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Sivasankar C, Hewawaduge C, Muthuramalingam P, Lee JH. Tumor-targeted delivery of lnc antisense RNA against RCAS1 by live-attenuated tryptophan-auxotrophic Salmonella inhibited 4T1 breast tumors and metastasis in mice. MOLECULAR THERAPY. NUCLEIC ACIDS 2023; 34:102053. [PMID: 37941832 PMCID: PMC10628790 DOI: 10.1016/j.omtn.2023.102053] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 10/11/2023] [Indexed: 11/10/2023]
Abstract
Emerging chemo- and radiotherapy resistance exacerbated the cancer risk and necessitated novel treatment strategies. Although RNA therapeutics against pro-oncogenic genes are highly effective, tumor-specific delivery remains a barrier to the implementation of this valuable tool. In this study, we report a tryptophan-auxotrophic Salmonella typhimurium strain as an onco-therapeutic delivery system with tumor-targeting ability using 4T1 mice breast-cancer model. The receptor-binding cancer antigen expressed on SiSo cell (RCAS1) is a cancer-specific protein that induces the apoptosis of peripheral lymphocytes and confers tumor immune evasion. We designed a long non-coding antisense-RNA against RCAS1 (asRCAS1) and delivered by Salmonella using a non-antibiotic, auxotrophic-selective, eukaryotic expression plasmid, pJHL204. After in vivo tumor-to-tumor passaging, the JOL2888 (ΔtrpA, ΔtrpE, Δasd + asRCAS1) strain exhibited high sustainability in tumors, but did not last in healthy organs, thereby demonstrating tumor specificity and safety. RCAS1 inhibition in the tumor was confirmed by western blotting and qPCR. In mice, JOL2888 treatment reduced tumor-associated macrophages, improved the T cell population, elicited cell-mediated immunity, and suppressed cancer-promoting genes. Consequently, the JOL2888 treatment significantly decreased the tumor volume by 80%, decreased splenomegaly by 30%, and completely arrested lung metastasis. These findings highlight the intrinsic tumor-targeting ability of tryptophan-auxotrophic Salmonella for delivering onco-therapeutic macromolecules.
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Affiliation(s)
- Chandran Sivasankar
- College of Veterinary Medicine, Jeonbuk National University, Iksan Campus 54596, Republic of Korea
| | - Chamith Hewawaduge
- College of Veterinary Medicine, Jeonbuk National University, Iksan Campus 54596, Republic of Korea
| | | | - John Hwa Lee
- College of Veterinary Medicine, Jeonbuk National University, Iksan Campus 54596, Republic of Korea
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Jia X, Zhang D, Zhou C, Yan Z, Jiang Z, Xie L, Jiang J. Eph receptor B6 shapes a cold immune microenvironment, inhibiting anti-cancer immunity and immunotherapy response in bladder cancer. Front Oncol 2023; 13:1175183. [PMID: 37637034 PMCID: PMC10450340 DOI: 10.3389/fonc.2023.1175183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 07/10/2023] [Indexed: 08/29/2023] Open
Abstract
Background The role of Eph receptors and related ephrin (EFN) ligands (as the largest family of transmembrane-bound RTKs) in immunomodulation in many types of cancer, especially bladder cancer (BLCA), is scarcely known. Methods A pan-cancer dataset was retrieved from The Cancer Genome Atlas (TCGA) to explore the relation between Eph receptor/EFN ligand family genes and immunomodulators and tumor-infiltrated immune cells (TIICs). Local BLCA, GSE32894, and GSE31684 cohorts were applied to validate. The IMvigor210 cohort was employed to explore the relationship between EPHB6 and immunotherapy response. Moreover, association between EPHB6 and molecular subtype was investigated to explore potential therapeutic strategies. Immunohistochemical staining of CD8 and CD68 was performed to validate the correlation between EPHB6 and TIICs. Results The pan-cancer analysis revealed variations in the immunological effects of Eph receptor/EFN ligand family genes across different types of cancer. EPHB6 expression negatively correlated with the expression of the majority of immunomodulators (including HLA and immune checkpoints), and CD8 T cells and macrophages in both the TCGA-BLCA and validation BLCA cohorts, shaping a cold immune microenvironment with inhibited immunity. In the IMvigor210 cohort, patients with high-EPHB6 highly correlated with a non-inflamed, low PD-L1 expression immune phenotype, and correspondingly, with less responders to immunotherapy. The high-EPHB6 group, enriched with the basal subtype, presented significantly fewer TP53 and more FGFR3 genomic alterations. Finally, a novel EPHB6-related Genes signature, with reliable and robust ability in prognosis prediction, was constructed. Conclusions This study comprehensively investigated the immunological effects of Eph receptor/EFN ligand family genes pan-cancer, and specially identified the immunosuppressive role of EPHB6 in BLCA. Furthermore, EPHB6 may predict the molecular subtype and prognosis of BLCA, and serve as a novel therapeutic target to improve the sensitivity of immunotherapy.
