1
|
Ibrahim HM, Abdelrahman AE, Elwan A, Gharieb SA, Refaat M, Elmesallamy W, Salem AA. Clinicopathological Impact of FOXM1 and MMP-9 Immunohistochemical Expression in Different Grades of Intracranial Meningioma. Appl Immunohistochem Mol Morphol 2024; 32:292-304. [PMID: 38863278 DOI: 10.1097/pai.0000000000001205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 04/05/2024] [Indexed: 06/13/2024]
Abstract
OBJECTIVES To find predictive biomarkers for recurrence and progression of meningioma. BACKGROUND Despite great advances in meningioma treatment, the prognosis remained unfavorable due to the high recurrence rate. METHODS In this study, we evaluated the immunohistochemical expression of FOXM1, MMP-9, and Ki67 in 50 cases of intracranial meningioma to detect its potential role in meningioma progression, recurrence, and patients' survival. RESULTS Strong FOXM1 expression was detected in 20% of the cases and was significantly associated with meningioma grade ( P = 0.002) and peritumoral brain edema (PTBE; P <0.001). Strong MMP-9 expression was noted in 32% of the cases and was significantly associated with meningioma grade and PTBE ( P <0.001, P <0.001, respectively). High Ki67 was noted in 50% and significantly associated with tumor grade and PTBE ( P <0.001, P = 0.002, respectively). The follow-up period revealed that meningiomas with strong FOXM1, strong MMP-9, and high Ki67 expression were associated with tumor recurrence, shorter OS, and recurrence-free survival. Furthermore, up-regulation of FOXM1 and MMP-9 expression had a significant relation with poor clinical response to the therapy ( P = 0.010, P = 0. 001, respectively). However, high Ki67 cases were more sensitive to clinical therapy ( P = 0.005). CONCLUSION Strong FOXM1, strong MMP-9, and high Ki67 in meningiomas indicate highly aggressive tumors with a shortened survival rate, dismal outcome, and high risk of recurrence after the standard protocol of therapy.
Collapse
Affiliation(s)
| | | | - Amira Elwan
- Department of Clinical Oncology and Nuclear Medicine
| | | | | | - Wael Elmesallamy
- Department of Neurosurgery, Faculty of Medicine, Zagazig University, Egypt
| | | |
Collapse
|
2
|
Dang DD, Mugge LA, Awan OK, Gong AD, Fanous AA. Spinal Meningiomas: A Comprehensive Review and Update on Advancements in Molecular Characterization, Diagnostics, Surgical Approach and Technology, and Alternative Therapies. Cancers (Basel) 2024; 16:1426. [PMID: 38611105 PMCID: PMC11011121 DOI: 10.3390/cancers16071426] [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: 02/04/2024] [Revised: 03/27/2024] [Accepted: 04/01/2024] [Indexed: 04/14/2024] Open
Abstract
Spinal meningiomas are the most common intradural, extramedullary tumor in adults, yet the least common entity when accounting for all meningiomas spanning the neuraxis. While traditionally considered a benign recapitulation of their intracranial counterpart, a paucity of knowledge exists regarding the differences between meningiomas arising from these two anatomic compartments in terms of histopathologic subtypes, molecular tumor biology, surgical principles, long-term functional outcomes, and recurrence rates. To date, advancements at the bench have largely been made for intracranial meningiomas, including the discovery of novel gene targets, DNA methylation profiles, integrated diagnoses, and alternative systemic therapies, with few exceptions reserved for spinal pathology. Likewise, evolving clinical research offers significant updates to our understanding of guiding surgical principles, intraoperative technology, and perioperative patient management for intracranial meningiomas. Nonetheless, spinal meningiomas are predominantly relegated to studies considering non-specific intradural extramedullary spinal tumors of all histopathologic types. The aim of this review is to comprehensively report updates in both basic science and clinical research regarding intraspinal meningiomas and to provide illustrative case examples thereof, thereby lending a better understanding of this heterogenous class of central nervous system tumors.
Collapse
Affiliation(s)
- Danielle D. Dang
- Department of Neurosurgery, Inova Fairfax Medical Campus, Falls Church, VA 22042, USA; (D.D.D.); (L.A.M.); (O.K.A.); (A.D.G.)
| | - Luke A. Mugge
- Department of Neurosurgery, Inova Fairfax Medical Campus, Falls Church, VA 22042, USA; (D.D.D.); (L.A.M.); (O.K.A.); (A.D.G.)
| | - Omar K. Awan
- Department of Neurosurgery, Inova Fairfax Medical Campus, Falls Church, VA 22042, USA; (D.D.D.); (L.A.M.); (O.K.A.); (A.D.G.)
| | - Andrew D. Gong
- Department of Neurosurgery, Inova Fairfax Medical Campus, Falls Church, VA 22042, USA; (D.D.D.); (L.A.M.); (O.K.A.); (A.D.G.)
