI) in colorectal cancer (CRC).


The aim of this study was to investigate the clinicopathological features of EMAST in CRC and its relation to outcome.


A population-based, consecutive cohort of surgically treated stage I–III CRC patients investigated for high-frequency MSI (MSI-H) and EMAST. Clinicopathological differences were reported as odds ratios (OR) and survival was presented as hazard ratios (HR) with 95% confidence intervals (CIs).


Of 161 patients included, 25% were aged > 79 years. There was a large overlap in the prevalence of EMAST (31.7%) and MSI-H (27.3%) [82.4% of EMAST were also MSI-H]. EMAST had the highest prevalence in the proximal colon (OR 15.9, 95% CI 5.6–45.1; p < 0.001) and in women (OR 4.1, 95% CI 1.9–8.6; p < 0.001), and were poorly differentiated (OR 5.0, 95% CI 2.3–10.7; p < 0.001). Compared with EMAST-negative patients, EMAST-positive patients were older (median age 77 vs. 69 years; p < 0.001), leaner (median weight 67.5 vs. 77 kg; p = 0.001), had significantly higher rates of hypoalbuminemia (24% vs. 6%; OR 2.3, 95% CI 1.5–3.6; p = 0.002) and anemia (45% vs. 20%; OR 3.3, 95% CI 1.6–6.8; p = 0.001), and had elevated preoperative C-reactive protein (CRP) levels (51% vs. 34%; OR 1.9, 95% CI 1.0–3.9; p = 0.046). Improved recurrence-free survival was found in both MSI-H and EMAST subtypes. In multivariable analysis, node status (pN +), together with elevated CRP and MSI-positive, were the strongest prognostic factors for recurrence-free survival.


EMAST in CRC is associated with an older, leaner, and frailer phenotype with a lower risk of recurrence. The relevance of, and putative mechanisms to, EMAST warrants further investigation.



The QiaCUBE instrument was generously donated by the Hartman Family Fund.


This study was funded by the Folke Hermansen Cancer Fund, an unrestricted grant from the Mjaaland Foundation, and from the University Fund at the University of Stavanger.


Martin M. Watson, Arezo Kanani, Dordi Lea, Ramesh B. Khajavi, Jon Arne Søreide, Hartwig Kørner, Hanne R. Hagland, and Kjetil Søreide declare no conflicts of interest.


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Copyright information

© Society of Surgical Oncology 2019

Authors and Affiliations

  1. 1.Gastrointestinal Translational Research Unit, Laboratory for Molecular BiologyStavanger University HospitalStavangerNorway
  2. 2.Department of Gastrointestinal SurgeryStavanger University HospitalStavangerNorway
  3. 3.Department of Clinical MedicineUniversity of BergenBergenNorway
  4. 4.Department of PathologyStavanger University HospitalStavangerNorway
  5. 5.Department of Chemistry, Bioscience and Environmental TechnologyUniversity of StavangerStavangerNorway

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