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Affiliation(s)
- Xiaolong Jia
- Department of Urology, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Department of Urology, Ningbo First Hospital, Ningbo Hospital of Zhejiang University, Ningbo, China
| | - Dongxu Zhang
- Department of Urology, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Department of Urology, Ningbo First Hospital, Ningbo Hospital of Zhejiang University, Ningbo, China
| | - Cheng Zhou
- Department of Urology, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Department of Urology, Ningbo First Hospital, Ningbo Hospital of Zhejiang University, Ningbo, China
| | - Zejun Yan
- Department of Urology, Ningbo First Hospital, Ningbo Hospital of Zhejiang University, Ningbo, China
| | - Zhaohui Jiang
- Department of Urology, Ningbo First Hospital, Ningbo Hospital of Zhejiang University, Ningbo, China
| | - Liping Xie
- Department of Urology, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Junhui Jiang
- Department of Urology, Ningbo First Hospital, Ningbo Hospital of Zhejiang University, Ningbo, China
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Sharma D, McNabb E, Law N, Cumal A, Czarnota GJ. Ultrasound-stimulated microbubbles enhancement of fractionated radiation for tumor treatment. BMC Cancer 2023; 23:693. [PMID: 37488490 PMCID: PMC10364378 DOI: 10.1186/s12885-023-10981-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 05/19/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND Radiation therapy (XRT) causes numerous biological changes in tumor microenvironment. Radiation vascular response, due to endothelial disruption, can influence treatment outcomes in a dose-dependent manner. Ultrasound-stimulated microbubbles (USMB) have also been demonstrated to create a vascular response in the tumor microenvironment and enhance tumor response when used in combination with XRT. Single doses of 8-10 Gy are known to induce activation of acid sphingomyelinase (ASMase)-induced ceramide production, causing vascular damage. Destruction of vasculature results in endothelial apoptosis followed by tumor cell death. The effect of tumor response is known to be synergistic by 10-fold higher cell kill observed when USMB is combined with radiation. METHODS In this study, we used an USMB approach in combination with conventional low dose fractionated radiation to enhance endothelial cell responses to XRT in human PC3 prostate cancer xenograft model. Mice were divided into untreated, USMB therapy, fractionated XRT, and combined USMB therapy followed by XRT (USMB + XRT) groups. USMB therapy was delivered twice per week in the USMB-alone and combined USMB + XRT treatment groups over four weeks. Radiation treatments were delivered in fractions of 2 Gy/day (total 40 Gy in 20 fractions, BED10 = 48 Gy) in the XRT-alone and combined USMB + XRT groups. The treatment outcome was evaluated using histopathology, power Doppler, and immunohistochemistry assays. RESULTS Tumor growth assessment showed that sizes of tumors increased in the control and the single treatment groups over a treatment period of four weeks, but significantly decreased with the combined treatments of USMB + XRT. Immunohistochemical analysis indicated a statistically significant vascular disruption in mice that received treatment involving a full 4-week schedule of combined (USMB + XRT) treatments. A statistically significant increase in vascular disruption was demonstrated through CD68 and trichrome fibrosis staining. Changes in local perfusion assessed using high-frequency power Doppler imaging demonstrated attenuated blood flow in the combined group. DISCUSSION AND CONCLUSIONS This work demonstrates the efficacy of using USMB as a radiation sensitizer in a mouse model of human PC3 tumor xenograft. This radiation treatment enhancement modality has the advantage of targeting tumor vasculature with ultrasound stimulation that can be implemented prior to radiation treatment.
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Affiliation(s)
- Deepa Sharma
- Physical Sciences, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Departments of Medical Biophysics, and Radiation Oncology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Evan McNabb
- Physical Sciences, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Niki Law
- Physical Sciences, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Aaron Cumal
- Physical Sciences, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Gregory J Czarnota
- Physical Sciences, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
- Departments of Medical Biophysics, and Radiation Oncology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
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Kazakova E, Iamshchikov P, Larionova I, Kzhyshkowska J. Macrophage scavenger receptors: Tumor support and tumor inhibition. Front Oncol 2023; 12:1096897. [PMID: 36686729 PMCID: PMC9853406 DOI: 10.3389/fonc.2022.1096897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 12/13/2022] [Indexed: 01/08/2023] Open
Abstract
Tumor-associated macrophages (TAMs) are a heterogeneous population of myeloid cells that constitute up to 50% of the cell mass of human tumors. TAMs interact with the components of the tumor microenvironment (TME) by using scavenger receptors (SRs), a large superfamily of multifunctional receptors that recognize, internalize and transport to the endosomal/lysosomal pathway apoptotic cells, cytokines, matrix molecules, lipid modified lipoproteins and other unwanted-self ligands. In our review, we summarized state-of-the art for the role of macrophage scavenger receptors in tumor development and their significance as cancer biomarkers. In this review we focused on functional activity of TAM-expressing SRs in animal models and in patients, and summarized the data for different human cancer types about the prognostic significance of TAM-expressed SRs. We discussed the role of SRs in the regulation of cancer cell biology, cell-cell and cell-matrix interaction in TME, immune status in TME, angiogenesis, and intratumoral metabolism. Targeting of tumor-promoting SRs can be a promising therapeutic approach in anti-cancer therapy. In our review we provide evidence for both tumor supporting and tumor inhibiting functions of scavenger receptors expressed on TAMs. We focused on the key differences in the prognostic and functional roles of SRs that are specific for cancer types. We highlighted perspectives for inhibition of tumor-promoting SRs in anti-cancer therapy.