| | - Andrew A. Fanous
- Department of Neurosurgery, Inova Alexandria Hospital, Alexandria, VA 22304, USA
| |
Collapse
|
3
|
Tomanelli M, Florio T, Vargas GC, Pagano A, Modesto P. Domestic Animal Models of Central Nervous System Tumors: Focus on Meningiomas. Life (Basel) 2023; 13:2284. [PMID: 38137885 PMCID: PMC10744527 DOI: 10.3390/life13122284] [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: 10/13/2023] [Accepted: 11/09/2023] [Indexed: 12/24/2023] Open
Abstract
Intracranial primary tumors (IPTs) are aggressive forms of malignancies that cause high mortality in both humans and domestic animals. Meningiomas are frequent adult IPTs in humans, dogs, and cats, and both benign and malignant forms cause a decrease in life quality and survival. Surgery is the primary therapeutic approach to treat meningiomas, but, in many cases, it is not resolutive. The chemotherapy and targeted therapy used to treat meningiomas also display low efficacy and many side effects. Therefore, it is essential to find novel pharmacological approaches to increase the spectrum of therapeutic options for meningiomas. This review analyzes the similarities between human and domestic animal (dogs and cats) meningiomas by evaluating the molecular and histological characteristics, diagnosis criteria, and treatment options and highlighting possible research areas to identify novel targets and pharmacological approaches, which are useful for the diagnosis and therapy of this neoplasia to be used in human and veterinary medicine.
Collapse
Affiliation(s)
- Michele Tomanelli
- Department of Experimental Medicine, University of Genova, 16132 Genova, Italy; (G.C.V.); (A.P.)
| | - Tullio Florio
- Pharmacology Section, Department of Internal Medicine (DIMI), University of Genova, 16126 Genova, Italy;
- IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy
| | - Gabriela Coronel Vargas
- Department of Experimental Medicine, University of Genova, 16132 Genova, Italy; (G.C.V.); (A.P.)
| | - Aldo Pagano
- Department of Experimental Medicine, University of Genova, 16132 Genova, Italy; (G.C.V.); (A.P.)
- IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy
| | - Paola Modesto
- National Reference Center for Veterinary and Comparative Oncology, Veterinary Medical Research Institute for Piemonte, Liguria and Valle d’Aosta, 10154 Torino, Italy
| |
Collapse
|
4
|
Elsamadicy AA, Reeves BC, Craft S, Sherman JJZ, Koo AB, Sayeed S, Sarkozy M, Kolb L, Lo SFL, Shin JH, Sciubba DM, Mendel E. A current review of spinal meningiomas: epidemiology, clinical presentation and management. J Neurooncol 2023; 161:395-404. [PMID: 36637710 DOI: 10.1007/s11060-023-04238-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 01/03/2023] [Indexed: 01/14/2023]
Abstract
PURPOSE To provide an up-to-date review of the epidemiology, histopathology, molecular biology, and etiology of spinal meningiomas, as well as discuss the clinical presentation, clinical evaluation, and most recent treatment recommendations for these lesions. METHODS PubMed and Google Scholar search was performed for studies related to meningiomas of the spine. The terms "meningioma," "spinal meningioma," "spine meningioma," "meningioma of the spine," "benign spinal tumors," and "benign spine tumors," were used to identify relevant studies. All studies, including primary data papers, meta-analyses, systematic reviews, general reviews, case reports, and clinical trials were considered for review. RESULTS Eighty-four studies were identified in the review. There were 22 studies discussing adverse postoperative outcomes, 21 studies discussing tumor genetics, 19 studies discussing epidemiology and current literature, 9 studies discussing radiation modalities and impact on subsequent tumor development, 5 studies on characteristic imaging findings, 5 studies discussing hormone use/receptor status on tumor development, 2 discussing operative techniques and 1 discussing tumor identification. CONCLUSION Investigations into spinal meningiomas generally lag behind that of intracranial meningiomas. Recent advancements in the molecular profiling of spinal meningiomas has expanded our understanding of these tumors, increasing our appreciation for their heterogeneity. Continued investigation into the defining characteristics of different spinal meningiomas will aid in treatment planning and prognostication.
Collapse
Affiliation(s)
- Aladine A Elsamadicy
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA.
| | - Benjamin C Reeves
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA
| | - Samuel Craft
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA
| | - Josiah J Z Sherman
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA
| | - Andrew B Koo
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA
| | - Sumaiya Sayeed
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA
| | - Margot Sarkozy
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA
| | - Luis Kolb
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA
| | - Sheng-Fu Larry Lo
- Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, NY, USA
| | - John H Shin
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, NY, USA
| | - Ehud Mendel
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA
| |
Collapse
|
5
|
Hachem LD, Nater A, Fehlings MG. Spinal Meningiomas. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2023; 1416:69-78. [PMID: 37432620 DOI: 10.1007/978-3-031-29750-2_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 07/12/2023]
Abstract
Spinal meningiomas are relatively rare, but account for a significant proportion of primary spinal tumors in adults. These meningiomas can be found anywhere along the spinal column and their diagnosis is often delayed due to their slow growth and the lack of significant neurological symptoms until they reach a critical size, at which point signs of spinal cord or nerve root compression generally manifest and progress. If left untreated, spinal meningiomas can cause severe neurological deficits including rendering patients paraplegic or tetraplegic. In this chapter we will review the clinical features of spinal meningiomas, their surgical management, and detail molecular features that differentiate them from intracranial meningiomas.
