This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
1
Elevated Growth Differentiation Factor 15 Expression Predict Poor Prognosis in
1 The State Key Laboratory of Cancer Biology, Biotechnology Center, School of
Pharmacy, the Fourth Military Medical University, Xi’an, Shaanxi 710032, China;2 Department of Gynecology and Obstetrics, the People's Liberation Army 323 Hospital,
Xi’an, Shaanxi 710045, China;
3 State Key Laboratory of Tumor Biology, Department of Pathology, Xijing Hospital,
The Fourth Military Medical University, Xi’an, Shaanxi 710033, China;4 Department of Health Service, School of Public Health, Fourth Military Medical
University, Xi’an, Shaanxi 710033, China;5 Department of Gynecology and Obstetrics, Xijing Hospital, Fourth Military Medical
2
University, Xi’an, Shaanxi 710033, China;* Ying Zhang and Wei Hua contributed equally to this work.#Correspondence to: Dr. Jian Wang, Department of Gynecology and Obstetrics, Xijing
Hospital, Fourth Military Medical University, 169 Changle West Road, 710033 Xi’an,
undifferentiated (5%); and (6) transitional cell cancer (rare)[21]. Over the last three
decades, CA125 has been used for distinguishing malignant from benign pelvic masses,
detecting recurrent disease, monitoring response to treatment, and for early detection[4, 6,
8]. However, serum CA125 is not an ideal biomarker for EOC screening because of its
low sensitivity and specificity. Høgdall et al.[22] found that the test for CA125 is positive
in 85%–90% of serous tumors, 40%–65% of clear cell and endometrioid tumors, and
only 6%–12% of mucinous tumors. Furthermore, serum CA125 levels may be in the
normal range in 50% of symptomatic stage I patients and in about 10%–20% of
advanced-stage patients[23-26]. The identification of valuable diagnostic and prognostic
biomarkers to improve the outcomes of EOC patients remains a challenge.
Under normal physiological conditions, GDF15, a member of the TGF-β
superfamily, is largely expressed in the placenta, and is expressed at low levels in the
liver, lungs, kidneys, and neuroepithelium[11, 27]. GDF15 has been found to play a role in
cell cycle regulation and cell proliferation, differentiation, and apoptosis[10, 11, 27]. Studies
24
have demonstrated that GDF15 is markedly increased in many cancer lines and tissues,
including breast cancer, gastric adenomas, oral squamous cell carcinoma (OSCC),
glioblastoma, prostate cancer, and colon cancer[28-35]. In OSCC, low GDF15 expression
predicts better survival, especially overall and distant metastasis–free survival[l,[33].
Wallin et al.[34] reported that colorectal cancer patients with moderate-to-high levels of
GDF15 had higher recurrence rates than did patients with no or low GDF15 expression.
In addition, colorectal cancer patients with high plasma GDF15 levels had statistically
shorter time to recurrence (p = 0.041) and reduced overall survival (p = 0.002)[34].
The clinical utility of GDF15 as a biomarker for EOC has not fully been explored.
Staff et al. reported that high GDF15 concentration was detected on ELISA in both
plasma and ascitic fluid samples obtained from patients with advanced ovarian cancer[36,
37]. As the plasma GDF15 concentration correlated inversely with survival time, GDF15
was proposed to be a potentially useful prognostic biomarker in ovarian cancer[36].
However, the study by Staff et al.[36] was restricted to serous ovarian cancer and limited
to patients with advanced tumors. Considering the complexity of the histologic subtypes
of EOCs and the diverse tumor properties, the value of GDF15 as a tumor biomarker for
early detection, surveillance treatment response, and prognosis prediction warranted
further investigation.
Therefore, in our study, we analyzed the expression of GDF15 in EOC tissues and
serum samples, and found that the serum levels of GDF15 were elevated, which was
consistent with the results observed in the EOC tissue samples. Importantly, we also
assessed the value of GDF15 as a diagnostic indicator in different stages of EOC, and
25
investigated the potential of serum GDF15 for predicting tumor progression and
chemoresistance.
First, we found that cytoplasmic GDF15 expression was observed in 79.3% of EOC
tumor tissues on immunohistochemical analysis. We further analyzed the correlation
between GDF15 expression and clinicopathologic characteristics in EOC patients. The
data showed that increased GDF15 expression was associated with advanced FIGO
stage, lymph node metastasis, ascites, and chemoresistance. However, GDF15
expression in the tumor tissues was not associated with histologic grade or type.