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Affiliation(s)
- Elena Kazakova
- Laboratory of translational cellular and molecular biomedicine, National Research Tomsk State University, Tomsk, Russia,Cancer Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, Russia
| | - Pavel Iamshchikov
- Laboratory of translational cellular and molecular biomedicine, National Research Tomsk State University, Tomsk, Russia,Cancer Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, Russia
| | - Irina Larionova
- Laboratory of translational cellular and molecular biomedicine, National Research Tomsk State University, Tomsk, Russia,Cancer Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, Russia,Laboratory of Genetic Technologies, Siberian State Medical University, Tomsk, Russia
| | - Julia Kzhyshkowska
- Laboratory of translational cellular and molecular biomedicine, National Research Tomsk State University, Tomsk, Russia,Laboratory of Genetic Technologies, Siberian State Medical University, Tomsk, Russia,Institute of Transfusion Medicine and Immunology, Mannheim Institute for Innate Immunoscience (MI3), Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany,German Red Cross Blood Service Baden-Württemberg – Hessen, Mannheim, Germany,*Correspondence: Julia Kzhyshkowska,
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Massenzio F, Cambiaghi M, Marchiotto F, Boriero D, Limatola C, D’Alessandro G, Buffelli M. In vivo morphological alterations of TAMs during KCa3.1 inhibition-by using in vivo two-photon time-lapse technology. Front Cell Neurosci 2022; 16:1002487. [PMID: 36589283 PMCID: PMC9798303 DOI: 10.3389/fncel.2022.1002487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 11/25/2022] [Indexed: 12/23/2022] Open
Abstract
Tumor associated macrophages (TAMs) are the mostprevalent cells recruited in the tumor microenvironment (TME). Once recruited, TAMs acquire a pro-tumor phenotype characterized by a typical morphology: ameboid in the tumor core and with larger soma and thick branches in the tumor periphery. Targeting TAMs by reverting them to an anti-tumor phenotype is a promising strategy for cancer immunotherapy. Taking advantage of Cx3cr1GFP/WT heterozygous mice implanted with murine glioma GL261-RFP cells we investigated the role of Ca2+-activated K+ channel (KCa3.1) on the phenotypic shift of TAMs at the late stage of glioma growth through in vivo two-photon imaging. We demonstrated that TAMs respond promptly to KCa3.1 inhibition using a selective inhibitor of the channel (TRAM-34) in a time-dependent manner by boosting ramified projections attributable to a less hypertrophic phenotype in the tumor core. We also revealed a selective effect of drug treatment by reducing both glioma cells and TAMs in the tumor core with no interference with surrounding cells. Taken together, our data indicate a TRAM-34-dependent progressive morphological transformation of TAMs toward a ramified and anti-tumor phenotype, suggesting that the timing of KCa3.1 inhibition is a key point to allow beneficial effects on TAMs.
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Affiliation(s)
- Francesca Massenzio
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy,*Correspondence: Mario Buffelli Francesca Massenzio
| | - Marco Cambiaghi
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Federica Marchiotto
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Diana Boriero
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Cristina Limatola
- Department of Physiology and Pharmacology, Sapienza University of Rome, Rome, Italy,IRCCS Neuromed, Pozzilli, Italy
| | - Giuseppina D’Alessandro
- Department of Physiology and Pharmacology, Sapienza University of Rome, Rome, Italy,IRCCS Neuromed, Pozzilli, Italy
| | - Mario Buffelli
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy,*Correspondence: Mario Buffelli Francesca Massenzio
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Lopez DC, Robbins YL, Kowalczyk JT, Lassoued W, Gulley JL, Miettinen MM, Gallia GL, Allen CT, Hodge JW, London NR. Multi-spectral immunofluorescence evaluation of the myeloid, T cell, and natural killer cell tumor immune microenvironment in chordoma may guide immunotherapeutic strategies. Front Oncol 2022; 12:1012058. [PMID: 36338744 PMCID: PMC9634172 DOI: 10.3389/fonc.2022.1012058] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 09/27/2022] [Indexed: 11/21/2022] Open
Abstract
Background Chordoma is a rare, invasive, and devastating bone malignancy of residual notochord tissue that arises at the skull base, sacrum, or spine. In order to maximize immunotherapeutic approaches as a potential treatment strategy in chordoma it is important to fully characterize the tumor immune microenvironment (TIME). Multispectral immunofluorescence (MIF) allows for comprehensive evaluation of tumor compartments, molecular co-expression, and immune cell spatial relationships. Here we implement MIF to define the myeloid, T cell, and natural killer (NK) cell compartments in an effort to guide rational design of immunotherapeutic strategies for chordoma. Methods Chordoma tumor tissue from 57 patients was evaluated using MIF. Three panels were validated to assess myeloid cell, T cell, and NK cell populations. Slides were stained using an automated system and HALO software objective analysis was utilized for quantitative immune cell density and spatial comparisons between tumor and stroma compartments. Results Chordoma TIME analysis revealed macrophage infiltration of the tumor parenchyma at a significantly higher density than stroma. In contrast, helper T cells, cytotoxic T cells, and T regulatory cells were significantly more abundant in stroma versus tumor. T cell compartment infiltration more commonly demonstrated a tumor parenchymal exclusion pattern, most markedly among cytotoxic T cells. NK cells were sparsely found within the chordoma TIME and few were in an activated state. No immune composition differences were seen in chordomas originating from diverse anatomic sites or between those resected at primary versus advanced disease stage. Conclusion This is the first comprehensive evaluation of the chordoma TIME including myeloid, T cell, and NK cell appraisal using MIF. Our findings demonstrate that myeloid cells significantly infiltrate chordoma tumor parenchyma while T cells tend to be tumor parenchymal excluded with high stromal infiltration. On average, myeloid cells are found nearer to target tumor cells than T cells, potentially resulting in restriction of T effector cell function. This study suggests that future immunotherapy combinations for chordoma should be aimed at decreasing myeloid cell suppressive function while enhancing cytotoxic T cell and NK cell killing.
