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Okkels N, Horsager J, Fedorova TD, Knudsen K, Skjærbæk C, Andersen KB, Labrador-Espinosa M, Vestergaard K, Mortensen JK, Klit H, Møller M, Danielsen EH, Johnsen EL, Bekan G, Hansen KV, Munk OL, Damholdt MF, Kjeldsen PL, Hansen AK, Gottrup H, Grothe MJ, Borghammer P. Impaired cholinergic integrity of the colon and pancreas in dementia with Lewy bodies. Brain 2024; 147:255-266. [PMID: 37975822 DOI: 10.1093/brain/awad391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 09/20/2023] [Accepted: 10/28/2023] [Indexed: 11/19/2023] Open
Abstract
Dementia with Lewy bodies is characterized by a high burden of autonomic dysfunction and Lewy pathology in peripheral organs and components of the sympathetic and parasympathetic nervous system. Parasympathetic terminals may be quantified with 18F-fluoroetoxybenzovesamicol, a PET tracer that binds to the vesicular acetylcholine transporter in cholinergic presynaptic terminals. Parasympathetic imaging may be useful for diagnostics, improving our understanding of autonomic dysfunction and for clarifying the spatiotemporal relationship of neuronal degeneration in prodromal disease. Therefore, we aimed to investigate the cholinergic parasympathetic integrity in peripheral organs and central autonomic regions of subjects with dementia with Lewy bodies and its association with subjective and objective measures of autonomic dysfunction. We hypothesized that organs with known parasympathetic innervation, especially the pancreas and colon, would have impaired cholinergic integrity. To achieve these aims, we conducted a cross-sectional comparison study including 23 newly diagnosed non-diabetic subjects with dementia with Lewy bodies (74 ± 6 years, 83% male) and 21 elderly control subjects (74 ± 6 years, 67% male). We obtained whole-body images to quantify PET uptake in peripheral organs and brain images to quantify PET uptake in regions of the brainstem and hypothalamus. Autonomic dysfunction was assessed with questionnaires and measurements of orthostatic blood pressure. Subjects with dementia with Lewy bodies displayed reduced cholinergic tracer uptake in the pancreas (32% reduction, P = 0.0003) and colon (19% reduction, P = 0.0048), but not in organs with little or no parasympathetic innervation. Tracer uptake in a region of the medulla oblongata overlapping the dorsal motor nucleus of the vagus correlated with autonomic symptoms (rs = -0.54, P = 0.0077) and changes in orthostatic blood pressure (rs = 0.76, P < 0.0001). Tracer uptake in the pedunculopontine region correlated with autonomic symptoms (rs = -0.52, P = 0.0104) and a measure of non-motor symptoms (rs = -0.47, P = 0.0230). In conclusion, our findings provide the first imaging-based evidence of impaired cholinergic integrity of the pancreas and colon in dementia with Lewy bodies. The observed changes may reflect parasympathetic denervation, implying that this process is initiated well before the point of diagnosis. The findings also support that cholinergic denervation in the brainstem contributes to dysautonomia.