Survival analysis revealed that EOC patients with high GDF15 expression exhibited
significantly poorer PFS and OS than did EOC patients with low GDF15 expression.
Multivariate analysis demonstrated that GDF15 expression was an independent
predictor of PFS in EOC patients. Consistent with data from previous studies[36], our
clinical data suggest that GDF15 expression may be an independent prognostic
predictor in EOC patients.
GDF15 concentration in effusion fluid has been correlated positively with the
GDF15 expression in EOC cells[36]. As a secreted protein, high plasma GDF15
concentrations most likely reflect the tumor burden of EOC. GDF15 has been suggested
to be a serological marker for the early diagnosis of and progression of EOC. In our
study, serum GDF15 levels were significantly higher in EOC patients than in healthy
controls. Furthermore, serum GDF15 levels in EOC patients were significantly
correlated with FIGO stage, ascites, and lymph node metastasis. Our results are in
agreement with the findings of Staff et al.[36], who found that GDF15 levels significantly
26
differed with FIGO stage and survival duration.
Therefore, to further evaluate the clinical value of GDF15, we compared the
diagnostic usefulness of GDF15 and CA125, which is often used as an EOC marker in
clinical practice. ROC analyses revealed that GDF15 had higher sensitivity than CA125
(75.5% vs. 68.2%) for the detection of EOC, although the specificity of both markers
was similar (83.3% vs. 88.1%). Notably, the AUC value of the combination of GDF15
with CA125 was 0.944, compared with 0.924 for CA125 alone, suggesting that the
combination of serum GDF15 and CA125 had a better performance than CA125 alone
in the detection of EOC. These data suggested that GDF15 could serve as a sensitive
marker for the detection of EOC, and the combination of GDF15 with CA125 may yield
a superior diagnostic performance than that of CA125 alone. Our study only compared
serum GDF15 levels between EOC patients and healthy controls; we did not include
patients with benign ovarian tumors and borderline ovarian tumors. Further studies are
needed to conclude whether GDF15 can serve as a more valuable tumor biomarker than
CA125 in the detection of EOC.
Another interesting finding of our study is that GDF15 levels, both in the EOC
tissues and serum samples, were significantly higher in EOC patients who were resistant
to first-line chemotherapy than in those who were sensitive to first-line chemotherapy.
Therefore, we detected the expression of GDF15 protein in two pairs of platinum-
resistant cell lines and their parental platinum-sensitive cell lines by using western blot
analysis (data not shown). We found that the GDF15 levels were obviously higher in the
platinum-resistant cell lines than in the parental platinum-sensitive cell lines, and that
27
platinum sensitivity significantly declined after increasing GDF15 expression by
GDF15 adenovirus (unpublished data). We have enough reason to presume that GDF15
plays a potential role in predicting the response to first-line chemotherapy in EOC
patients. In 2015, Meier et al. [38]used whole genome microarrays and linear model
analysis to identify potential resistance-related genes by comparing the expression
profiles of the parental human ovarian cancer model A2780 and its cisplatin-resistant
variant A2780cis, before and after carboplatin treatment in vivo. It was found that
GDF15 levels to be notably increased during carboplatin treatment in the A2780 but not
in A2780cis in vivo. In accordance with microarray and qRT-PCR data, serum GDF15
levels were obviously increased during carboplatin short-treatment in A2780 tumor-
bearing mice compared to vehicle treatment, but only slightly in A2780cis tumor-
bearing mice. Additionally, basal GDF15 plasma levels were higher in A2780cis-
bearing mice than in mice with A2780 tumors. Furthermore, knockdown of GDF15 in
A2780cis in vivo resulted in enhanced subcutaneous tumor growth in mice but
increased sensitivity to carboplatin treatment. In summary, there are enough reasons to
believe that GDF15 levels is correlated with platinum-resistance in ovarian cancer cells,
and GDF15 might serve as a novel treatment target in women with platinumresistant
ovarian cancer.
Conclusions
In summary, our results demonstrated that GDF15 may be involved in the
progression of EOC, and high levels of GDF15, both in the serum and EOC tissue, may
28
be related with advanced FIGO stage, lymph node metastasis, ascites, and
chemoresistance. GDF15 expression was significantly associated with poor survival,
and was an independent predictor of PFS in EOC patients. GDF15 has the potential to
expedite the clinical diagnosis of EOC and aid in predicting patient outcomes and the
response to chemotherapy.
