N-telopeptide of type I collagen is useful for monitoring therapeutic response in non-small cell lung cancer patients with bone metastases

Multiple roles for basement membrane proteins in cancer progression and EMT

Metastasis or the progression of malignancy poses a major challenge in cancer therapy and is the principal reason for increased mortality. The epithelial-Mesenchymal transition (EMT) of the Basement Membrane (BM) allows cells of epithelial phenotype to transform into a mesenchymal-like (quasi-mesenchymal) phenotype and metastasize via the lymphovascular system through a metastatic cascade by intravasation and extravasation. This helps in the progression of carcinoma from the primary site to distant organs. Collagen, laminin, and integrin are the prime components of BM and help in tumor cell metastasis, which makes them ideal cancer drug targets. Further, recent studies have shown that collagen, laminin, and integrin can be used as a biomarker for metastatic cells. In this review, we have summarized the current knowledge of such therapeutics, which are either currently in preclinical or clinical stages and could be promising cancer therapeutics. DATA AVAILABILITY: Not applicable.

Targeting Type I Collagen for Cancer Treatment

Collagen is the most abundant protein in animals. Interactions between tumor cells and collagen influence every step of tumor development. Type I collagen is the main fibrillar collagen in the extracellular matrix and is frequently up-regulated during tumorigenesis. The binding of type I collagen to its receptors on tumor cells promotes tumor cell proliferation, epithelial-mesenchymal transition, and metastasis. Type I collagen also regulates the efficacy of tumor therapies, such as chemotherapy, radiotherapy, and immunotherapy. Furthermore, type I collagen fragments are diagnostic markers of metastatic tumors and have prognostic value. Inhibition of type I collagen synthesis has been reported to have anti-tumor effects in animal models. However, collagen has also been shown to possess anti-tumor activity. Therefore, the roles that type I collagen plays in tumor biology are complex and tumor type-dependent. In this review, we discuss the expression and regulation of synthesis of type I collagen, as well as the role up-regulated type I collagen plays in various stages of cancer progression. We also discuss the role of collagen in tumor therapy. Finally, we highlight several recent approaches targeting type I collagen for cancer treatment. This article is protected by copyright. All rights reserved.

Predictive and Prognostic Biomarkers for Lung Cancer Bone Metastasis and Their Therapeutic Value

Lung cancer is the leading cause of cancer-related death worldwide. Bone metastasis, which usually accompanies severe skeletal-related events, is the most common site for tumor distant dissemination and detected in more than one-third of patients with advanced lung cancer. Biopsy and imaging play critical roles in the diagnosis of bone metastasis; however, these approaches are characterized by evident limitations. Recently, studies regarding potential biomarkers in the serum, urine, and tumor tissue, were performed to predict the bone metastases and prognosis in patients with lung cancer. In this review, we summarize the findings of recent clinical research studies on biomarkers detected in samples obtained from patients with lung cancer bone metastasis. These markers include the following: (1) bone resorption-associated markers, such as N-terminal telopeptide (NTx)/C-terminal telopeptide (CTx), C-terminal telopeptide of type I collagen (CTx-I), tartrate-resistant acid phosphatase isoform 5b (TRACP-5b), pyridinoline (PYD), and parathyroid hormone related peptide (PTHrP); (2) bone formation-associated markers, including total serum alkaline phosphatase (ALP)/bone specific alkaline phosphatase(BAP), osteopontin (OP), osteocalcin (OS), amino-terminal extension propeptide of type I procollagen/carboxy-terminal extension propeptide of type I procollagen (PICP/PINP); (3) signaling markers, including epidermal growth factor receptor/Kirsten rat sarcoma/anaplastic lymphoma kinase (EGFR/KRAS/ALK), receptor activator of nuclear factor κB ligand/receptor activator of nuclear factor κB/osteoprotegerin (RANKL/RANK/OPG), C-X-C motif chemokine ligand 12/C-X-C motif chemokine receptor 4 (CXCL12/CXCR4), complement component 5a receptor (C5AR); and (4) other potential markers, such as calcium sensing receptor (CASR), bone sialoprotein (BSP), bone morphogenetic protein 2 (BMP2), cytokeratin 19 fragment/carcinoembryonic antigen (CYFRA/CEA), tissue factor, cell-free DNA, long non-coding RNA, and microRNA. The prognostic value of these markers is also investigated. Furthermore, we listed some clinical trials targeting hotspot biomarkers in advanced lung cancer referring for their therapeutic effects.

Utility of urinary type I collagen cross-linked N-telopeptide as a prognostic indicator in breast cancer patients with bone metastases

BACKGROUND

Breast cancer patients with bone metastases are usually managed with bone modifying agents, such as zoledronic acid and denosumab, and some bone turnover markers (BTMs) have been recognized as prognostic indicators in such patients. Although several studies have demonstrated the validity of BTMs as prognostic markers in patients treated with zoledronic acid, few studies have reported the utility of BTMs with denosumab treatment. In this study, we evaluated whether urinary N-telopeptide of type I collagen (u-NTX) can be a prognostic indicator in patients treated with denosumab.

