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Flak RV, Kofod-Olsen E, Sølvsten ND, Naujokaite G, Agger R, Stender MT, Christensen S, Shim S, Poulsen LØ, Detlefsen S, Thorlasius-Ussing O, Ladekarl M. Pembrolizumab followed by irreversible electroporation of a liver metastasis in pancreatic cancer patients. iScience 2024; 27:111026. [PMID: 39610376 PMCID: PMC11602522 DOI: 10.1016/j.isci.2024.111026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 05/29/2024] [Accepted: 09/20/2024] [Indexed: 11/30/2024] Open
Abstract
Preclinical studies suggest that irreversible electroporation (IRE) increases the effect of immune checkpoint inhibition in pancreatic cancer (PC). Patients with PC received PD-1 inhibitor pembrolizumab and, on day 10, percutaneous IRE of a liver metastasis. Blood samples were analyzed for immune cell subsets and inflammation related proteins. mRNA expression profiling was done in sequential biopsies. Treatment was safe, but the trial was terminated early. The response rate in eight patients was 0% and tumor growth was exponential. A drop in circulating plasmacytoid dendritic cells and a rise in several cytokines and proteins, especially PD-1, after immunotherapy was observed. In liver metastases, immune stimulatory genes were upregulated and immune suppressive genes were downregulated after pembrolizumab, while markers of effector T cells were unchanged. Treatment was safe but showed no efficacy in PC. Immunotherapy induced an immune permissive tumor microenvironment but with no increase in effector cells.
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Affiliation(s)
- Rasmus Virenfeldt Flak
- Department of Gastrointestinal Surgery and Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark
| | - Emil Kofod-Olsen
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Nikolaj Dich Sølvsten
- Department of Gastrointestinal Surgery and Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark
| | | | - Ralf Agger
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Mogens Tornby Stender
- Department of Gastrointestinal Surgery and Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Signe Christensen
- Department of Oncology and Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark
| | - Susy Shim
- Department of Oncology and Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark
| | - Laurids Østergaard Poulsen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Department of Oncology and Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark
| | - Sönke Detlefsen
- Department of Pathology, Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Ole Thorlasius-Ussing
- Department of Gastrointestinal Surgery and Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Morten Ladekarl
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Department of Oncology and Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark
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Tian Z, Jia W, Wang Z, Mao H, Zhang J, Shi Q, Li X, Song S, Zhang J, Zhu Y, Yang B, Huang C, Huang J. Clinical significance of immune-related antigen CD58 in gliomas and analysis of its potential core related gene clusters. Heliyon 2024; 10:e29275. [PMID: 38699747 PMCID: PMC11063413 DOI: 10.1016/j.heliyon.2024.e29275] [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] [Scholar Register] [Received: 03/23/2024] [Accepted: 04/03/2024] [Indexed: 05/05/2024] Open
Abstract
Background The clinical significance of immune-related antigen CD58 in gliomas remains uncertain. The aim of this study was to examine the clinical importance and possible core related genes of CD58 in gliomas. Methods Pan-cancer analysis was to observe the association between CD58 and different tumors, glioma RNA sequencing data and clinical sample analyses were used to observe the relationship between CD58 and glioma, shRNA interference models were to observe the impact of CD58 on glioma cell function, and four glioma datasets and two online analysis platforms were used to explore the core related genes affecting the correlation between CD58 and glioma. Results High CD58 expression was associated with worse prognosis in various tumors and higher malignancy in glioma. Down regulation of CD58 expression was linked to decreased proliferation, increased apoptosis, and reduced metastasis in glioma cells. The pathways involved in CD58-related effects were enriched for immune cell adhesion and immune factor activation, and the core genes were CASP1, CCL2, IL18, MYD88, PTPRC, and TLR2. The signature of CD58 and its core-related genes showed superior predictive power for glioma prognosis. Conclusion High CD58 expression is correlated with more malignant glioma types, and also an independent risk factor for mortality in glioma. CD58 and its core-related genes may serve as novel biomarkers for diagnosing and treating glioma.