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Affiliation(s)
- Niels Okkels
- Department of Nuclear Medicine and PET, Aarhus University Hospital, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, 8000 Aarhus C, Denmark
- Department of Neurology, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Jacob Horsager
- Department of Nuclear Medicine and PET, Aarhus University Hospital, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, 8000 Aarhus C, Denmark
| | - Tatyana D Fedorova
- Department of Nuclear Medicine and PET, Aarhus University Hospital, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, 8000 Aarhus C, Denmark
| | - Karoline Knudsen
- Department of Nuclear Medicine and PET, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Casper Skjærbæk
- Department of Nuclear Medicine and PET, Aarhus University Hospital, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, 8000 Aarhus C, Denmark
| | - Katrine B Andersen
- Department of Nuclear Medicine and PET, Aarhus University Hospital, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, 8000 Aarhus C, Denmark
| | - Miguel Labrador-Espinosa
- Unidad de Trastornos del Movimiento, Servicio de Neurología y Neurofisiología Clínica, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, 41013 Seville, Spain
- Centro de Investigación Biomédica en Red Sobre Enfermedades Neurodegenerativas (CIBERNED), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | | | - Janne K Mortensen
- Department of Clinical Medicine, Aarhus University, 8000 Aarhus C, Denmark
- Department of Neurology, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Henriette Klit
- Department of Neurology, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Mette Møller
- Department of Neurology, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Erik H Danielsen
- Department of Neurology, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Erik L Johnsen
- Department of Neurology, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Goran Bekan
- Department of Neurology, Regionshospitalet Gødstrup, 7400 Herning, Denmark
| | - Kim V Hansen
- Department of Nuclear Medicine and PET, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Ole L Munk
- Department of Nuclear Medicine and PET, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Malene F Damholdt
- Department of Clinical Medicine, Aarhus University, 8000 Aarhus C, Denmark
| | - Pernille L Kjeldsen
- Department of Nuclear Medicine and PET, Aarhus University Hospital, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, 8000 Aarhus C, Denmark
- Department of Neurology, Aalborg University Hospital, 9000 Aalborg, Denmark
| | - Allan K Hansen
- Department of Nuclear Medicine and PET, Aarhus University Hospital, 8200 Aarhus N, Denmark
- Department of Nuclear Medicine, Aalborg University Hospital, 9000 Aalborg, Denmark
| | - Hanne Gottrup
- Department of Neurology, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Michel J Grothe
- Unidad de Trastornos del Movimiento, Servicio de Neurología y Neurofisiología Clínica, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, 41013 Seville, Spain
- Centro de Investigación Biomédica en Red Sobre Enfermedades Neurodegenerativas (CIBERNED), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Per Borghammer
- Department of Nuclear Medicine and PET, Aarhus University Hospital, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, 8000 Aarhus C, Denmark
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Schumacher J, Kanel P, Dyrba M, Storch A, Bohnen NI, Teipel S, Grothe MJ. Structural and molecular cholinergic imaging markers of cognitive decline in Parkinson's disease. Brain 2023; 146:4964-4973. [PMID: 37403733 PMCID: PMC10689921 DOI: 10.1093/brain/awad226] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 06/14/2023] [Accepted: 06/23/2023] [Indexed: 07/06/2023] Open
Abstract
Cognitive decline in Parkinson's disease is related to cholinergic system degeneration, which can be assessed in vivo using structural MRI markers of basal forebrain volume and PET measures of cortical cholinergic activity. In the present study we aimed to examine the interrelation between basal forebrain degeneration and PET-measured depletion of cortical acetylcholinesterase activity as well as their relative contribution to cognitive impairment in Parkinson's disease. This cross-sectional study included 143 Parkinson's disease participants without dementia and 52 healthy control participants who underwent structural MRI, PET scanning with 11C-methyl-4-piperidinyl propionate (PMP) as a measure of cortical acetylcholinesterase activity, and a detailed cognitive assessment. Based on the fifth percentile of the overall cortical PMP PET signal from the control group, people with Parkinson's disease were subdivided into a normo-cholinergic (n = 94) and a hypo-cholinergic group (n = 49). Volumes of functionally defined posterior and anterior basal forebrain subregions were extracted using an established automated MRI volumetry approach based on a stereotactic atlas of cholinergic basal forebrain nuclei. We used Bayesian t-tests to compare basal forebrain volumes between controls, and normo- and hypo-cholinergic Parkinson's participants after covarying out age, sex and years of education. Associations between the two cholinergic imaging measures were assessed across all people with Parkinson's disease using Bayesian correlations and their respective relations with performance in different cognitive domains were assessed with Bayesian ANCOVAs. As a specificity analysis, hippocampal volume was added to the analysis. We found evidence for a reduction of posterior basal forebrain volume in the hypo-cholinergic compared to both normo-cholinergic Parkinson's disease [Bayes factor against the null model (BF10) = 8.2] and control participants (BF10 = 6.0), while for the anterior basal forebrain the evidence was inconclusive (BF10 < 3). In continuous association analyses, posterior basal forebrain volume was significantly associated with cortical PMP PET signal in a temporo-posterior distribution. The combined models for the prediction of cognitive scores showed that both cholinergic markers (posterior basal forebrain volume and cortical PMP PET signal) were independently related to multi-domain cognitive deficits, and were more important predictors for all cognitive scores, including memory scores, than hippocampal volume. We conclude that degeneration of the posterior basal forebrain in Parkinson's disease is accompanied by functional cortical changes in acetylcholinesterase activity and that both PET and MRI cholinergic imaging markers are independently associated with multi-domain cognitive deficits in Parkinson's disease without dementia. Comparatively, hippocampal atrophy only seems to have minimal involvement in the development of early cognitive impairment in Parkinson's disease.
