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Wang Y, Butaney M, Wilder S, Ghani K, Rogers CG, Lane BR. The evolving management of small renal masses. Nat Rev Urol 2024; 21:406-421. [PMID: 38365895 DOI: 10.1038/s41585-023-00848-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Accepted: 12/19/2023] [Indexed: 02/18/2024]
Abstract
Small renal masses (SRMs) are a heterogeneous group of tumours with varying metastatic potential. The increasing use and improving quality of abdominal imaging have led to increasingly early diagnosis of incidental SRMs that are asymptomatic and organ confined. Despite improvements in imaging and the growing use of renal mass biopsy, diagnosis of malignancy before treatment remains challenging. Management of SRMs has shifted away from radical nephrectomy, with active surveillance and nephron-sparing surgery taking over as the primary modalities of treatment. The optimal treatment strategy for SRMs continues to evolve as factors affecting short-term and long-term outcomes in this patient cohort are elucidated through studies from prospective data registries. Evidence from rapidly evolving research in biomarkers, imaging modalities, and machine learning shows promise in improving understanding of the biology and management of this patient cohort.
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Affiliation(s)
- Yuzhi Wang
- Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI, USA
| | - Mohit Butaney
- Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI, USA
| | - Samantha Wilder
- Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI, USA
| | - Khurshid Ghani
- Department of Urology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Craig G Rogers
- Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI, USA
| | - Brian R Lane
- Division of Urology, Corewell Health West, Grand Rapids, MI, USA.
- Department of Surgery, Michigan State University College of Human Medicine, Grand Rapids, MI, USA.
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2
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Hayden JP, Wiggins A, Sullivan T, Kalantzakos T, Hooper K, Moinzadeh A, Rieger-Christ K. Use of Droplet Digital Polymerase Chain Reaction to Identify Biomarkers for Differentiation of Benign and Malignant Renal Masses. Cancers (Basel) 2024; 16:787. [PMID: 38398177 PMCID: PMC10886675 DOI: 10.3390/cancers16040787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 01/23/2024] [Revised: 02/08/2024] [Accepted: 02/13/2024] [Indexed: 02/25/2024] Open
Abstract
Several microRNAs (miRNAs) have been identified as cell-free biomarkers for detecting renal cell carcinoma (RCC). Droplet digital polymerase chain reaction (ddPCR) is a unique technology for nucleic acid quantification. It has the potential for superior precision, reproducibility, and diagnostic performance in identifying circulating miRNA biomarkers compared to conventional quantitative real-time PCR (qRT-PCR). This study aims to evaluate the performance of ddPCR compared to qRT- PCR in identifying miRNA biomarkers that differentiate malignant from benign renal masses. Potential biomarkers of RCC were identified from a literature review. RNA was extracted from the plasma of 56 patients. All the samples underwent analysis via ddPCR as well as qRT-PCR, and expression levels were recorded for the following miRNAs: miR-93, -144, -210, -221, and -222. Tumors were grouped into low-grade ccRCC, high-grade ccRCC, papillary RCC, and benign masses (primarily angiomyolipoma). The miRNA miR-210 (p = 0.034) and the combination of miRs-210 and miR-222 (p = 0.003) were expressed at significantly higher rates among those with RCC than those with benign masses, as measured by ddPCR. Using the combination of miR-210 and miR-222, ddPCR identified significant differences between the subgroups: papillary RCC versus benign (p = 0.03), low-grade ccRCC versus benign (p = 0.026), and high-grade ccRCC versus benign (p = 0.002). The only significant difference between these subgroups using qRT-PCR was between high-grade ccRCC and benign (p = 0.045). All the AUCs were significant when comparing each RCC subgroup with benign for both PCR technologies. Using a combination of miR-210 and miR-222, ddPCR identified significant differences between benign and malignant renal masses that were not identified as significant by conventional qRT-PCR.
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Affiliation(s)
- Joshua P. Hayden
- Department of Urology, Lahey Hospital & Medical Center, Burlington, MA 01805, USA; (J.P.H.); (A.W.); (A.M.)
| | - Adam Wiggins
- Department of Urology, Lahey Hospital & Medical Center, Burlington, MA 01805, USA; (J.P.H.); (A.W.); (A.M.)
| | - Travis Sullivan
- Department of Translational Research, Lahey Hospital & Medical Center, Burlington, MA 01805, USA; (T.S.); (T.K.); (K.H.)
| | - Thomas Kalantzakos
- Department of Translational Research, Lahey Hospital & Medical Center, Burlington, MA 01805, USA; (T.S.); (T.K.); (K.H.)
| | - Kailey Hooper
- Department of Translational Research, Lahey Hospital & Medical Center, Burlington, MA 01805, USA; (T.S.); (T.K.); (K.H.)
| | - Alireza Moinzadeh
- Department of Urology, Lahey Hospital & Medical Center, Burlington, MA 01805, USA; (J.P.H.); (A.W.); (A.M.)
| | - Kimberly Rieger-Christ
- Department of Urology, Lahey Hospital & Medical Center, Burlington, MA 01805, USA; (J.P.H.); (A.W.); (A.M.)