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Affiliation(s)
- Diana C. Lopez
- Sinonasal and Skull Base Tumor Program, National Institute on Deafness and Other Communication Disorders, National Institutes of Health, Bethesda, MD, United States
- Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, United States
| | - Yvette L. Robbins
- Section on Translational Tumor Immunology, National Institute on Deafness and Other Communication Disorders, National Institutes of Health, Bethesda, MD, United States
| | - Joshua T. Kowalczyk
- Center for Immuno-Oncology, National Cancer Institute, Center for Cancer Research, National Institutes of Health (CCR, NIH), Bethesda, MD, United States
| | - Wiem Lassoued
- Center for Immuno-Oncology, National Cancer Institute, Center for Cancer Research, National Institutes of Health (CCR, NIH), Bethesda, MD, United States
| | - James L. Gulley
- Center for Immuno-Oncology, National Cancer Institute, Center for Cancer Research, National Institutes of Health (CCR, NIH), Bethesda, MD, United States
| | - Markku M. Miettinen
- Laboratory for Pathology, Center for Cancer Research, National Cancer Institute, Bethesda, MD, United States
| | - Gary L. Gallia
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Clint T. Allen
- Section on Translational Tumor Immunology, National Institute on Deafness and Other Communication Disorders, National Institutes of Health, Bethesda, MD, United States
| | - James W. Hodge
- Center for Immuno-Oncology, National Cancer Institute, Center for Cancer Research, National Institutes of Health (CCR, NIH), Bethesda, MD, United States
| | - Nyall R. London
- Sinonasal and Skull Base Tumor Program, National Institute on Deafness and Other Communication Disorders, National Institutes of Health, Bethesda, MD, United States
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- *Correspondence: Nyall R. London Jr., ;
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Baraya YS, Wee CL, Mustapha Z, Wong KK, Yaacob NS. Strobilanthes crispus elicits anti-tumor immunogenicity in in vitro and in vivo metastatic breast carcinoma. PLoS One 2022; 17:e0271203. [PMID: 35972917 PMCID: PMC9380931 DOI: 10.1371/journal.pone.0271203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 06/26/2022] [Indexed: 12/02/2022] Open
Abstract
Plant-based anticancer agents have the potential to stimulate the immune system to act against cancer cells. A standardized bioactive subfraction of the Malaysian herb, Strobilanthes crispus (L.) Blume (S. crispus) termed F3, demonstrates strong anticancer effects in both in vitro and in vivo models. The anticancer effects might be attributable to its immunomodulatory properties as S. crispus has been traditionally used to enhance the immune system. The current study examined whether F3 could stimulate anti-tumorigenic immunogenicity against 4T1 cells in vitro and in 4T1 cell-induced mammary carcinoma mouse model. We observed that F3 induced significant increase in MHC class I and class II molecules. CD4+, CD8+ and IL-2+ (p<0.05 for all) cells infiltration was also significantly increased in the breast tumor microenvironment of F3-treated mice compared with the tumors of untreated mice. The number of CD68+ macrophages was significantly lower in F3-treated mice. We conclude that the antitumor and antimetastatic effects of S. crispus involve strong infiltration of T cells in breast cancer potentially through increased tumor antigen presentation via MHC proteins, as well as reduction of infiltrating tumor-associated macrophages.
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Affiliation(s)
- Yusha’u Shu’aibu Baraya
- Department of Chemical Pathology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
- Faculty of Veterinary Medicine, Department of Veterinary Pathology, Usmanu Danfodiyo University, Sokoto, Nigeria
| | - Chee Lee Wee
- Department of Chemical Pathology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - Zulkarnain Mustapha
- Department of Chemical Pathology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - Kah Keng Wong
- Department of Immunology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - Nik Soriani Yaacob
- Department of Chemical Pathology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
- * E-mail: ,
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Role of CD68 in tumor immunity and prognosis prediction in pan-cancer. Sci Rep 2022; 12:7844. [PMID: 35550532 PMCID: PMC9098459 DOI: 10.1038/s41598-022-11503-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 04/11/2022] [Indexed: 12/24/2022] Open
Abstract
CD68 plays a critical role in promoting phagocytosis; however, the function of CD68 in tumor immunity and prognosis remains unknown. We analyzed CD68 expression among 33 tumor and normal tissues from The Cancer Genome Atlas and Genotype-Tissue Expression datasets. The relationship between CD68 expression and cancer prognosis, immune infiltration, checkpoint markers, and drug response was explored. Upregulated CD68 levels were observed in various cancer types, which were verified through tumor tissue chips using immunohistochemistry. High levels of CD68 in tumor samples correlated with an adverse prognosis in glioblastoma, kidney renal clear cell carcinoma, lower-grade glioma, liver hepatocellular carcinoma, lung squamous cell carcinoma, thyroid carcinoma, and thymoma and a favorable prognosis in kidney chromophobe. The top three negatively enriched Kyoto Encyclopedia of Genes and Genomes terms in the high CD68 subgroup were chemokine signaling pathway, cytokine-cytokine receptor interaction, and cell adhesion molecule cams. The top negatively enriched HALLMARK terms included complement, allograft rejection, and inflammatory response. A series of targeted drugs and small-molecule drugs with promising therapeutic effects were predicted. The clinical prognosis and immune infiltration of high expression levels of CD68 differ across tumor types. Inhibiting CD68-dependent signaling could be a promising therapeutic strategy for immunotherapy in many tumor types.