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Affiliation(s)
- Julia Schumacher
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE) Rostock-Greifswald, 18147 Rostock, Germany
- Department of Neurology, University Medical Center Rostock, 18147 Rostock, Germany
| | - Prabesh Kanel
- University of Michigan Morris K. Udall Center for Excellence in Parkinson’s Disease Research, Ann Arbor, MI 48109, USA
- University of Michigan Parkinson’s Foundation Research Center of Excellence, Ann Arbor, MI 48109, USA
- Department of Radiology, University of Michigan, Ann Arbor, MI 48105, USA
| | - Martin Dyrba
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE) Rostock-Greifswald, 18147 Rostock, Germany
| | - Alexander Storch
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE) Rostock-Greifswald, 18147 Rostock, Germany
- Department of Neurology, University Medical Center Rostock, 18147 Rostock, Germany
| | - Nicolaas I Bohnen
- University of Michigan Morris K. Udall Center for Excellence in Parkinson’s Disease Research, Ann Arbor, MI 48109, USA
- University of Michigan Parkinson’s Foundation Research Center of Excellence, Ann Arbor, MI 48109, USA
- Department of Radiology, University of Michigan, Ann Arbor, MI 48105, USA
- Neurology Service and GRECC, Veterans Administration Ann Arbor Healthcare System, Ann Arbor, MI 48105, MI, USA
- Department of Neurology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Stefan Teipel
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE) Rostock-Greifswald, 18147 Rostock, Germany
- Department of Psychosomatic Medicine, University Medical Center Rostock, 18147 Rostock, Germany
| | - Michel J Grothe
- Unidad de Trastornos del Movimiento, Servicio de Neurología y Neurofisiología Clínica, Instituto de Biomedicina de Sevilla, Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, 41013 Seville, Spain
- Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), 28031 Madrid, Spain
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Silva-Rodríguez J, Labrador-Espinosa MA, Moscoso A, Schöll M, Mir P, Grothe MJ. Characteristics of amnestic patients with hypometabolism patterns suggestive of Lewy body pathology. Brain 2023; 146:4520-4531. [PMID: 37284793 PMCID: PMC10629761 DOI: 10.1093/brain/awad194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 04/27/2023] [Accepted: 05/16/2023] [Indexed: 06/08/2023] Open
Abstract
A clinical diagnosis of Alzheimer's disease dementia (ADD) encompasses considerable pathological and clinical heterogeneity. While Alzheimer's disease patients typically show a characteristic temporo-parietal pattern of glucose hypometabolism on 18F-fluorodeoxyglucose (FDG)-PET imaging, previous studies have identified a subset of patients showing a distinct posterior-occipital hypometabolism pattern associated with Lewy body pathology. Here, we aimed to improve the understanding of the clinical relevance of these posterior-occipital FDG-PET patterns in patients with Alzheimer's disease-like amnestic presentations. Our study included 1214 patients with clinical diagnoses of ADD (n = 305) or amnestic mild cognitive impairment (aMCI, n = 909) from the Alzheimer's Disease Neuroimaging Initiative, who had FDG-PET scans available. Individual FDG-PET scans were classified as being suggestive of Alzheimer's (AD-like) or Lewy body (LB-like) pathology by using a logistic regression classifier trained on a separate set of patients with autopsy-confirmed Alzheimer's disease or Lewy body pathology. AD- and LB-like subgroups were compared on amyloid-β and tau-PET, domain-specific cognitive profiles (memory versus executive function performance), as well as the presence of hallucinations and their evolution over