Beyond anaemia management: evolving role of erythropoietin therapy in neurological disorders, multiple myeloma and tumour hypoxia models

Prognostic Nomogram for Patients with Radical Surgery for Non-Metastatic Colorectal Cancer Incorporating Hematological Biomarkers and Clinical Characteristics

BACKGROUND

There is a large difference in postoperative survival in patients with non-metastatic colorectal cancer. We aimed to develop nomograms incorporating both hematological biomarkers and clinical characteristics to predict overall survival (OS) in patients with radical surgery for non-metastatic colorectal cancer.

METHODS

A retrospective analysis was performed on date from 508 patients who underwent radical resection of colorectal cancer at the Affiliated Tumor Hospital of Guangxi Medical University from December 2011 to December 2015. Simple random sampling was performed by dividing these patients into a training set (n=355) and validation set(n=153), which yielded a 7:3 ratio in the sample sizes between these groups. Based on COX regression analysis of the results from the training cohort, a nomogram was developed to predict the three-year and five-year overall survival rate, and internal verification was also performed. The nomogram prediction accuracy and discriminating ability were evaluated by Harrell's C-index (C-index), calibration curves and were compared with the colorectal cancer TNM staging system.

RESULTS

We found that age, degree of differentiation, T stage, N stage, neurological invasion, neutrophils, monocytes, HGB, and LDH were independent risk factors for predicting OS in patients with colorectal cancer. In the training cohort, the C index was 0.796 (95% CI: 0.761-0.831). In the validation cohort, the C index was 0.671 (95% CI: 0.656-0.686).The nomogram showed a stronger predictive ability than did TNM staging. Decision curve analysis showed that the nomogram had value in terms of clinical application.

CONCLUSION

Our nomogram combined hematological biomarkers and clinical characteristics and was highly effective in predicting OS in patients with non-metastatic colorectal cancer. Hence, our nomogram may provide a reference tool for clinicians to guide individualized treatment and follow-ups for patients with colorectal cancer.

Preoperative mean corpuscular hemoglobin affecting long-term outcomes of hepatectomized patients with hepatocellular carcinoma

Pretreatment anemia has been reported to be associated with survival in several solid tumor types. In terms of survival, only limited data on the hemoglobin (HGB) level in hepatocellular carcinoma (HCC) have been published and no data on mean corpuscular hemoglobin (MCH) level in HCC is available. The present study sought to examine the role of HGB and MCH levels in predicting long-term survival of patients with HCC who undergo resection. A retrospective study of 399 consecutive patients (1987-1994) who underwent hepatic resection for HCC in Sun Yat-Sen University Cancer Centre was performed. Serum HGB and MCH levels were examined preoperatively, and their prognostic capabilities were evaluated by Cox's proportional hazard model. Among the whole cohort, the HGB level appeared to be positively correlated with the MCH level (P<0.001). Survival analysis revealed that low levels of HGB (P=0.007) and MCH (P<0.001) were correlated with shorter overall survival (OS). Multivariate analysis revealed that MCH level was independently associated with OS (P<0.001), however, not HGB (P=0.278). In addition, 129 patients with large HCC (≥10 cm) tended to have a poorer OS (P<0.001) when compared with patients with smaller HCC. On subanalysis of patients with large HCC, MCH level also retained its stratified significance (P=0.001). Along with common clinicopathological variables, these results suggested that MCH, however, not HGB, may be useful in assessing prognosis for patients with HCC who undergo hepatectomy, particularly in identifying patients with large HCC who are most likely benefit from resection.

Presence of anemia and poor prognostic factors in patients with endometrial carcinoma

This study evaluated the relationship between pretreatment hemoglobin (Hb) and prognostic factors in Thai patients with endometrial cancer. Medical records of 228 patients who had undergone surgery between January 2005 and December 2007 were retrospectively reviewed. Associations between clinicopathological variables and pretreatment Hb levels were described using Pearson's chi square test or two-tailed Fisher's exact test. Survival analysis was performed with Kaplan-Meier estimates. Univariate and Cox-regression models were used to evaluate the prognostic impact of various factors, including Hb levels, in term of disease-free survival. The median duration of follow-up was 38.2 months. Eighty-nine patients (39%) had a preoperative Hb level of <12 g/dL, these having significantly higher rates of non-endometrioid histology, advanced FIGO stage, lymphovascular space invasion, cervical involvement, adnexal involvement, positive peritoneal cytology, and lymph node involvement than patients with Hb ≥12 g/dL. The 5-year disease-free and overall survival were significantly lower in patients with pretreatment Hb levels <12 g/dL compared with those with Hb ≥12 g/dL (79.3% vs. 89.2%, p=0.044 and 87.6% vs. 99.3%, p<0.001, respectively). In the multivariate analysis only histology, myometrial invasion, and lymphovascular invasion proved to be independent prognostic factors, whereas tumor grading, stage, cervical involvement, adnexal involvement, positive peritoneal cytology, lymph node involvement, and low Hb were not. In conclusion, presence of anemia before treatment may reflect poor prognostic factors in patients with endometrial cancer and low pretreatment hemoglobin level may have a prognostic impact on clinical outcome.