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Öztürk Ç, Paşaoğlu HE, Emre F, Tetikkurt ÜS, Şentürk Ege T. Do immunohistochemical studies have a role in predicting prognosis of laryngeal squamous cell carcinomas? CD44 and Fascin experience. ACTA BIO-MEDICA : ATENEI PARMENSIS 2022; 92:e2021309. [PMID: 35075092 PMCID: PMC8823588 DOI: 10.23750/abm.v92i6.10432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 10/12/2020] [Indexed: 01/30/2023]
Abstract
BACKGROUND AND OBJECTIVES The diagnosis of laryngeal squamous cell carcinoma (LSCC) can be made easily based on histopathological findings, but the relationship between morphological findings and prognosis is not clear. In addition to morphological findings, the use of novel markers may contribute to the development of new treatment strategies and improved patient prognosis. CD44, which is a cancer stem cell marker, and Fascin-1, an actin-binding protein has been associated with poor prognosis in many tumors. The aim of this study was to investigate the relationship between CD44 and Fascin-1 expression and clinicopathologic parameters in LSCC and their roles in the determination of clinical behavior and prognosis. The aim of this study is to investigate whether CD44 and Fascin have a relationship with clinicopathological parameters and have a role in determining clinical behavior and prognosis in LSCC. METHODS 130 patients who were operated in our hospital for LSCC between 2012 and 2018 were included in this study. Fascin-1 and CD44 stains were applied immunohistochemically to the paraffin blocks of the tumors. Immunostained specimens were scored according to the intensity of staining and the percentage of staining for each marker. Overall scores were summed and was designated as immunoreactivity score (IRS). Finally, IRS was categorized into two groups; Low and High CD44/Fascin IRS. RESULTS There were no statistically significant differences between low and high CD44 and Fascin IRS groups in terms of clinicopathologic parameters, overall and disease-free survival (p> 0.05). CONCLUSION Immunhistochemical studies are not yet sufficient to predict patient prognosis. Morphological findings still remain of priority and importance for pathologists.
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Affiliation(s)
- Çiğdem Öztürk
- Recep Tayyip Erdogan University Training and Research Hospital, Pathology Department, Rize, Merkez, Rize, Turkey.
| | - Hüsniye Esra Paşaoğlu
- University of Health Science Bagcilar Training and Research Hospital, Pathology Department.
| | - Funda Emre
- University of Health Science Bagcilar Training and Research Hospital, Pathology Department.
| | | | - Tülin Şentürk Ege
- University of Health Science Bagcilar Training and Research Hospital, Otolaryngology Department.
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Zhang P, Zhang Y, Wang L, Lou W. Tumor-regulated macrophage type 2 differentiation promotes immunosuppression in laryngeal squamous cell carcinoma. Life Sci 2020; 267:118798. [PMID: 33220295 DOI: 10.1016/j.lfs.2020.118798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 11/04/2020] [Accepted: 11/16/2020] [Indexed: 10/23/2022]
Abstract
AIMS Tumor-associated macrophage (TAM) residing in tumor microenvironment as the major niche cell made remarkable contribution to tumor growth. However, the functional role of macrophage and its different differentiating state as well as the regulating mechanism in laryngeal squamous cell carcinoma (LSCC) remains not fully clear. MATERIALS AND METHODS LSCC samples were collected from patients. Human peripheral blood mononuclear cells (PBMC) were collected from volunteers' blood, and used for macrophage induction. Enzyme-Linked Immunosorbent Assay (ELISA) was performed to detect proinflammatory cytokines. Immunostaining was prepared to observe tumor tissues. KEY FINDINGS Here, we found the number of type 2 macrophage (MΦ2) and PDL-1 expression was increased in LSCC that was correlated with poor prognosis in patients with LSCC. Tumor cells induced macrophage into type 2 differentiation by TGF-β/Smad3 signaling. The primed MΦ2 produced IL-10 by activating JAK/STAT signaling that promoted PDL-1 expression in tumor cells leading to its immunosuppression. Inhibition of JAK/STAT signaling promoted tumor cells death from immune cells killing by regulating PDL-1 expression. Targeting cytokines TGF-β or IL-10 synergistically enhances the sensitivity of tumors to chemotherapy in vivo. SIGNIFICANCE In conclusion, our findings showed tumor cells and MΦ2 were bilaterally regulated through cytokines production that integrally advanced tumor progression through boosting anti-tumor immunity. It provides insight to develop immune strategies synergy with chemotherapy in treating laryngeal squamous cell carcinoma.