follow-up (≈6 years for aMCI, ≈3 years for ADD). Around 12% of the aMCI and ADD patients were classified as LB-like. For both aMCI and ADD patients, the LB-like group showed significantly lower regional tau-PET burden than the AD-like subgroup, but amyloid-β load was only significantly lower in the aMCI LB-like subgroup. LB- and AD-like subgroups did not significantly differ in global cognition (aMCI: d = 0.15, P = 0.16; ADD: d = 0.02, P = 0.90), but LB-like patients exhibited a more dysexecutive cognitive profile relative to the memory deficit (aMCI: d = 0.35, P = 0.01; ADD: d = 0.85 P < 0.001), and had a significantly higher risk of developing hallucinations over follow-up [aMCI: hazard ratio = 1.8, 95% confidence interval = (1.29, 3.04), P = 0.02; ADD: hazard ratio = 2.2, 95% confidence interval = (1.53, 4.06) P = 0.01]. In summary, a sizeable group of clinically diagnosed ADD and aMCI patients exhibit posterior-occipital FDG-PET patterns typically associated with Lewy body pathology, and these also show less abnormal Alzheimer's disease biomarkers as well as specific clinical features typically associated with dementia with Lewy bodies.
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Affiliation(s)
- Jesús Silva-Rodríguez
- Unidad de Trastornos del Movimiento, Servicio de Neurología y Neurofisiología Clínica, Instituto de Biomedicina de Sevilla, Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, 41013 Sevilla, Spain
| | - Miguel A Labrador-Espinosa
- Unidad de Trastornos del Movimiento, Servicio de Neurología y Neurofisiología Clínica, Instituto de Biomedicina de Sevilla, Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, 41013 Sevilla, Spain
- Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), 28029 Madrid, Spain
| | - Alexis Moscoso
- Wallenberg Center for Molecular and Translational Medicine and Department of Psychiatry and Neurochemistry, University of Gothenburg, 41345 Gothenburg, Sweden
| | - Michael Schöll
- Wallenberg Center for Molecular and Translational Medicine and Department of Psychiatry and Neurochemistry, University of Gothenburg, 41345 Gothenburg, Sweden
- Dementia Research Centre, Queen Square Institute of Neurology, University College London, WC1ELondon, UK
| | - Pablo Mir
- Unidad de Trastornos del Movimiento, Servicio de Neurología y Neurofisiología Clínica, Instituto de Biomedicina de Sevilla, Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, 41013 Sevilla, Spain
- Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), 28029 Madrid, Spain
- Departamento de Medicina, Facultad de Medicina, Universidad de Sevilla, 41009 Sevilla, Spain
| | - Michel J Grothe
- Unidad de Trastornos del Movimiento, Servicio de Neurología y Neurofisiología Clínica, Instituto de Biomedicina de Sevilla, Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, 41013 Sevilla, Spain
- Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), 28029 Madrid, Spain
- Wallenberg Center for Molecular and Translational Medicine and Department of Psychiatry and Neurochemistry, University of Gothenburg, 41345 Gothenburg, Sweden
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Castaño M, González-Cantó E, Aghababyan C, Tomás-Pérez S, Oto J, Herranz R, Medina P, Götte M, Mc Cormack BA, Marí-Alexandre J, Gilabert-Estellés J. New Roles for Old Friends: Involvement of the Innate Immune System in Tumor Progression. Int J Mol Sci 2023; 24:ijms24087604. [PMID: 37108767 PMCID: PMC10144334 DOI: 10.3390/ijms24087604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 04/17/2023] [Indexed: 04/29/2023] Open
Abstract
The association between the immune system and tumor progression has attracted much interest in the research community in recent years [...].