Collapse
Affiliation(s)
- Laureen D Hachem
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Anick Nater
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Michael G Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.
| |
Collapse
|
6
|
Abd Elhakeem AAE, Essa AA, Soliman RK, Hamdan ARK. Novel evaluation of the expression patterns CD44 and MMP9 proteins in intracranial meningiomas and their relationship to the overall survival. EGYPTIAN JOURNAL OF NEUROSURGERY 2022. [DOI: 10.1186/s41984-022-00173-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Abstract
Background
Meningiomas are common primary brain neoplasms. CD44 is a cell surface glycoprotein receptor that is involved in matrix-mediated cell signaling and cell–matrix adhesion. Matrix metalloproteinase-9 (MMP-9) plays important role in angiogenesis and tumor invasion. The expression of CD44 protein membranous and cytoplasmic (CD44M and CD44C) has been reported in several tumors (such as lobular carcinoma, renal cell carcinoma, sinonasal melanoma, and lymphoma) except CNS tumors.
Methods
This study addressed the expression of CD44M and CD44C and MMP9 proteins in intracranial meningiomas and their relationship to overall survival. The expression patterns of CD44M&C and MMP-9 proteins were examined in 32 cases of benign meningiomas, 12 cases of atypical meningiomas, and 6 cases of anaplastic meningiomas using immunohistochemical staining methods.
Results
There was more evidence of CD44M expression in atypical and anaplastic meningioma (p = < 0.001). Interestingly, Spearman correlation analyses revealed significant positive correlation between CD44M and MMP9 protein (r = 0.572, p = < 0.001) in spite of the negative correlation between MMP9 and CD44 score (r = − 0.035 p = 0.405). There was a significant association between Ki67 protein expression and the grade of meningiomas (p < 0.001) and gender (p = 0.026). There was a significant correlation between overall survival (OS) and age, gender, tumor grade, and Ki-67.
Conclusions
Extensive CD44M expression in high-grade meningioma may reflect a tendency toward more invasive power of meningioma cells into surrounding structures (dura, bone, and brain).CD44M/MMP-9 axis presented by this study is open for future investigations.
Collapse
|
7
|
Guadarrama-Ortíz P, Montes de Oca-Vargas I, Choreño-Parra JA, Gallegos-Garza C, Sánchez-Garibay C, Garibay-Gracián A, Salinas-Lara C, Guinto G. Expression of IL-6 and matrix metalloproteinases in a convexity meningiomas with hyperostosis: Case report. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2021.101374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
|
8
|
Ozek E, Ozcan D, Celik SE, Iplikcioglu AC. Matrix metalloprotease-9 expresssion in meningioma: Correlation with growth fraction and role of gender. A pilot immunohistochemical study. Clin Neurol Neurosurg 2018; 172:169-173. [PMID: 30021149 DOI: 10.1016/j.clineuro.2018.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Revised: 06/28/2018] [Accepted: 07/01/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Matrix metalloproteases (MMPs), particularly MMP2 and MMP9 increase tumor invasion and edema in meningiomas. Although lesser recognized, MMPs may also enhance cell growth via liberating growth factors or via cleaving inactive growth factors into active isoforms. However, there exist very few studies, which investigated correlation of MMPs with growth fraction in meningiomas. Meningiomas are seen more frequently in women and their growth accelarate during pregnancy. However, no study examined whether MMP-expressions in meningioma differ with gender. PATIENTS AND METHODS In a pilot immunohistochemical study, we analyzed the correlation of MMP9 expression with Ki67 index and whether gender influences MMP9 expression. We retrospectively selected 24 meningioma cases including 10 cases with WHO Grade-1 tumors and 7 cases each with WHO Grade-2 and 3 tumors, respectively. RESULTS We separately determined the intensity and area of MMP9 staining and also calculated an expression index by multiplying these two parameters. Spearman correlation analyses revealed that MMP9 staining intensity, staining area and expression index significantly correlated with Ki67 proliferation index. MMP9 staining indices were significantly higher in women specimens. CONCLUSION If these findings will be confirmed in larger series, MMP-inhibitors and female hormone receptor-antagonists may be combined to augment chemotherapy efficacy and to attenuate invasion in high-grade meningiomas.
Collapse
Affiliation(s)
- Erdinc Ozek
- Neurosurgery Department, Bezmialem Vakif University, Fatih, Istanbul, Turkey.