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Affiliation(s)
- Peng Zhang
- Department of Otolaryngology-Head and Neck Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.
| | - Yanfei Zhang
- Department of Otolaryngology-Head and Neck Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Liang Wang
- Department of Otolaryngology-Head and Neck Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Weihua Lou
- Department of Otolaryngology-Head and Neck Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
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11
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Differential association of CD68 + and CD163 + macrophages with macrophage enzymes, whole tumour gene expression and overall survival in advanced melanoma. Br J Cancer 2020; 123:1553-1561. [PMID: 32843682 PMCID: PMC7653046 DOI: 10.1038/s41416-020-01037-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 07/20/2020] [Accepted: 08/06/2020] [Indexed: 12/28/2022] Open
Abstract
Background The density and phenotype of tumour-associated macrophages have been linked with prognosis in a range of solid tumours. While there is strong preclinical evidence that tumour-associated macrophages promote aspects of tumour progression, it can be challenging to infer clinical activity from surface markers and ex vivo behaviour. We investigated the association of macrophage infiltration with prognosis and functional changes in the tumour microenvironment in primary human melanoma. Methods Fifty-seven formalin-fixed, paraffin-embedded primary melanomas were analysed by immunohistochemical analysis of CD68, CD163, inducible nitric oxide synthase (iNOS) and arginase expression. RNA sequencing was performed on serial sections of 20 of the stained tumours to determine the influence of macrophage infiltration on gene expression. Results CD68+ cells are a functionally active subset of macrophages that are associated with increased iNOS and arginase staining and altered gene expression. In comparison, while there is a greater accumulation of CD163+ macrophages in larger tumours, these cells are comparatively inactive, with no association with the level of iNOS or arginase staining, and no effect on gene expression within the tumour. The infiltration of either subset of macrophages did not correlate to overall survival. Conclusions Thus, melanomas contain distinct macrophage populations with diverse phenotypes, but with no observable prognostic role.
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Zhao X, Ding L, Lu Z, Huang X, Jing Y, Yang Y, Chen S, Hu Q, Ni Y. Diminished CD68 + Cancer-Associated Fibroblast Subset Induces Regulatory T-Cell (Treg) Infiltration and Predicts Poor Prognosis of Oral Squamous Cell Carcinoma Patients. THE AMERICAN JOURNAL OF PATHOLOGY 2020; 190:886-899. [PMID: 32035062 DOI: 10.1016/j.ajpath.2019.12.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 11/14/2019] [Accepted: 12/09/2019] [Indexed: 12/15/2022]
Abstract
Although cancer-associated fibroblasts (CAFs) are crucial stromal cells, characterizing their heterogeneity is far from complete. This study reports a novel subset of CAFs in oral squamous cell carcinoma (OSCC), which positively expressed CD68, the classic marker of macrophages. The spatial and temporal distribution of the CD68+ CAF subset of OSCC (n = 104) was determined by CD68/actin alpha 2, smooth muscle (ACTA2+; α-SMA) immunohistochemistry of serial sections. The CD68+ α-SMA+ CAF subset was elevated from dysplasia to OSCC. Moreover, although both the tumor center and invasive front harbor an abundant CD68+ CAF subset, patients with low-CD68+ CAFs in the tumor center showed more recurrence after operation and shorter survival time, indicating the different function of CD68+ CAFs in tumor initiation and progression. Functional analysis in the OSCC-CAF co-culture system found knockdown of CD68 did not change the phenotype of CAFs, tumor growth, or migration. Unexpectedly, low-CD68+ CAFs were associated with aberrant immune balance. A high proportion of tumor-supportive Tregs was found in patients with low-CD68+ CAFs. Mechanistically, knockdown of CD68 in CAFs contributed to the up-regulation of chemokine CCL17 and CCL22 of tumor cells to enhance Treg recruitment. Thus, up-regulated CD68+ fibroblasts participate in tumor initiation, but the low-CD68+ CAF subset in OSCC is conducive to regulatory T-cell (Treg) recruitment in the tumor microenvironment and contribute to poor prognosis of OSCC patients.
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MESH Headings
- Antigens, CD/metabolism
- Antigens, Differentiation, Myelomonocytic/metabolism
- Cancer-Associated Fibroblasts/immunology
- Cancer-Associated Fibroblasts/metabolism
- Cancer-Associated Fibroblasts/pathology
- Carcinoma, Squamous Cell/immunology
- Carcinoma, Squamous Cell/metabolism
- Carcinoma, Squamous Cell/pathology
- Female
- Gene Expression Regulation, Neoplastic
- Humans
- Male
- Middle Aged
- Mouth Neoplasms/immunology
- Mouth Neoplasms/metabolism
- Mouth Neoplasms/pathology
- Neoplasm Recurrence, Local/immunology
- Neoplasm Recurrence, Local/metabolism
- Neoplasm Recurrence, Local/pathology
- Prognosis
- Stromal Cells/immunology
- Stromal Cells/metabolism
- Stromal Cells/pathology
- Survival Rate
- T-Lymphocytes, Regulatory/immunology
- T-Lymphocytes, Regulatory/metabolism
- T-Lymphocytes, Regulatory/pathology
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Affiliation(s)
- Xingxing Zhao
- Central Laboratory of Stomatology, Nanjing Stomatological Hospital, Medical School of Nanjing University, Nanjing, China
| | - Liang Ding
- Central Laboratory of Stomatology, Nanjing Stomatological Hospital, Medical School of Nanjing University, Nanjing, China
| | - Zhanyi Lu
- Central Laboratory of Stomatology, Nanjing Stomatological Hospital, Medical School of Nanjing University, Nanjing, China
| | - Xiaofeng Huang
- Department of Oral and Maxillofacial Surgery, Nanjing Stomatological Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yue Jing
- Central Laboratory of Stomatology, Nanjing Stomatological Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yan Yang
- Department of Oral and Maxillofacial Surgery, Nanjing Stomatological Hospital, Medical School of Nanjing University, Nanjing, China
| | - Sheng Chen
- Department of Oral and Maxillofacial Surgery, Nanjing Stomatological Hospital, Medical School of Nanjing University, Nanjing, China
| | - Qingang Hu
- Department of Oral and Maxillofacial Surgery, Nanjing Stomatological Hospital, Medical School of Nanjing University, Nanjing, China.
| | - Yanhong Ni
- Central Laboratory of Stomatology, Nanjing Stomatological Hospital, Medical School of Nanjing University, Nanjing, China.