- Department of Translational Research, Lahey Hospital & Medical Center, Burlington, MA 01805, USA; (T.S.); (T.K.); (K.H.)
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3
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Kalantzakos TJ, Sebel LE, Trussler J, Sullivan TB, Burks EJ, Sarita-Reyes CD, Canes D, Moinzadeh A, Rieger-Christ KM. MicroRNA Associated with the Invasive Phenotype in Clear Cell Renal Cell Carcinoma: Let-7c-5p Inhibits Proliferation, Migration, and Invasion by Targeting Insulin-like Growth Factor 1 Receptor. Biomedicines 2022; 10:2425. [PMID: 36289686 PMCID: PMC9598558 DOI: 10.3390/biomedicines10102425] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 08/24/2022] [Revised: 09/22/2022] [Accepted: 09/25/2022] [Indexed: 01/20/2025] Open
Abstract
Differential microRNA (miRNA) expression can portend clear cell renal cell carcinoma (ccRCC) progression. In a previous study, we identified a subset of dysregulated miRNA in small renal masses, pT1 ccRCC (≤5 cm) that are associated with an aggressive phenotype. The present study investigated miRNA expression in clinical stage I (cT1) tumors (≤5 cm), comparing pathologic stage I (pT1) tumors to those upstaged to pathologic stage 3 (pT3) after surgery following identification of renal vein invasion or invasion into adjacent fat tissue within Gerota's fascia. Twenty cT1 tumors were examined in an miRNA screening, 10 pT1 and 10 pT3 tumors. The ccRCC cell lines 786-O and Caki-1 were used to assess the impact of let-7c-5p and its protein target insulin-like growth factor 1 receptor (IGF1R). Cells were transfected with pre-let-7c-5p and assessed through cell proliferation, migration, and invasion assays. IGF1R expression was evaluated through Simple Western, and interaction between let-7c-5p and IGF1R was confirmed via luciferase reporter assay. Screening identified 20 miRNA, including let-7c-5p, that were dysregulated between pT1 and pT3 upstaged tumors. This miRNA was also downregulated in our previous study of pT1 tumors that progressed to metastatic disease. Transfection of ccRCC cells with pre-let-7c-5p significantly inhibited proliferation, migration, invasion, and IGF1R expression. These findings suggest that miRNA dysregulation is involved in ccRCC progression, specifically through invasion, and that let-7c-5p downregulation contributes to the aggressiveness of small ccRCC tumors, in part, through its regulation of IGF1R.
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Affiliation(s)
- Thomas J. Kalantzakos
- Department of Translational Research, Lahey Hospital & Medical Center, Burlington, MA 01805, USA
| | - Luke E. Sebel
- Department of Urology, Lahey Hospital & Medical Center, Burlington, MA 01805, USA
| | - James Trussler
- Department of Urology, Lahey Hospital & Medical Center, Burlington, MA 01805, USA
| | - Travis B. Sullivan
- Department of Translational Research, Lahey Hospital & Medical Center, Burlington, MA 01805, USA
| | - Eric J. Burks
- Department of Pathology & Laboratory Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA 02118, USA
| | - Carmen D. Sarita-Reyes
- Department of Pathology & Laboratory Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA 02118, USA
| | - David Canes
- Department of Urology, Lahey Hospital & Medical Center, Burlington, MA 01805, USA
| | - Alireza Moinzadeh
- Department of Urology, Lahey Hospital & Medical Center, Burlington, MA 01805, USA
| | - Kimberly M. Rieger-Christ
- Department of Translational Research, Lahey Hospital & Medical Center, Burlington, MA 01805, USA
- Department of Urology, Lahey Hospital & Medical Center, Burlington, MA 01805, USA
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Wang Y, Shen Z, Mo S, Dai L, Song B, Gu W, Ding X, Zhang X. Construction and validation of a novel ten miRNA-pair based signature for the prognosis of clear cell renal cell carcinoma. Transl Oncol 2022; 25:101519. [PMID: 35998436 PMCID: PMC9421317 DOI: 10.1016/j.tranon.2022.101519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 04/11/2022] [Revised: 07/12/2022] [Accepted: 08/10/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Clear cell renal cell carcinoma (ccRCC) is the most predominate pathological subtype of renal cell carcinoma, causing a recurrence or metastasis rate as high as 20% to 40% after operation, for which effective prognostic signature is urgently needed. METHODS The mRNA and miRNA profiles of ccRCC specimens were collected from the Cancer Genome Atlas. MiRNA-pair risk score (miPRS) for each miRNA pair was generated as a signature and validated by univariate and multivariate Cox proportional hazards regression analysis. Functional enrichment was performed, and immune cells infiltration, as well as tumor mutation burden (TMB), and immunophenoscore (IPS) were evaluated between high and low miPRS groups. Target gene-prediction and differentially expressed gene-analysis were performed based on databases of miRDB, miRTarBase, and TargetScan. Multivariate Cox proportional hazards regression analysis was adopted to establish the prognostic model and Kaplan-Meier survival analysis was performed. FINDINGS A novel 10 miRNA-pair based signature was established. Area under the time-dependent receiver operating curve proved the performance of the signature in the training, validation, and testing cohorts. Higher TMB, as well as the higher CTLA4-negative PD1-negative IPS, were discovered in high miPRS patients. A prognostic model was built based on miPRS (1 year-, 5 year-, 10 year- ROC-AUC=0.92, 0.84, 0.82, respectively). INTERPRETATION The model based on miPRS is a novel and valid tool for predicting the prognosis of ccRCC. FUNDING This study was supported by research grants from the China National Natural Scientific Foundation (81903972, 82002018, and 82170752) and Shanghai Sailing Program (19YF1406700 and 20YF1406000).
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Affiliation(s)
- Yulin Wang
- Department of Nephrology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai 200032, China; Shanghai Medical Center of Kidney Disease, Shanghai 200032, China; Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai 200032, China
| | - Ziyan Shen
- Department of Nephrology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai 200032, China; Shanghai Medical Center of Kidney Disease, Shanghai 200032, China; Shanghai Institute of Kidney and Dialysis, No. 136 Medical College Road, Shanghai 200032, China
| | - Shaocong Mo
- Department of Digestive Diseases, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Leijie Dai
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China
| | - Biao Song
- Department of Dermatology, Peking Union Medical College Hospital, Beijing, 100005, China
| | - Wenchao Gu
- Department of Diagnostic Radiology and Nuclear Medicine, Gunma University Graduate School of Medicine, Maebashi, 371-8511, Japan
| | - Xiaoqiang Ding
- Department of Nephrology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai 200032, China; Shanghai Medical Center of Kidney Disease, Shanghai 200032, China; Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai 200032, China; Shanghai Institute of Kidney and Dialysis, No. 136 Medical College Road, Shanghai 200032, China.
| | - Xiaoyan Zhang
- Department of Nephrology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai 200032, China; Shanghai Medical Center of Kidney Disease, Shanghai 200032, China; Shanghai Key Laboratory of Kidney and Blood Purification, Shanghai 200032, China; Shanghai Institute of Kidney and Dialysis, No. 136 Medical College Road, Shanghai 200032, China.
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Liu YP, Cai Y, Lei YD, Yuan XY, Wang Y, Yi S, Li XY, Huang L, Long DX, Zhang ZH. Circular RNA expression profiles in human bronchial epithelial cells treated with beryllium sulfate. Toxicol Res (Camb) 2021; 10:1013-1021. [PMID: 34733486 DOI: 10.1093/toxres/tfab086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 04/27/2021] [Revised: 07/21/2021] [Accepted: 08/05/2021] [Indexed: 11/13/2022] Open
Abstract
Circular RNAs (circRNAs), is a novel type of endogenous non-coding RNAs (ncRNAs) participated in the pathogenesis of many diseases. Beryllium is one of the carcinogenesis elements. However, the mechanism and function of circRNAs in human bronchial epithelial cells (16HBE) induced by beryllium sulfate (BeSO4) was rarely reported. Therefore, the high-throughput RNA sequencing analysis was performed to detect the circRNA profiles between control groups and BeSO4-induced groups. Furthermore, circRNA-miRNA-mRNA network, Gene Ontology (GO), Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analysis, and PPI network analysis were used for bioinformatics analysis. CircRNA sequencing analysis revealed that 36 circRNAs were up-regulated and 35 circRNAs were down-regulated in the BeSO4-exposed groups. The selected circRNAs were verified by real-time fluorescent quantitative PCR (qRT-PCR). Hsa_circ_0004214 and hsa_circ_0003586 were validated to be up-regulated, hsa_circ_0047958, hsa_circ_0001944, and hsa_circ_0008982 were down-regulated. The circRNA-miRNA-mRNA network annotated the key signaling pathway including cellular senescence, TNF signaling pathway, NF-kappa B signaling pathway, HIF-1 signaling pathway, and Hippo signaling pathway. The PPI network indicated the most circRNAs might participate in the BeSO4 toxicity by acting as a sponge for the miR-663b through JAK-STAT signaling pathway. In summary, our study suggests that circRNAs may play roles in the mechanism of beryllium toxicity.