| | - Deniz Ozcan
- Pathology Department, Okmeydani Training and Research Hospital, Sisli, Istanbul, Turkey
| | - Suat Erol Celik
- Neurosurgery Department, Okmeydani Training and Research Hospital, Sisli, Istanbul, Turkey
| | | |
Collapse
|
9
|
Mandara M, Reginato A, Foiani G, De Luca S, Guelfi G. Gene Expression of Matrix Metalloproteinases and their Inhibitors (TIMPs) in Meningiomas of Dogs. J Vet Intern Med 2017; 31:1816-1821. [PMID: 28875568 PMCID: PMC5697205 DOI: 10.1111/jvim.14809] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 06/10/2017] [Accepted: 07/19/2017] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) are considered to be key mediators of tumor invasion and metastasis. MMP-2 and MMP-9 are expressed in meningiomas of dogs, but TIMP expression, and variations of specific MMP/TIMP ratios still are unknown in this tumor. HYPOTHESIS/OBJECTIVES Expression of MMP/TIMP might increase progressively from grade I to grade III meningioma. Therefore, genetic expression of MMP-2 and MMP-9, and specific TIMP-2 and TIMP-1, respectively, has been investigated in meningiomas of different grades. ANIMALS Selected formalin-fixed paraffin-embedded tissue from 43 meningiomas of dogs was evaluated. METHODS Genetic material was obtained from pathologic samples and used for quantitative reverse transcriptase real-time polymerase chain reaction (RT-qPCR). RESULTS MMP-9 was not expressed in all of the tumors, but MMP-2 was significantly more expressed in papillary meningioma. Likewise, the MMP-2/TIMP-2 ratio was numerically higher in papillary meningiomas compared to all grades (>3.5 times) showing a strong bias in favor of metalloproteinase. In the papillary meningioma, TIMP-1 gene expression was significantly higher than in grades I and III. CONCLUSIONS AND CLINICAL IMPORTANCE MMP-2/TIMP-2 imbalance might contribute to the aggressive biologic behavior of papillary meningiomas in dogs. TIMP-1 expression may play a role independent of MMP-9 expression in neoplastic progression. These results further support that therapeutic and prognostic evaluations of dogs with meningioma need to be addressed according to different histologic patterns as is performed in humans.
Collapse
Affiliation(s)
- M.T. Mandara
- Department of Veterinary MedicineUniversity of PerugiaPerugiaItaly
| | - A. Reginato
- Department of Veterinary MedicineUniversity of PerugiaPerugiaItaly
| | - G. Foiani
- Department of Veterinary MedicineUniversity of PerugiaPerugiaItaly
| | - S. De Luca
- Department of Veterinary MedicineUniversity of PerugiaPerugiaItaly
| | - G. Guelfi
- Department of Veterinary MedicineUniversity of PerugiaPerugiaItaly
| |
Collapse
|
10
|
Unique Extrancranial-to-Intracranial Neovascularization Found on Diagnostic Angiography Prior to Skull Base Atypical Grade 2 Meningioma Resection: A Case Report and Hypothesis. World Neurosurg 2016; 95:617.e1-617.e6. [DOI: 10.1016/j.wneu.2016.08.081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 08/17/2016] [Accepted: 08/18/2016] [Indexed: 11/24/2022]
|
11
|
Rooprai HK, Martin AJ, King A, Appadu UD, Jones H, Selway RP, Gullan RW, Pilkington GJ. Comparative gene expression profiling of ADAMs, MMPs, TIMPs, EMMPRIN, EGF-R and VEGFA in low grade meningioma. Int J Oncol 2016; 49:2309-2318. [DOI: 10.3892/ijo.2016.3739] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Accepted: 06/06/2016] [Indexed: 11/06/2022] Open
|
12
|
Ricci S, Guadagno E, Bruzzese D, Del Basso De Caro M, Peca C, Sgulò FG, Maiuri F, Di Carlo A. Evaluation of matrix metalloproteinase type IV-collagenases in serum of patients with tumors of the central nervous system. J Neurooncol 2016; 131:223-232. [PMID: 27757720 PMCID: PMC5306235 DOI: 10.1007/s11060-016-2297-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Accepted: 10/09/2016] [Indexed: 11/30/2022]
Abstract
The basement membrane collagen IV-degrading matrix metalloproteinases -2 and -9 (MMPs) are most often linked to the malignant phenotype of tumor cells by playing a critical role in invasion, metastasis, angiogenesis, and vasculogenesis. We verified the activity of these two MMPs in the sera of patients affected by brain tumors (20 gliomas, 28 meningiomas and 20 metastasis) by zymography. The sera of 25 healthy volunteers with no concomitant illnesses were used for controls. Zymography showed four dominant gelatinolytic bands of 240, 130, 92 (MMP-9) and 72 (MMP-2) kDa. No statistically significant variations of MMP-2 proteolytic activity between patients and healthy individuals were observed. On the contrary, MMP-9 (both monomeric and multimeric forms) lytic activities were significantly higher in tumors specimens compared to healthy controls (p < 0.001). Moreover, MMP-9 immunohistochemistry revealed: (1) a strong reactivity in neoplastic vessels of high-grade gliomas showing an inverse correlation with serum multimeric gelatinolytic activity; (2) a cytoplasmatic reactivity in meningiomas with a significantly increase in atypical meningioma compared with low-grade ones (p = 0.036); (3) a positive correlation between MMP-9 and Ki-67 (Sperman Rho coefficient r = 0.418 and p = 0.034). Our results suggest that serum and tissue MMP-9 might provide clinicians additional objective information in intracranial neoplasms. Finally, it should be possible to use MMP-9 as a target for new forms of therapy. Nevertheless, due to the small number of patients included in the study, the conclusion may not be transferable to the general population and therefore further evaluations are needed.