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Iseulys R, Anne GB, Corinne B, Gonzague DBDP, Marie K, Jean-Yves B, Aurélie D. The immune landscape of chondrosarcoma reveals an immunosuppressive environment in the dedifferentiated subtypes and exposes CSFR1+ macrophages as a promising therapeutic target. J Bone Oncol 2019; 20:100271. [PMID: 31956474 PMCID: PMC6961717 DOI: 10.1016/j.jbo.2019.100271] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 11/20/2019] [Accepted: 11/25/2019] [Indexed: 01/22/2023] Open
Abstract
Survival rate for Chondrosarcoma (CHS) is at a standstill, more effective treatments are urgently needed. Consequently, a better understanding of CHS biology and its immune environment is crucial to identify new prognostic factors and therapeutic targets. Here, we exhaustively describe the immune landscape of conventional and dedifferentiated CHS. Using IHC and molecular analyses (RT-qPCR), we mapped the expression of immune cell markers (CD3, CD8, CD68, CD163) and immune checkpoints (ICPs) from a cohort of 27 conventional and 49 dedifferentiated CHS. The impact of the density of tumor-infiltrating lymphocytes (TILs), tumor-associated macrophages (TAMs) and immune checkpoints (ICPs) on clinical outcome were analyzed. We reveal that TAMs are the main immune population in CHS. Focusing on dedifferentiated CHS, we found that immune infiltrate composition is correlated with patient outcome, a high CD68+/CD8+ ratio being an independent poor prognostic factor (p < 0.01), and high CD68+ levels being associated with the presence of metastases at diagnosis (p < 0.05). Among the ICPs evaluated, CSF1R, B7H3, SIRPA, TIM3 and LAG3 were expressed at the mRNA level in both CHS subtypes. Furthermore, PDL1 expression was confirmed by IHC exclusively in dedifferentiated CHS (42.6% of the patients) and CSF1R was expressed by TAMs in 89.7% of dedifferentiated CHS (vs 62.9% in conventional). Our results show that the immune infiltrate of CHS is mainly composed of immunosuppressive actors favoring tumor progression. Our results indicate that dedifferentiated CHS could be eligible for anti-PDL1 therapy and more importantly immunomodulation through CSF1R + macrophages could be a promising therapeutic approach for both CHS subtypes.
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Key Words
- APC, Antigen Presenting Cells
- B7H3, B7 superfamily member-H3
- CD, Cluster of Differentiation
- CHS, Chondrosarcoma
- CSF1, Colony Stimulating Factor 1
- CSF1R, Colony Stimulating Factor 1 Receptor
- CTLA4, cytotoxic T-lymphocyte–associated
- HH, hedgehog
- HLA, Human Leucocytes Antigen
- ICOS, Inducible Costimulator
- ICOSL, inducible costimulator ligand
- ICP, Immune checkpoint
- IDH, isocitrate deshydrogenase
- LAG3, Lymphocyte activation gene-3
- MDR1, Multi Drug Resistance 1
- PD1, Programmed death 1
- PDL1, Programmed Death Ligand 1
- SIRPa, Signal regulatory protein alpha
- SMO, Smoothened Homolog Precursor
- TAMs, Tumor Associated Macrophages
- TILs, Tumor Infiltrating Lymphocytes
- TIM3, T cell immunoglobulin mucin
- Treg, T regulator lymphocytes
- mTOR, mammalian Target Of Rapamycin
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Affiliation(s)
- Richert Iseulys
- CRCL/CLB INSERM, Cell Death and Pediatric Cancers Team, U1052, UMR5286, CNRS U5286, 28 rue Laennec, 69373 Lyon cedex 8, France
| | - Gomez-Brouchet Anne
- Department of Pathology, IUCT-Oncopole, CHU of Toulouse, Université de Toulouse 3, UMR1037 INSERM, ERL5294 CNRS, Toulouse, France
| | - Bouvier Corinne
- Department of Pathology, APHM La Timone, Aix Marseille University, MMG, France
| | | | - Karanian Marie
- Department of Pathology, Centre Léon Bérard, Lyon, France
| | - Blay Jean-Yves
- CRCL/CLB INSERM, Cell Death and Pediatric Cancers Team, U1052, UMR5286, CNRS U5286, 28 rue Laennec, 69373 Lyon cedex 8, France.,Department of Pathology, Centre Léon Bérard, Lyon, France
| | - Dutour Aurélie
- CRCL/CLB INSERM, Cell Death and Pediatric Cancers Team, U1052, UMR5286, CNRS U5286, 28 rue Laennec, 69373 Lyon cedex 8, France
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Rzepakowska A, Żurek M, Grzybowski J, Pihowicz P, Górnicka B, Niemczyk K, Osuch-Wójcikiewicz E. Microvascular density and hypoxia-inducible factor in intraepithelial vocal fold lesions. Eur Arch Otorhinolaryngol 2019; 276:1117-1125. [PMID: 30840126 PMCID: PMC6426810 DOI: 10.1007/s00405-019-05355-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Accepted: 02/20/2019] [Indexed: 12/18/2022]
Abstract