METHODS

Thirty-six breast cancer patients newly diagnosed with bone metastases were evaluated retrospectively. Patients were treated with denosumab and anti-cancer drugs. u-NTX levels were measured 1 month before and after administration of denosumab, and the ratio of u-NTX levels before and after denosumab (change ratio) was assessed for its association with prognosis.

RESULTS

Levels of u-NTX decreased after denosumab administration in all patients except for one. The median value of the u-NTX change ratio was 0.766. Based on the change ratio, patients were divided into either a "high group" (n = 18) or a "low group" (n = 18). The low group showed significantly shorter overall survival (OS) compared with the high group (low group 15.0 months; high group 54.0 months; P = 0.012). Multivariate analysis indicated that the "low group" was an independent prognostic factor for OS (P = 0.028).

CONCLUSION

We demonstrated that the u-NTX change ratio in denosumab-treated breast cancer patients with bone metastases can be a prognostic marker.

[Progress of Biomarkers in Diagnosis of Bone Metastases of Lung Cancer]

Bone is one of the most metastatic sites of advanced malignant tumors. With the continuous improvement of diagnosis and treatment of malignant tumors, the survival time of patients is prolonged and incidence of bone metastases also increases. Lung cancer is the leading cause of cancer-related mortality worldwide. It is estimated that the incidence of bone metastases in patients advanced lung cancer is about 30%-40%. The traditional diagnosis of bone metastases in lung cancer is based on clinical symptoms, X ray, computed tomography (CT), magnetic resonance imaging (MRI) and pathology. Recently, a large number of exploratory studies have reported blood biomarkers as indicators of bone metastasis screening and efficacy evaluation. In this review, we summarize the progress of biomarkers in diagnosis of bone metastases of lung cancer.
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A meta-analysis survey of appropriate bone turnover markers in the detection of bone metastasis in lung cancer

BACKGROUND

A number of studies have investigated the clinical significance of bone turnover markers (BTMs) for the diagnosis of bone metastasis (BM) in lung cancer; however, they led to contradictory results. The aim of this meta-analysis was to investigate whether BTMs differ between lung cancer patients with and without BM.

METHODS

Articles were identified by searching Medline, Embase, Web of Science and Scopus. The studies that were identified were pooled and the weighted mean difference (WMD) and its corresponding 95% confidence interval (CI) were calculated. Subgroup analyses and publication bias detection were also conducted.

RESULTS

A final analysis of 1720 subjects (707 patients with BM and 1013 patients without BM) was performed from 16 cohort studies. From the pooled data in the meta-analysis, the total alkaline phosphatase (TALP) (104.35 U/l [95% CI 33.36-175.34]), bone-specific ALP (BALP) (13.24 μg/l [95% CI 8.50-17.98] or 6.84 U/l [95% CI 2.98-10.70]), C-terminal cross-linked telopeptide of type I collagen (ICTP) (5.07 μg/l [95% CI 3.58-6.56]) and N-terminal cross-linked telopeptide of type I collagen (NTX) (5.08 nM bone collagen equivalent/l [95% CI 2.82-7.33]) were significantly lower among BM patients than non-BM patients. Subgroup analyses detected that the serum level of tartrate-resistant acid phosphatase isoform 5b was significantly reduced in Caucasian patients with BM (-0.64 U/l [95% CI -1.02 to -0.25]), while increased in Asian patients with BM (2.69 U/l [95% CI 0.08-5.31]), compared to patients without BM.

CONCLUSIONS

The present meta-analysis suggested that serum measurement of TALP, BALP, ICTP and NTX might be helpful in detecting BM in lung cancer.

Bone markers for monitoring efficacy in patients with bone metastases receiving zoledronic acid: a review of published data

Bone metastases occur frequently in patients with advanced solid tumors and can create serious clinical problems that are commonly referred to as skeletal-related events. Although bisphosphonates, especially zoledronic acid, have emerged as an integral determinant of managing metastatic bone disease, their application remains a challenge because of the lack of standardized measures and their side effects. Since factors derived from bone metabolism are potentially useful to measure the efficacy of zoledronic acid, several clinical trials have investigated these bone markers with respect to their monitoring values. The results suggest that a greater decline in bone marker levels is associated with a more reduced incidence of skeletal-related events and a better improvement of symptoms. This review summarizes the available evidence on the clinical use of bone markers in monitoring zoledronic acid in various cancers with bone metastases including breast, prostate and lung cancer.

Bisphosphonates in the treatment of patients with lung cancer and metastatic bone disease: a systematic review and meta-analysis

PURPOSE

Bisphosphonates are known to prevent skeletal-related events (SREs) in advanced breast cancer, prostate cancer, and multiple myeloma. This systematic review assessed the efficacy of bisphosphonates in preventing SREs, controlling pain, and overall survival in patients with bone metastases from lung cancer.