29
REFERENCES
1 R. Siegel, J. Ma, Z. Zou, et al. Cancer statistics, 2014[J]. CA: a cancer journal for clinicians, 2014,64(1):9-29.2 A. Jemal, F. Bray, M. M. Center, et al. Global cancer statistics[J]. CA: a cancer journal for clinicians, 2011,61(2):69-90.3 B. S. Gloss and G. Samimi. Epigenetic biomarkers in epithelial ovarian cancer[J]. Cancer letters, 2014,342(2):257-263.4 M. Felder, A. Kapur, J. Gonzalez-Bosquet, et al. MUC16 (CA125): tumor biomarker to cancer therapy, a work in progress[J]. Molecular cancer, 2014,13:129.5 J. Menczer, E. Ben-Shem, A. Golan, et al. The Significance of Normal Pretreatment Levels of CA125 (<35 U/mL) in Epithelial Ovarian Carcinoma[J]. Rambam Maimonides medical journal, 2015,6(1):e0005.6 J. G. Cohen, M. White, A. Cruz, et al. In 2014, can we do better than CA125 in the early detection of ovarian cancer?[J]. World journal of biological chemistry, 2014,5(3):286-300.7 A. K. Karam and B. Y. Karlan. Ovarian cancer: the duplicity of CA125 measurement[J]. Nature reviews. Clinical oncology, 2010,7(6):335-339.8 M. J. Duffy, J. M. Bonfrer, J. Kulpa, et al. CA125 in ovarian cancer: European Group on Tumor Markers guidelines for clinical use[J]. International journal of gynecological cancer : official journal of the International Gynecological Cancer Society, 2005,15(5):679-691.9 T. Ago and J. Sadoshima. GDF15, a cardioprotective TGF-beta superfamily protein[J]. Circulation research, 2006,98(3):294-297.10 T. E. Eling, S. J. Baek, M. Shim, et al. NSAID activated gene (NAG-1), a modulator of tumorigenesis[J]. Journal of biochemistry and molecular biology, 2006,39(6):649-655.11 S. N. Breit, H. Johnen, A. D. Cook, et al. The TGF-beta superfamily cytokine, MIC-1/GDF15: a pleotrophic cytokine with roles in inflammation, cancer and metabolism[J]. Growth factors, 2011,29(5):187-195.12 D. A. Brown, R. L. Ward, P. Buckhaults, et al. MIC-1 serum level and genotype: associations with progress and prognosis of colorectal carcinoma[J]. Clinical cancer research : an official journal of the American Association for Cancer Research, 2003,9(7):2642-2650.13 G. Yang, Q. Tan, Y. Xie, et al. Variations in NAG-1 expression of human gastric carcinoma and normal gastric tissues[J]. Experimental and therapeutic medicine, 2014,7(1):241-245.14 S. Kaur, S. Chakraborty, M. J. Baine, et al. Potentials of plasma NGAL and MIC-1 as biomarker(s) in the diagnosis of lethal pancreatic cancer[J]. PloS one, 2013,8(2):e55171.15 R. S. Mehta, M. Song, N. Bezawada, et al. A prospective study of macrophage inhibitory cytokine-1 (MIC-1/GDF15) and risk of colorectal cancer[J]. Journal of the National Cancer Institute, 2014,106(4):dju016.