Objective The promotion of neovascularisation is a crucial aspect of carcinogenesis. The study evaluates the microvascular density (MVD) and expression of hypoxia-induced factor (HIF-1α) in hypertrophic vocal fold (VF) lesions of different histopathological states including non-dysplastic, low-grade, high-grade dysplasia and invasive glottic cancer. Materials and methods Histological specimens collected from patients diagnosed and treated in a single centre with different histological grades were immunohistochemically stained with CD31, CD34 and HIF-1α. Of the total number of 77 analysed VF specimens, 20 were non-dysplastic, 20 had low-grade dysplasia, 17 high-grade dysplasia and 20 were invasive cancers. Results The highest mean value for MVD evaluated with expression of CD31 (MVD CD31) was 21.23 ± 14.46 and identified in the low-grade dysplasia group. The average MVD CD31 was 13.74 ± 5.56 and 20.11 ± 9.28 in the high-grade dysplasia and invasive cancer group, respectively. The highest MVD evaluated with CD34 (MVD CD34) was revealed for invasive cancer 35.64 ± 17.21. The MVD CD34 was higher for low-grade than in high-grade dysplasia (25.87 ± 12.30 vs 24.65 ± 15.92, respectively). The expression of HIF-1α was strong or very strong in 60% of non-dysplastic lesions, 100% of low-grade dysplasia cases, 53% of high-grade dysplasia cases and 50% of invasive cancer cases. The comparison of MVD CD31 with MVD CD34 revealed a strong positive correlation (ρ value 0.727). The comparison of both MVD CD31 and MVD CD34 with HIF-1α resulted in no linear relationship (ρ value of 0.143 and 0.165, respectively). Conclusion The stage of low-grade dysplasia in intraepithelial vocal fold lesions is related to significant advancement of angiogenesis together with the highest hypoxia level. Electronic supplementary material The online version of this article (10.1007/s00405-019-05355-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anna Rzepakowska
- Otolaryngology Department, Medical University of Warsaw, Warsaw, Poland
| | - Michał Żurek
- Students Scientific Research Group by Otolaryngology Department, Medical University of Warsaw, Warsaw, Poland
| | - Jakub Grzybowski
- Department of Pathology, Medical University of Warsaw, 7, Pawińskiego Str., 02-004, Warsaw, Poland.
| | - Paweł Pihowicz
- Department of Pathology, Medical University of Warsaw, 7, Pawińskiego Str., 02-004, Warsaw, Poland
| | - Barbara Górnicka
- Department of Pathology, Medical University of Warsaw, 7, Pawińskiego Str., 02-004, Warsaw, Poland
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Lee JR, Roh JL, Lee SM, Park Y, Cho KJ, Choi SH, Nam SY, Kim SY. Overexpression of glutathione peroxidase 1 predicts poor prognosis in oral squamous cell carcinoma. J Cancer Res Clin Oncol 2017; 143:2257-2265. [PMID: 28653098 DOI: 10.1007/s00432-017-2466-7] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 06/23/2017] [Indexed: 12/14/2022]
Abstract
PURPOSE Intracellular antioxidant enzymes are commonly upregulated in various cancer types and are associated with treatment outcomes. Because the relationship has rarely been examined in oral squamous cell carcinoma (OSCC), we aimed to evaluate the association between the levels of glutathione peroxidase (GPX)1, GPX4, and thioredoxin reductase (TrxR)1 expression and prognosis in patients with OSCC who underwent curative surgical resection. METHODS This study included 233 patients who underwent curative surgery for previously untreated OSCC between 2000 and 2012. Tumour GPX1, GPX4, and TrxR1 expression was evaluated by immunohistochemistry and was dichotomised to low and high values according to defined expression levels. The association between GPX1, GPX4, and TrxR1 expression and clinicopathological results was analysed. Univariate and multivariate analyses using the Cox proportional hazards model were conducted to assess the significance of differences in recurrence or survival outcomes between variables. RESULTS High GPX1, GPX4, and TrxR1 expression was observed in 99 (42.5%), 133 (57.1%), and 46 (19.7%) patients, respectively. GPX1 overexpression was significantly correlated with nodal metastasis, advanced overall stage, depth of invasion of >10 mm, high grade and perineural invasion (P < 0.05). High GPX4 expression was also related to nodal metastasis, overall advanced stage and high grade (P < 0.05). Univariate and multivariate analyses showed that increased GPX1 expression was significantly associated with poor disease-free, cancer-specific and overall survival (all P < 0.05), while increased GPX4 or TrxR1 expression was not (all P > 0.1). CONCLUSIONS Tumour GPX1 expression is a useful biomarker predictive of recurrence and survival in OSCC patients.
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Affiliation(s)
- Jae Ryung Lee
- Department of Otolaryngology, Asan Medical Centre, University of Ulsan College of Medicine, 88 Olympic-ro, 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Jong-Lyel Roh
- Department of Otolaryngology, Asan Medical Centre, University of Ulsan College of Medicine, 88 Olympic-ro, 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
| | - Sun Mi Lee
- Department of Pathology, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yangsoon Park
- Department of Pathology, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kyung-Ja Cho
- Department of Pathology, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seung-Ho Choi
- Department of Otolaryngology, Asan Medical Centre, University of Ulsan College of Medicine, 88 Olympic-ro, 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Soon Yuhl Nam
- Department of Otolaryngology, Asan Medical Centre, University of Ulsan College of Medicine, 88 Olympic-ro, 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Sang Yoon Kim
- Department of Otolaryngology, Asan Medical Centre, University of Ulsan College of Medicine, 88 Olympic-ro, 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
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