Protein phosphatase 2A catalytic subunit α (PP2Acα) maintains survival of committed erythroid cells in fetal liver erythropoiesis through the STAT5 pathway

Suppression of programmed cell death is critical for the final maturation of red blood cells and depends largely on the anti-apoptotic effects of EpoR-STAT5-Bcl-x(L) signaling. As the major eukaryotic serine/threonine phosphatase, protein phosphatase 2A (PP2A) regulates multiple cellular processes, including apoptosis. However, whether PP2A plays a role in preventing erythroid cells from undergoing apoptosis remains to be elucidated. We conditionally inactivated the catalytic subunit α of PP2A (PP2Acα), which is the predominant form of PP2Ac, during early embryonic hematopoiesis. Loss of PP2Acα in hematopoietic cells perturbed definitive erythropoiesis characterized by fetal liver atrophy, reduced Ter119(+) cell number, abnormal expression patterns of molecular markers, less colony formation, and a reduction in definitive globin expression. Levels of erythropoiesis-promoting cytokines and initial seeding with hematopoietic progenitors remained unchanged in PP2Acα(TKO) fetal livers. We noted impaired expansion of the fetal erythroid compartment, which was associated with increased apoptosis of committed erythroid cells. Mechanistically, PP2Acα depletion markedly reduced Tyr(694) phosphorylation of STAT5 and expression of Bcl-x(L). Unexpectedly, PP2Acα-deficient embryos did not manifest any early embryonic vascular defects. Collectively, these data provide direct loss-of-function evidence demonstrating the importance of PP2Acα for the survival of committed erythroid cells during fetal liver erythropoiesis.

Breast tumour angiogenesis

The central importance of tumour neovascularization has been emphasized by clinical trials using antiangiogenic therapy in breast cancer. This review gives a background to breast tumour neovascularization in in situ and invasive breast cancer, outlines the mechanisms by which this is achieved and discusses the influence of the microenvironment, focusing on hypoxia. The regulation of angiogenesis and the antivascular agents that are used in an antiangiogenic dosing schedule, both novel and conventional, are also summarized.

Alternative vascularization mechanisms in cancer: Pathology and therapeutic implications

Although cancer cells are not generally controlled by normal regulatory mechanisms, tumor growth is highly dependent on the supply of oxygen, nutrients, and host-derived regulators. It is now established that tumor vasculature is not necessarily derived from endothelial cell sprouting; instead, cancer tissue can acquire its vasculature by co-option of pre-existing vessels, intussusceptive microvascular growth, postnatal vasculogenesis, glomeruloid angiogenesis, or vasculogenic mimicry. The best-known molecular pathway driving tumor vascularization is the hypoxia-adaptation mechanism. However, a broad and diverse spectrum of genetic aberrations is associated with the development of the "angiogenic phenotype." Based on this knowledge, novel forms of antivascular modalities have been developed in the past decade. When applying these targeted therapies, the stage of tumor progression, the type of vascularization of the given cancer tissue, and the molecular machinery behind the vascularization process all need to be considered. A further challenge is finding the most appropriate combinations of antivascular therapies and standard radio- and chemotherapies. This review intends to integrate our recent knowledge in this field into a rational strategy that could be the basis for developing effective clinical modalities using antivascular therapy for cancer.

Erythropoietin-dependent erythropoiesis: New insights and questions

Committed erythroid progenitor cells require exposure to erythropoietin (Epo) for their survival and for their quantitatively regulated transition to red blood cells. With regard to Epo signal transduction mechanisms, much has been learned from analyses in cell line models, fetal liver or spleen-derived primary erythroblasts and human CD34pos progenitor cells from cord blood or mobilized bone marrow. Presently, we have developed an ex vivo system that efficiently supports the expansion and development of murine adult bone-marrow-derived erythroid progenitor cells. This system is outlined together with its demonstrated utility in studying (for the first time) the signaling capacities of two knocked-in phosphotyrosine-deficient Epo receptor alleles (EpoR-H and EpoR-HM). Ways in which these studies advance an understanding of core Epo signal transduction events are outlined. Also introduced are two new putative negative regulators of Epo-dependent erythropoiesis, DYRK3 and DAPK2 kinases.