METHODS

We searched MEDLINE, EMBASE, Web of Science, and the Cochrane Library databases through November 10, 2011 for controlled trials that included lung cancer patients with bone metastases treated with bisphosphonates. Two reviewers independently extracted data on pain control, survival, and SREs and evaluated the quality of each study. Meta-analyses were performed when there were two or more trials with similar outcomes.

RESULTS

Twelve trials met our inclusion criteria and included 1,767 patients. Studies were placebo-controlled, or had compared bisphosphonates with other modalities (chemotherapy, radiation therapy, or radioisotope therapy), or had used different bisphosphonates as active controls. Randomized controlled trials did not report adequate descriptions of randomization procedures, allocation concealment, and blinding, resulting in low-quality scores. Patients treated with zoledronic acid + chemotherapy had fewer SREs than those receiving chemotherapy alone (relative risk (RR) 0.81, 95 % confidence interval (CI) 0.67-0.97). Pain control improved when a bisphosphonate was added to another treatment modality (chemotherapy or radiation; RR 1.18, 95 %CI 1.0-1.4). Bisphosphonate therapy improved survival compared to controls, but the difference failed to reach statistical significance (mean of 72 days, 95 %CI -8.9 to 152.9).

CONCLUSIONS

Treatment with bisphosphonates reduced SREs, improved pain control, and showed a trend to increased survival. Bisphosphonates should be used in the treatment of patients with lung cancer and bone metastases.

Clinical significance of the serum crosslinked N-telopeptide of type I collagen as a prognostic marker for non-small-cell lung cancer

INTRODUCTION

Lung cancer is the leading cause of cancer-related death. Many patients with lung cancer are in its advanced stages at the time of diagnosis. The 5-year survival rate for lung cancer is 10% to 20%, and the prognosis for patients with lung cancer is still poor. The crosslinked N-terminal telopeptide of type I collagen (NTx) is a metabolite of type I collagen, the main constituent of bone matrix.

PATIENTS AND METHODS

We measured serum NTx levels in patients who underwent staging during hospitalization for the initial treatment of lung cancer in our department. We examined whether serum NTx levels would be relevant to the prognosis of non-small-cell lung cancer (NSCLC).

RESULTS

This study included 176 patients with lung cancer (125 men and 51 women), including 109 with adenocarcinoma, 53 with squamous cell carcinoma, 6 with large-cell carcinoma, and 8 with other cancer types. Univariate and multivariate analysis using the Cox proportional hazards model revealed a particularly close association between sex, performance status, disease stage, and serum NTx levels and overall survival (OS). A median OS of 368 days was observed for patients with a serum NTx level < 22 nmol BCE/L, which was significantly longer than the 197 days for patients with a serum NTx level ≥ 22 nmol BCE/L (hazard ratio [HR], 2.02; 95% confidence interval [CI], 1.36-2.99; log-rank P = .00037).

CONCLUSIONS

We have revealed that a high serum NTx level (> 22 nmol BCE/L) appears to be a risk factor for a reduction in OS in patients with NSCLC.

Prognostic significance of bone markers in patients with lung cancer metastatic to the skeleton: a review of published data

The presence of bone metastases significantly affects clinical outcome and quality of life parameters in patients with lung cancer. In this review, we aimed to evaluate the predictive value of markers of bone turnover in skeletal morbidity and clinical parameters, including disease-free survival (DFS) and overall survival (OS), in patients with lung cancer metastatic to the skeleton who were receiving bisphosphonate treatment. A comprehensive overview of all articles published from 1995 to date in 3 medical databases (PubMed, Scopus, and Cochrane) was performed using the keywords bone markers and lung cancer. Most bone formation markers (including bone alkaline phosphatase [bALP], osteocalcin [OC], and osteoprotegerin [OPG]), most bone absorption markers (including urinary calcium, osteopontin [OPN], receptor activator of nuclear factor κ-B ligand [RANKL], tartrate-resistant acid phosphatase isoform-5b [TRACP 5b]), and the metabolites of type I collagen had elevated concentrations in patients with lung cancer and bone metastases compared with patients without skeletal involvement. Two large studies showed that urinary N-terminal telopeptide (NTX) levels are a valid diagnostic method for early detection of bone metastases and a more consistent prognosticator than bALP. Treatment with zoledronic acid reduces NTX, TRACP-5b, RANKL, and OPG levels. Furthermore posttherapeutic reduction of urinary NTX levels seems to correlate with lower risk of skeletal-related events (SREs). Levels of markers of bone remodeling reflect the presence of bone metastases and may contribute to early detection of occult skeletal disease or monitor the effect of bisphosphonate treatment. However their ability to predict SREs, as well as DFS and OS, remains debatable.