Collapse
Affiliation(s)
- Serena Ricci
- Department of Medico-Surgical Sciences and Biotechnologies, "Sapienza" University of Rome, Corso della Repubblica 79, 04100, Latina, Italy.,Department of Translational Medical Science, University of Naples "Federico II", Via S. Pansini 5, 80131, Naples, Italy
| | - Elia Guadagno
- Department of Advanced Biomorphological Sciences, University of Naples "Federico II", Via S. Pansini 5, 80131, Naples, Italy
| | - Dario Bruzzese
- Department of Public Health, University of Naples "Federico II", Via S. Pansini 5, 80131, Naples, Italy
| | - Marialaura Del Basso De Caro
- Department of Advanced Biomorphological Sciences, University of Naples "Federico II", Via S. Pansini 5, 80131, Naples, Italy
| | - Carmela Peca
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples "Federico II", Via S. Pansini 5, 80131, Naples, Italy
| | - Francesco G Sgulò
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples "Federico II", Via S. Pansini 5, 80131, Naples, Italy
| | - Francesco Maiuri
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples "Federico II", Via S. Pansini 5, 80131, Naples, Italy
| | - Angelina Di Carlo
- Department of Medico-Surgical Sciences and Biotechnologies, "Sapienza" University of Rome, Corso della Repubblica 79, 04100, Latina, Italy.
| |
Collapse
|
13
|
Karsy M, Guan J, Sivakumar W, Neil JA, Schmidt MH, Mahan MA. The genetic basis of intradural spinal tumors and its impact on clinical treatment. Neurosurg Focus 2015; 39:E3. [DOI: 10.3171/2015.5.focus15143] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Genetic alterations in the cells of intradural spinal tumors can have a significant impact on the treatment options, counseling, and prognosis for patients. Although surgery is the primary therapy for most intradural tumors, radiochemothera-peutic modalities and targeted interventions play an ever-evolving role in treating aggressive cancers and in addressing cancer recurrence in long-term survivors. Recent studies have helped delineate specific genetic and molecular differences between intradural spinal tumors and their intracranial counterparts and have also identified significant variation in therapeutic effects on these tumors. This review discusses the genetic and molecular alterations in the most common intradural spinal tumors in both adult and pediatrie patients, including nerve sheath tumors (that is, neurofibroma and schwannoma), meningioma, ependymoma, astrocytoma (that is, low-grade glioma, anaplastic astrocytoma, and glioblastoma), hemangioblastoma, and medulloblastoma. It also examines the genetics of metastatic tumors to the spinal cord, arising either from the CNS or from systemic sources. Importantly, the impact of this knowledge on therapeutic options and its application to clinical practice are discussed.
Collapse
|
14
|
Deficiency of the protein-tyrosine phosphatase DEP-1/PTPRJ promotes matrix metalloproteinase-9 expression in meningioma cells. J Neurooncol 2015; 122:451-9. [PMID: 25672645 DOI: 10.1007/s11060-015-1740-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 02/01/2015] [Indexed: 10/24/2022]
Abstract
Brain-invasive growth of a subset of meningiomas is associated with less favorable prognosis. The molecular mechanisms causing invasiveness are only partially understood, however, the expression of matrix metalloproteinases (MMPs) has been identified as a contributing factor. We have previously found that loss of density enhanced phosphatase-1 (DEP-1, also designated PTPRJ), a transmembrane protein-tyrosine phosphatase, promotes meningioma cell motility and invasive growth in an orthotopic xenotransplantation model. We have now analyzed potential alterations of the expression of genes involved in motility control, caused by DEP-1 loss in meningioma cell lines. DEP-1 depleted cells exhibited increased expression of mRNA encoding MMP-9, and the growth factors EGF and FGF-2. The increase of MMP-9 expression in DEP-1 depleted cells was also readily detectable at the protein level by zymography. MMP-9 upregulation was sensitive to chemical inhibitors of growth factor signal transduction. Conversely, MMP-9 mRNA levels could be stimulated with growth factors (e.g. EGF) and inflammatory cytokines (e.g. TNFα). Increase of MMP-9 expression by DEP-1 depletion, or growth factor/cytokine stimulation qualitatively correlated with increased invasiveness in vitro scored as transmigration through matrigel-coated membranes. The studies suggest induction of MMP-9 expression promoted by DEP-1 deficiency, or potentially by growth factors and inflammatory cytokines, as a mechanism contributing to meningioma brain invasiveness.
Collapse
|
15
|
Yun S, Koh JM, Lee KS, Seo AN, Nam KH, Choe G. Expression of c-MET in Invasive Meningioma. J Pathol Transl Med 2015; 49:44-51. [PMID: 25812657 PMCID: PMC4357404 DOI: 10.4132/jptm.2014.10.13] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Revised: 10/07/2014] [Accepted: 10/13/2014] [Indexed: 11/17/2022] Open
Abstract
Background: Meningiomas show high recurrence rates even after curative tumor removal. The invasiveness of meningiomas may contribute to their high recurrence rates. Recently, c-MET and hepatocyte growth factor (HGF) have been reported to be involved in cancer invasion. Methods: We examined the immunohistochemical expression of c-MET and HGF in 100 cases of patients with meningiomas who have undergone complete tumor removal. Results: c-MET-High and HGFHigh were found in 17% and 13% of meningiomas, respectively. Brain invasion was observed in 17.6% of c-MET-High meningiomas, but in only 2.4% of c-MET-Low meningiomas (p=.033). Bone/soft tissue invasion was observed in 23.5% of c-MET-High meningiomas and in 9.6% of c-MET-Low meningiomas (p=.119). HGF-High did not show statistical association with brain invasion or bone/soft tissue invasion. c-MET-High demonstrated shorter recurrence-free survival (RFS, 93.5±8.2 months vs 96.1±1.9 months); however, this difference was not statistically significant (p=.139). There was no association of HGF-High with RFS. Conclusions: This study demonstrates that c- MET-High is associated with brain invasion of meningiomas, and that c-MET expression may be a useful predictive marker for meningioma recurrence. Patients with invasive meningiomas with high expressions of c-MET may be good candidates for targeted therapy using c-MET inhibitors.