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Affiliation(s)
- María Castaño
- Haemostasis, Thrombosis, Arteriosclerosis and Vascular Biology Research Group, Medical Research Institute Hospital La Fe, 46026 Valencia, Spain
| | - Eva González-Cantó
- Research Laboratory in Biomarkers in Reproduction, Gynaecology, and Obstetrics, Research Foundation of the General University Hospital of Valencia, 46014 Valencia, Spain
| | - Cristina Aghababyan
- Research Laboratory in Biomarkers in Reproduction, Gynaecology, and Obstetrics, Research Foundation of the General University Hospital of Valencia, 46014 Valencia, Spain
- Department of Obstetrics and Gynecology, General University Hospital of Valencia Consortium, 46014 Valencia, Spain
| | - Sarai Tomás-Pérez
- Research Laboratory in Biomarkers in Reproduction, Gynaecology, and Obstetrics, Research Foundation of the General University Hospital of Valencia, 46014 Valencia, Spain
| | - Julia Oto
- Haemostasis, Thrombosis, Arteriosclerosis and Vascular Biology Research Group, Medical Research Institute Hospital La Fe, 46026 Valencia, Spain
- Department of Gynecology and Obstetrics, Münster University Hospital, 48149 Muenster, Germany
| | - Raquel Herranz
- Haemostasis, Thrombosis, Arteriosclerosis and Vascular Biology Research Group, Medical Research Institute Hospital La Fe, 46026 Valencia, Spain
| | - Pilar Medina
- Haemostasis, Thrombosis, Arteriosclerosis and Vascular Biology Research Group, Medical Research Institute Hospital La Fe, 46026 Valencia, Spain
| | - Martin Götte
- Department of Gynecology and Obstetrics, Münster University Hospital, 48149 Muenster, Germany
| | - Bárbara Andrea Mc Cormack
- Haemostasis, Thrombosis, Arteriosclerosis and Vascular Biology Research Group, Medical Research Institute Hospital La Fe, 46026 Valencia, Spain
- Research Laboratory in Biomarkers in Reproduction, Gynaecology, and Obstetrics, Research Foundation of the General University Hospital of Valencia, 46014 Valencia, Spain
| | - Josep Marí-Alexandre
- Research Laboratory in Biomarkers in Reproduction, Gynaecology, and Obstetrics, Research Foundation of the General University Hospital of Valencia, 46014 Valencia, Spain
- Department of Pathology, General University Hospital of Valencia Consortium, 46014 Valencia, Spain
| | - Juan Gilabert-Estellés
- Research Laboratory in Biomarkers in Reproduction, Gynaecology, and Obstetrics, Research Foundation of the General University Hospital of Valencia, 46014 Valencia, Spain
- Department of Obstetrics and Gynecology, General University Hospital of Valencia Consortium, 46014 Valencia, Spain
- Department of Pediatrics, Obstetrics, and Gynecology, University of Valencia, 46014 Valencia, Spain
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Castaño M, Tomás-Pérez S, González-Cantó E, Aghababyan C, Mascarós-Martínez A, Santonja N, Herreros-Pomares A, Oto J, Medina P, Götte M, Mc Cormack BA, Marí-Alexandre J, Gilabert-Estellés J. Neutrophil Extracellular Traps and Cancer: Trapping Our Attention with Their Involvement in Ovarian Cancer. Int J Mol Sci 2023; 24:ijms24065995. [PMID: 36983067 PMCID: PMC10056926 DOI: 10.3390/ijms24065995] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/17/2023] [Accepted: 03/20/2023] [Indexed: 03/30/2023] Open
Abstract
Neutrophils, the most abundant circulating leukocytes, play a well-known role in defense against pathogens through phagocytosis and degranulation. However, a new mechanism involving the release of neutrophil extracellular traps (NETs) composed of DNA, histones, calprotectin, myeloperoxidase, and elastase, among others, has been described. The so-called NETosis process can occur through three different mechanisms: suicidal, vital, and mitochondrial NETosis. Apart from their role in immune defense, neutrophils and NETs have been involved in physiopathological conditions, highlighting immunothrombosis and cancer. Notably, neutrophils can either promote or inhibit tumor growth in the tumor microenvironment depending on cytokine signaling and epigenetic modifications. Several neutrophils' pro-tumor strategies involving NETs have been documented, including pre-metastatic niche formation, increased survival, inhibition of the immune response, and resistance to oncologic therapies. In this review, we focus on ovarian cancer (OC), which remains the second most incidental but the most lethal gynecologic malignancy, partly due to the presence of metastasis, often omental, at diagnosis and the resistance to treatment. We deepen the state-of-the-art on the participation of NETs in OC metastasis establishment and progression and their involvement in resistance to chemo-, immuno-, and radiotherapies. Finally, we review the current literature on NETs in OC as diagnostic and/or prognostic markers, and their contribution to disease progression at early and advanced stages. The panoramic view provided in this article might pave the way for enhanced diagnostic and therapeutic strategies to improve the prognosis of cancer patients and, specifically, OC patients.