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Affiliation(s)
- Yan-Ping Liu
- Department of Preventive Medicine, School of Public Health, Hengyang Medical School, University of South China, Hengyang, China
| | - Ying Cai
- Department of Preventive Medicine, School of Public Health, Hengyang Medical School, University of South China, Hengyang, China
| | - Yuan-di Lei
- Department of Preventive Medicine, School of Public Health, Hengyang Medical School, University of South China, Hengyang, China
| | - Xiao-Yan Yuan
- Department of Preventive Medicine, School of Public Health, Hengyang Medical School, University of South China, Hengyang, China
| | - Ye Wang
- Department of Preventive Medicine, School of Public Health, Hengyang Medical School, University of South China, Hengyang, China
| | - Shan Yi
- Department of Preventive Medicine, School of Public Health, Hengyang Medical School, University of South China, Hengyang, China
| | - Xun-Ya Li
- Department of Preventive Medicine, School of Public Health, Hengyang Medical School, University of South China, Hengyang, China
| | - Lian Huang
- Department of Preventive Medicine, School of Public Health, Hengyang Medical School, University of South China, Hengyang, China
| | - Ding-Xin Long
- Department of Preventive Medicine, School of Public Health, Hengyang Medical School, University of South China, Hengyang, China
| | - Zhao-Hui Zhang
- Department of Preventive Medicine, School of Public Health, Hengyang Medical School, University of South China, Hengyang, China
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Kalantzakos TJ, Sullivan TB, Gloria T, Canes D, Moinzadeh A, Rieger-Christ KM. MiRNA-424-5p Suppresses Proliferation, Migration, and Invasion of Clear Cell Renal Cell Carcinoma and Attenuates Expression of O-GlcNAc-Transferase. Cancers (Basel) 2021; 13:cancers13205160. [PMID: 34680309 PMCID: PMC8533684 DOI: 10.3390/cancers13205160] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Academic Contribution Register] [Received: 09/16/2021] [Revised: 10/08/2021] [Accepted: 10/12/2021] [Indexed: 12/20/2022] Open
Abstract
Simple Summary The identification of biomarkers that predict the metastatic potential of tumors is a current area of interest in cancer research. A previous study from our laboratory identified numerous microRNA (miRNA) biomarkers that are differentially expressed in pathologic stage I clear cell renal cell carcinoma (ccRCC) tumors that progress to metastatic disease. This study investigated the role of aberrant expression of one of these miRNA, miR-424-5p, and one of its associated protein targets, O-GlcNAc-transferase (OGT). We examined the influence of miR-424-5p and OGT expression on the proliferation, migration, and invasion of ccRCC cells, and confirmed the direct interaction between miR-424-5p and OGT. These findings suggest that the decrease in miR-424-5p expression observed in these small renal masses leads to an increase in OGT, which facilitates metastasis. Abstract MicroRNAs (miRNAs) are non-coding post-transcriptional regulators of gene expression that are dysregulated in clear cell renal cell carcinoma (ccRCC) and play an important role in tumor progression. Our prior work identified a subset of miRNAs in pT1 ccRCC tumors, including miR-424-5p, that are associated with an aggressive phenotype. We investigate the impact of this dysregulated miRNA and its protein target O-GlcNAc-transferase (OGT) to better understand the mechanisms behind aggressive stage I ccRCC. The ccRCC cell lines 786-O and Caki-1 were used to assess the impact of miR-424-5p and OGT. Cells were transfected with pre-miR-424-5p, a lentiviral anti-OGT shRNA, or were treated with the demethylating agent 5-Aza-2′-deoxycytidine. Cell proliferation was measured via MT cell viability assay. Cell migration and invasion were analyzed using Transwell assays. The expression of miR-424-5p was determined through qRT-PCR, while OGT protein expression was evaluated through Western blotting. The interaction between miR-424-5p and OGT was confirmed via luciferase reporter assay. The transfection of ccRCC cells with pre-miR-424-5p or anti-OGT shRNA significantly inhibited cell proliferation, migration, and OGT expression, while miR-424-5p also attenuated cell invasion. Addition of the demethylating agent significantly reduced cell proliferation, migration, invasion, and OGT expression, while significantly increasing the expression of miR-424-5p. Altogether, these findings suggest that epigenetic downregulation of miR-424-5p, which in turn augments OGT expression, contributes to the creation of aggressive forms of stage I ccRCC.