Collapse
Affiliation(s)
- Sumi Yun
- Department of Pathology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Moon Koh
- Department of Pathology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Kyu Sang Lee
- Department of Pathology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - An Na Seo
- Department of Pathology, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Korea
| | - Kyung Han Nam
- Department of Pathology, Haeundae Paik Hospital, Inje University, Busan, Korea
| | - Gheeyoung Choe
- Department of Pathology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| |
Collapse
|
16
|
Cheng G, Zhang L, Lv W, Dong C, Wang Y, Zhang J. Overexpression of cyclin D1 in meningioma is associated with malignancy grade and causes abnormalities in apoptosis, invasion and cell cycle progression. Med Oncol 2014; 32:439. [DOI: 10.1007/s12032-014-0439-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 12/05/2014] [Indexed: 11/29/2022]
|
17
|
Simon F, Dittmar JO, Brons S, Orschiedt L, Urbschat S, Weber KJ, Debus J, Combs SE, Rieken S. Integrin-based meningioma cell migration is promoted by photon but not by carbon-ion irradiation. Strahlenther Onkol 2014; 191:347-55. [PMID: 25445155 DOI: 10.1007/s00066-014-0778-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Accepted: 10/29/2014] [Indexed: 12/11/2022]
Abstract
PURPOSE Sublethal doses of photon irradiation (IR) are suspected to increase tumor cell migration and support locoregional recurrence of disease, which has already been shown in other cell lines. This manuscript describes the effect of photon and carbon-ion IR on WHO class I meningioma cell migration and provides an approach to the underlying cellular mechanisms. MATERIALS AND METHODS Meningioma cells were gained operatively at the university hospital in Homburg/Saar, Germany. For migration, membranes (8-µm pore sizes) were coated with collagen I, with collagen IV, and with fibronectin. Cells were analyzed in migration experiments with or without serum stimulation, with or without photon and carbon IR 24 h prior to experiments, and with or without integrin antibodies. Fluorescence-activated cell sorting (FACS) analyses of the integrins ανβ1, ανβ3, and ανβ5 were performed without IR and 6, 12 and 24 h after IR. Enzyme-linked immunosorbent assay (ELISA) analyses of matrix metalloproteinases (MMP)-2 and MMP-9 were realized with and without IR after cells were cultured on collagen I, collagen IV, or fibronectin for 24 h. Cells and supernatants for FACS and ELISA were stored at - 18 °C. The significance level was set at 5 % using both Student's t test and two-way ANOVA. RESULTS Migration of meningioma cells was serum-inducible (p < 0.001). It could be increased by photon IR (p < 0.02). The integrins ανβ1 and ανβ5 showed a 21 and 11 % higher expression after serum stimulation (not significant), respectively, and ανβ1 expression was raised by 14 % (p = 0.0057) after photon IR. Antibody blockage of the integrins ανβ1 and ανβ5 inhibited serum- and photon-induced migration. Expression of MMP-2 and MMP-9 remained unchanged after both IR and fetal bovine serum (FBS). Carbon-ion IR left both integrin expression and meningioma cell migration unaffected. CONCLUSION Photon but not carbon-ion IR promotes serum-based meningioma cell migration. Fibronectin receptor integrin ανβ1 signaling can be identified as an important mechanism for serum- and photon-induced migration of WHO class I meningioma cells.
Collapse
Affiliation(s)
- Florian Simon
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany,
| | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Embolized meningiomas: risk of overgrading and neo-angiogenesis. J Neurooncol 2013; 113:207-19. [DOI: 10.1007/s11060-013-1117-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Accepted: 03/12/2013] [Indexed: 12/23/2022]
|
19
|
Proteins involved in regulating bone invasion in skull base meningiomas. Acta Neurochir (Wien) 2013; 155:421-7. [PMID: 23238945 PMCID: PMC3569595 DOI: 10.1007/s00701-012-1577-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2012] [Accepted: 10/18/2012] [Indexed: 12/31/2022]
Abstract
Background Bone invasive skull base meningiomas are a subset of meningiomas that present a unique clinical challenge due to brain and neural structure involvement and limitations in complete surgical resection, resulting in higher recurrence and need for repeat surgery. To date, the pathogenesis of meningioma bone invasion has not been investigated. We investigated immunoexpression of proteins implicated in bone invasion in other tumor types to establish their involvement in meningioma bone invasion. Methods Retrospective review of our database identified bone invasive meningiomas operated on at our institution over the past 20 years. Using high-throughput tissue microarray (TMA), we established the expression profile of osteopontin (OPN), matrix metalloproteinase-2 (MMP2), and integrin beta-1 (ITGB1). Differential expression in tumor cell and vasculature was evaluated and comparisons were made between meningioma anatomical locations. Results MMP2, OPN, and ITGB1 immunoreactivity was cytoplasmic in tumor and/or endothelial cells. Noninvasive transbasal meningiomas exhibited higher vascular endothelial cell MMP2 immunoexpression compared to invasive meningiomas. We found higher expression levels of OPN and ITGB1 in bone invasive transbasal compared to noninvasive meningiomas. Strong vascular ITGB1 expression extending from the endothelium through the media and into the adventitia was found in a subset of meningiomas. Conclusions We have demonstrated that key proteins are differentially expressed in bone invasive meningiomas and that the anatomical location of bone invasion is a key determinant of expression pattern of MMP1, OPN, and ITGB1. This data provides initial insights into the pathophysiology of bone invasion in meningiomas and identifies factors that can be pursued as potential therapeutic targets.