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Affiliation(s)
- María Castaño
- Haemostasis, Thrombosis, Arteriosclerosis and Vascular Biology Research Group, Medical Research Institute Hospital La Fe, 46026 Valencia, Spain
| | - Sarai Tomás-Pérez
- Research Laboratory in Biomarkers in Reproduction, Gynaecology, and Obstetrics, Research Foundation of the General University Hospital of Valencia, 46014 Valencia, Spain
| | - Eva González-Cantó
- Research Laboratory in Biomarkers in Reproduction, Gynaecology, and Obstetrics, Research Foundation of the General University Hospital of Valencia, 46014 Valencia, Spain
| | - Cristina Aghababyan
- Research Laboratory in Biomarkers in Reproduction, Gynaecology, and Obstetrics, Research Foundation of the General University Hospital of Valencia, 46014 Valencia, Spain
- Department of Obstetrics and Gynecology, General University Hospital of Valencia Consortium, 46014 Valencia, Spain
| | - Andrea Mascarós-Martínez
- Department of Pathology, General University Hospital of Valencia Consortium, 46014 Valencia, Spain
| | - Nuria Santonja
- Department of Pathology, General University Hospital of Valencia Consortium, 46014 Valencia, Spain
| | | | - Julia Oto
- Haemostasis, Thrombosis, Arteriosclerosis and Vascular Biology Research Group, Medical Research Institute Hospital La Fe, 46026 Valencia, Spain
- Department of Gynecology and Obstetrics, Münster University Hospital, 48149 Münster, Germany
| | - Pilar Medina
- Haemostasis, Thrombosis, Arteriosclerosis and Vascular Biology Research Group, Medical Research Institute Hospital La Fe, 46026 Valencia, Spain
| | - Martin Götte
- Department of Gynecology and Obstetrics, Münster University Hospital, 48149 Münster, Germany
| | - Bárbara Andrea Mc Cormack
- Research Laboratory in Biomarkers in Reproduction, Gynaecology, and Obstetrics, Research Foundation of the General University Hospital of Valencia, 46014 Valencia, Spain
| | - Josep Marí-Alexandre
- Research Laboratory in Biomarkers in Reproduction, Gynaecology, and Obstetrics, Research Foundation of the General University Hospital of Valencia, 46014 Valencia, Spain
- Department of Pathology, General University Hospital of Valencia Consortium, 46014 Valencia, Spain
| | - Juan Gilabert-Estellés
- Research Laboratory in Biomarkers in Reproduction, Gynaecology, and Obstetrics, Research Foundation of the General University Hospital of Valencia, 46014 Valencia, Spain
- Department of Obstetrics and Gynecology, General University Hospital of Valencia Consortium, 46014 Valencia, Spain
- Department of Pediatrics, Obstetrics, and Gynaecology, University of Valencia, 46014 Valencia, Spain
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