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Affiliation(s)
- Thomas J. Kalantzakos
- Department of Translational Research, Lahey Hospital & Medical Center, Burlington, MA 01805, USA; (T.J.K.); (T.B.S.); (T.G.)
| | - Travis B. Sullivan
- Department of Translational Research, Lahey Hospital & Medical Center, Burlington, MA 01805, USA; (T.J.K.); (T.B.S.); (T.G.)
| | - Thales Gloria
- Department of Translational Research, Lahey Hospital & Medical Center, Burlington, MA 01805, USA; (T.J.K.); (T.B.S.); (T.G.)
| | - David Canes
- Department of Urology, Lahey Hospital & Medical Center, Burlington, MA 01805, USA; (D.C.); (A.M.)
| | - Alireza Moinzadeh
- Department of Urology, Lahey Hospital & Medical Center, Burlington, MA 01805, USA; (D.C.); (A.M.)
| | - Kimberly M. Rieger-Christ
- Department of Translational Research, Lahey Hospital & Medical Center, Burlington, MA 01805, USA; (T.J.K.); (T.B.S.); (T.G.)
- Department of Urology, Lahey Hospital & Medical Center, Burlington, MA 01805, USA; (D.C.); (A.M.)
- Correspondence:
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Kalantzakos TJ, Sullivan TB, Sebel LE, Canes D, Burks EJ, Moinzadeh A, Rieger-Christ KM. MicroRNAs MiR-15a and MiR-26a cooperatively regulate O-GlcNAc-transferase to control proliferation in clear cell renal cell carcinoma. Cancer Biomark 2021; 30:343-351. [PMID: 33337348 DOI: 10.3233/cbm-200553] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Academic Contribution Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND MicroRNAs (miRNAs), a group of non-coding post-transcriptional regulators of gene expression, are dysregulated in clear cell renal cell carcinoma (ccRCC) and play an important role in carcinogenesis. Our prior work identified a subset of miRNAs in pT1 ccRCC tumors associated with progression to metastatic disease. OBJECTIVE To investigate the impact of two of these dysregulated miRNA, miR-15a-5p and -26a-5p, in an effort to elucidate the mechanisms underpinning aggressive forms of stage I ccRCC. METHODS The ccRCC cell line 786-O was transfected with pre-miRs-15a-5p and -26a-5p to rescue expression. Cell proliferation was measured via MT Cell Viability Assay. O-GlcNAc-transferase (OGT), a known protein in ccRCC proliferation, was identified by bioinformatics analysis as a target of both miRNA and validated via luciferase reporter assay to confirm binding of each miR to the 3' untranslated region (UTR). OGT protein expression was evaluated via western blotting. RESULTS Luciferase assay confirmed specificity of miR-15a-5p and -26a-5p for the OGT UTR. Western blot analysis for OGT showed reduced expression following co-transfection of both miRNAs compared to negative control or individual transfection. Co-transfection of these miRNAs greatly reduced proliferation when compared to negative control or the individual transfections. CONCLUSION Our results indicate that the dysregulation of miR-15a-5p and -26a-5p contribute cooperatively to the proliferation of ccRCC through their regulation of OGT. These results give insight into the pathogenesis of aggressive early stage ccRCC and suggest potential therapeutic targets for future research.
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Affiliation(s)
- Thomas J Kalantzakos
- Department of Translational Research, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Travis B Sullivan
- Department of Translational Research, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Luke E Sebel
- Department of Urology, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - David Canes
- Department of Urology, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Eric J Burks
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Alireza Moinzadeh
- Department of Urology, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Kimberly M Rieger-Christ
- Department of Translational Research, Lahey Hospital and Medical Center, Burlington, MA, USA.,Department of Urology, Lahey Hospital and Medical Center, Burlington, MA, USA
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