Collapse
|
20
|
Increased MMP-21 expression is associated with poor overall survival of patients with gastric cancer. Med Oncol 2012; 30:323. [PMID: 23275114 DOI: 10.1007/s12032-012-0323-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2012] [Accepted: 07/14/2012] [Indexed: 12/19/2022]
Abstract
Matrix metalloproteinase-21 (MMP-21) has been shown to enhance tumor invasion and metastasis ability in some solid tumors. In the present study, we investigated the expression of MMP-21 as well as its association with overall survival of gastric cancer patients. MMP-21 expression was investigated in 296 cases of gastric cancer by immunohistochemistry assay. Statistical analysis was utilized to evaluate the association of MMP-21 expression with overall survival of patients. MMP-21 expression was proved to be increased in gastric cancer compared with that in normal tissues (P < 0.05). It was also proved MMP-21 expression was associated with tumor invasion, metastasis and TNM stage (P < 0.001). MMP-21 expression was showed to be associated with overall survival of gastric cancer patients for patients with tumor of higher MMP-21 expression tend to have worse overall survival (P < 0.001). Multivariate analysis proved MMP-21 to be an independent prognostic factor for overall survival of gastric cancer patients (P < 0.001). These results suggested the potential role of MMP-21 in progression of human gastric cancer. It might also be a novel molecular marker to predict overall survival of patients with gastric cancer.
Collapse
|
21
|
Kwon MJ, Sung CO, Kang SY, Do IG, Suh YL. Differential expression of extracellular matrix-related genes in rare variants of meningioma. Hum Pathol 2012; 44:260-8. [PMID: 22995327 DOI: 10.1016/j.humpath.2012.05.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2012] [Revised: 05/22/2012] [Accepted: 05/23/2012] [Indexed: 11/16/2022]
Abstract
Secretory, clear cell, and rhabdoid meningiomas are rare variants of meningiomas characterized by unique histologies and behaviors. Extracellular matrix proteins provide a morphologic structure and influence the biologic behavior of tumors. However, the effects of extracellular matrix proteins on morphologies and biologic behaviors of secretory meningioma, clear cell meningioma, and rhabdoid meningioma have not been established. We evaluated the expression of matrix metalloproteinase 2, matrix metalloproteinase 9, galectin-3, fibronectin, and collagen IV in a series of those rare variants of meningioma and verified their clinicopathologic significance. A total 51 cases included 12 secretory meningiomas, 9 clear cell meningiomas, and 30 rhabdoid meningiomas. Extracellular matrix proteins showed different expression patterns according to the histologic subtypes, and messenger RNA levels were well correlated with immunoexpressions. Secretory meningiomas showed high expressions of fibronectin and galectin-3. Clear cell meningiomas showed high expression of matrix metalloproteinase 2, matrix metalloproteinase 9, and collagen IV. Rhabdoid meningiomas showed high expressions of matrix metalloproteinase 9, galectin-3, and fibronectin. Clinically, high expression of matrix metalloproteinase 9 was associated with tumor recurrence (P < .001) and local invasion at the time of diagnosis (P = .018) among the extracellular matrix-related proteins, and was also associated with shorter recurrence-free survival (P = .025) in the patients with rhabdoid meningioma. In conclusion, the differential expressions of extracellular matrix-related genes according to the histologic subtypes appear to be involved in biologic behavior and clinical outcome, and high matrix metalloproteinase 9 expression is associated with recurrences in rhabdoid meningiomas.