30
16 A. B. Marjono, D. A. Brown, K. E. Horton, et al. Macrophage inhibitory cytokine-1 in gestational tissues and maternal serum in normal and pre-eclamptic pregnancy[J]. Placenta, 2003,24(1):100-106.17 J. Koopmann, P. Buckhaults, D. A. Brown, et al. Serum macrophage inhibitory cytokine 1 as a marker of pancreatic and other periampullary cancers[J]. Clinical cancer research : an official journal of the American Association for Cancer Research, 2004,10(7):2386-2392.18 D. G. Mutch and J. Prat. 2014 FIGO staging for ovarian, fallopian tube and peritoneal cancer[J]. Gynecologic oncology, 2014,133(3):401-404.19 T. Kaku, S. Watanabe and Y. Ohishi. [Pathology of ovarian cancer][J]. Nihon rinsho. Japanese journal of clinical medicine, 2012,70 Suppl 4:512-516.20 R. Simon, M. Mirlacher and G. Sauter. Immunohistochemical analysis of tissue microarrays[J]. Methods in molecular biology, 2010,664:113-126.21 S. Vaughan, J. I. Coward, R. C. Bast, Jr., et al. Rethinking ovarian cancer: recommendations for improving outcomes[J]. Nature reviews. Cancer, 2011,11(10):719-725.22 E. V. Hogdall, L. Christensen, S. K. Kjaer, et al. CA125 expression pattern, prognosis and correlation with serum CA125 in ovarian tumor patients. From The Danish "MALOVA" Ovarian Cancer Study[J]. Gynecologic oncology, 2007,104(3):508-515.23 V. Nossov, M. Amneus, F. Su, et al. The early detection of ovarian cancer: from traditional methods to proteomics. Can we really do better than serum CA-125?[J]. American journal of obstetrics and gynecology, 2008,199(3):215-223.24 J. R. van Nagell, Jr. and E. J. Pavlik. Ovarian cancer screening[J]. Clinical obstetrics and gynecology, 2012,55(1):43-51.25 O. Dorigo and J. S. Berek. Personalizing CA125 levels for ovarian cancer screening[J]. Cancer prevention research, 2011,4(9):1356-1359.26 W. D. Kang, H. S. Choi and S. M. Kim. Value of serum CA125 levels in patients with high-risk, early stage epithelial ovarian cancer[J]. Gynecologic oncology, 2010,116(1):57-60.27 X. Wang, S. J. Baek and T. E. Eling. The diverse roles of nonsteroidal anti-inflammatory drug activated gene (NAG-1/GDF15) in cancer[J]. Biochemical pharmacology, 2013,85(5):597-606.28 J. Xu, T. R. Kimball, J. N. Lorenz, et al. GDF15/MIC-1 functions as a protective and antihypertrophic factor released from the myocardium in association with SMAD protein activation[J]. Circulation research, 2006,98(3):342-350.29 P. Buckhaults, C. Rago, B. St Croix, et al. Secreted and cell surface genes expressed in benign and malignant colorectal tumors[J]. Cancer research, 2001,61(19):6996-7001.30 J. Y. Park, K. H. Park, S. Bang, et al. Expression of nonsteroidal anti-inflammatory drug-activated gene-1 (NAG-1) inversely correlates with tumor progression in gastric adenomas and carcinomas[J]. Journal of cancer research and clinical oncology, 2008,134(9):1029-1035.31 M. Blanco-Calvo, N. Tarrio, M. Reboredo, et al. Circulating levels of GDF15,
31
MMP7 and miR-200c as a poor prognostic signature in gastric cancer[J]. Future oncology, 2014,10(7):1187-1202.32 E. Schiegnitz, P. W. Kammerer, F. P. Koch, et al. GDF 15 as an anti-apoptotic, diagnostic and prognostic marker in oral squamous cell carcinoma[J]. Oral oncology, 2012,48(7):608-614.33 C. Z. Yang, J. Ma, D. W. Zhu, et al. GDF15 is a potential predictive biomarker for TPF induction chemotherapy and promotes tumorigenesis and progression in oral squamous cell carcinoma[J]. Annals of oncology : official journal of the European Society for Medical Oncology / ESMO, 2014,25(6):1215-1222.34 U. Wallin, B. Glimelius, K. Jirstrom, et al. Growth differentiation factor 15: a prognostic marker for recurrence in colorectal cancer[J]. British journal of cancer, 2011,104(10):1619-1627.35 S. Shnaper, I. Desbaillets, D. A. Brown, et al. Elevated levels of MIC-1/GDF15 in the cerebrospinal fluid of patients are associated with glioblastoma and worse outcome[J]. International journal of cancer. Journal international du cancer, 2009,125(11):2624-2630.36 A. C. Staff, A. J. Bock, C. Becker, et al. Growth differentiation factor-15 as a prognostic biomarker in ovarian cancer[J]. Gynecologic oncology, 2010,118(3):237-243.37 A. J. Bock, H. T. Stavnes, T. Kempf, et al. Expression and clinical role of growth differentiation factor-15 in ovarian carcinoma effusions[J]. International journal of gynecological cancer : official journal of the International Gynecological Cancer Society, 2010,20(9):1448-1455.38 J. C. Meier, B. Haendler, H. Seidel, et al. Knockdown of platinum-induced growth differentiation factor 15 abrogates p27-mediated tumor growth delay in the chemoresistant ovarian cancer model A2780cis[J]. Cancer medicine, 2015,4(2):253-267.