Collapse
Affiliation(s)
- Mi Jung Kwon
- Department of Pathology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Gyeonggi-do 431-070, South Korea
| | | | | | | | | |
Collapse
|
22
|
Barresi V, Alafaci C, Caffo M, Barresi G, Tuccari G. Clinicopathological characteristics, hormone receptor status and matrix metallo-proteinase-9 (MMP-9) immunohistochemical expression in spinal meningiomas. Pathol Res Pract 2012; 208:350-5. [PMID: 22494536 DOI: 10.1016/j.prp.2012.02.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Revised: 02/21/2012] [Accepted: 02/29/2012] [Indexed: 11/17/2022]
Abstract
Meningiomas involving the spinal meninges show a reduced tendency to recur compared to those of the intracranial compartment. Nonetheless, due to the few reports with a significant number of patients, their biological characteristics largely remain to be investigated. With the aim of clarifying the biology of these tumors, we examined in the present paper the clinicopathological features, the estrogen receptor (ER) and progesterone receptor (PR) status, as well as the Ki-67 labeling index (LI) and matrix metallo-proteinase-9 (MMP-9) expression of 58 spinal meningiomas. Ki-67 LI ranged between 1% and 5% (median: 1%); no expression of ER was found in all the cases, whereas PR immunoexpression was found in 86% of the tumors. High MMP-9 expression was encountered in 46% of meningiomas, and it was significantly correlated with the percentage of PR expression. The recurrence rate was 1.7%. The only recurred case showed high MMP-9 expression, absence of PR and low Ki-67 LI. Our findings confirm that spinal meningiomas are indolent tumors with low growth fraction and recurrence rate. In these neoplasms, high MMP-9 expression seems to be associated with the development of recurrences only in the absence of PR expression. Thus, the evaluation of both MMP-9 and PR expression might be of use in the identification of spinal meningiomas at higher risk of relapse.
Collapse
Affiliation(s)
- Valeria Barresi
- Department of Human Pathology, University of Messina, Messina, Italy.
| | | | | | | | | |
Collapse
|
23
|
Iwado E, Ichikawa T, Kosaka H, Otsuka S, Kambara H, Tamiya T, Kondo S, Date I. Role of VEGF and matrix metalloproteinase-9 in peritumoral brain edema associated with supratentorial benign meningiomas. Neuropathology 2012; 32:638-46. [DOI: 10.1111/j.1440-1789.2012.01312.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
24
|
Barresi V, Caffo M, Alafaci C, Granata F, Tuccari G. Intradural chordoma of the Meckel's cave: A challenging differential diagnosis. Neuropathology 2012; 32:577-82. [DOI: 10.1111/j.1440-1789.2011.01295.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
|
25
|
BARRESI VALERIA, TUCCARI GIOVANNI. Meningioma with zellballen growth pattern: histological and immunohistochemical findings. APMIS 2011; 119:815-7. [DOI: 10.1111/j.1600-0463.2011.02787.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
26
|
Neutrophil gelatinase-associated lipocalin (NGAL) and matrix metalloproteinase-9 (MMP-9) prognostic value in stage I colorectal carcinoma. Pathol Res Pract 2011; 207:479-86. [PMID: 21726963 DOI: 10.1016/j.prp.2011.05.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2011] [Revised: 05/11/2011] [Accepted: 05/30/2011] [Indexed: 01/25/2023]
Abstract
The expression of neutrophil gelatinase-associated lipocalin (NGAL) has been suggested to behave like a negative prognostic marker in stage I colorectal carcinoma. In the aim of clarifying whether its association with adverse outcome may descend from NGAL's ability to regulate matrix metallo-proteinase-9 (MMP-9), we analyzed the correlation, prognostic value, and association with neo-angiogenesis of NGAL and MMP-9 immunohistochemical expression in a series of stage I colorectal carcinomas. A variable NGAL immunoexpression was demonstrated in 17 of the 48 analyzed cases with a significantly higher frequency of positive cases among patients showing disease progression. NGAL expression was also positively correlated with VEGF expression detected in the same cases. MMP-9 immunostaining was present in the cytoplasm of the neoplastic cells in 30 cases; no significant correlations were evidenced with NGAL expression, as well as with the various clinico-pathological parameters or with progression of the colorectal carcinomas. By contrast, NGAL expression was confirmed as a significant independent negative prognostic marker related to a shorter disease-free survival in stage I colorectal carcinoma. Our preliminary results suggest that the association of NGAL with poor outcome might be independent from MMP-9 regulation, thus highlighting its prognostic value in this neoplasia. If our findings are confirmed in further analyses, NGAL assessment might be used in order to select those patients with a higher progression risk and to submit them to adjuvant therapies useful to prevent adverse outcome.
Collapse
|
27
|
Barresi V. Angiogenesis in meningiomas. Brain Tumor Pathol 2011; 28:99-106. [PMID: 21290262 DOI: 10.1007/s10014-010-0012-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2010] [Accepted: 11/14/2010] [Indexed: 12/25/2022]
Abstract
Neoangiogenesis has been correlated to biological aggressiveness and an adverse clinical course of several neoplasias. Its prognostic role in meningiomas appears to be controversial. Nonetheless, if adequately quantified with specific markers and appropriate scoring methods, angiogenesis seems to be significantly associated with a high growth fraction, development of recurrences and shorter overall survival of meningiomas. As a consequence, neoangiogenesis may represent a target for therapies aimed at reducing the growth of inoperable meningiomas or recurrence risk of totally resected tumors. Even more significantly, the identification of the factors that mediate angiogenesis in meningiomas could help us to determine appropriate novel anti-angiogenic therapies for these tumors. Herein the methods for quantification of angiogenesis as well as its regulating factors in meningiomas are reviewed.
Collapse
Affiliation(s)
- Valeria Barresi
- Department of Human Pathology, University of Messina, Messina, Italy.
| |
Collapse
|