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Affiliation(s)
- Zhi Tian
- Department of Neurosurgery, First Affiliated Hospital, Jishou University, Jishou, Hunan, 416000 PR China
| | - Wei Jia
- Medical College of Jishou University, Jishou, Hunan, 416000 PR China
| | - Zhao Wang
- Department of Neurosurgery, First Affiliated Hospital, Jishou University, Jishou, Hunan, 416000 PR China
| | - Hui Mao
- Department of Neurosurgery, First Affiliated Hospital, Jishou University, Jishou, Hunan, 416000 PR China
| | - Jingjing Zhang
- Department of Neurosurgery, First Affiliated Hospital, Jishou University, Jishou, Hunan, 416000 PR China
| | - Qiongya Shi
- Medical College of Jishou University, Jishou, Hunan, 416000 PR China
| | - Xing Li
- Medical College of Jishou University, Jishou, Hunan, 416000 PR China
| | - Shaoyu Song
- Department of Neurosurgery, First Affiliated Hospital, Jishou University, Jishou, Hunan, 416000 PR China
| | - Jiao Zhang
- Department of Neurosurgery, First Affiliated Hospital, Jishou University, Jishou, Hunan, 416000 PR China
| | - Yingjie Zhu
- Department of Neurosurgery, First Affiliated Hospital, Jishou University, Jishou, Hunan, 416000 PR China
| | - Bo Yang
- Department of Pathology, First Affiliated Hospital, Jishou University, Jishou, Hunan, 416000 PR China
| | - Chunhai Huang
- Department of Neurosurgery, First Affiliated Hospital, Jishou University, Jishou, Hunan, 416000 PR China
| | - Jun Huang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan 410008 PR China
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Wu M, Chen Y, Hua G, Chunhui L. The CD2-CD58 axis: A novel marker predicting poor prognosis in patients with low-grade gliomas and potential therapeutic approaches. Immun Inflamm Dis 2023; 11:e1022. [PMID: 37904707 PMCID: PMC10571499 DOI: 10.1002/iid3.1022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 07/31/2023] [Accepted: 09/09/2023] [Indexed: 11/01/2023] Open
Abstract
INTRODUCTION Low-grade gliomas (LGGs) are currently considered a premalignant condition for high-grade gliomas (HGGs) and are characterized by a relatively intact immune system. Immunotherapeutic modalities may offer a safe and effective treatment option for these patients. However, the CD2-CD58 axis, an important component of the immunological synapse, remains unknown in LGG. METHODS RNA-seq data from TCGA databases were analyzed. Immune cell infiltration was determined using a single-sample gene set enrichment analysis (ssGSEA) based on integrated immune gene sets from published studies. Kaplan-Meier survival analysis, univariate and multivariate logistic analysis, and the ESTIMATE algorithm were employed to evaluate the impact of the CD2-CD58 axis on adult LGG patients. RESULTS The expression of the CD2-CD58 axis was found to be elevated with increasing of WHO grade (p < .05). Uni- and multi-variable logistic analysis demonstrated that age, WHO grade, and CD58 levels were associated with poor prognosis in LGG patients with (p < .01). MetaSape pathways analysis revealed the involvement of CD58 in regulating T cell activation, leukocyte-mediated immunity, and the positive regulation of cell activation in WHO grade II and III. CD58 expression correlated with infiltrations of CD4+ lymphocytes, NK cells, and macrophages cells. The ESTIMATE algorithm indicated that patients with high CD58 expression had significantly higher immune scores compared with low CD58 expression in WHO grade II/III, but no statistical difference was observed in WHO grade IV (p < .05). Furthermore, correlation analysis demonstrated the significant association between CD58 and CD274 (r = 0.581, p < .001), HAVCR2 (r = 0.58i7, p < .001), and LGALS9 (r = 0.566, p < .001). Immunohistochemical staining further confirmed the relationship of CD58, HAVCR2, WHO grade, and prognosis in grade II and III patients. CONCLUSION Overall, our findings highlight the significant association between the CD2-CD58 axis and poor survival in LGG patients. High CD58 expression is implicated in T cell-mediated immune responses as an immunosuppressive factor and affect inhibitory immune checkpoint genes.
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Affiliation(s)
- Mingwei Wu
- Qinzhou First People's HospitalQinzhouChina
| | - Yiyuan Chen
- Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Gao Hua
- Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Liu Chunhui
- Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
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Sahni S, Nahm C, Ahadi MS, Sioson L, Byeon S, Chou A, Maloney S, Moon E, Pavlakis N, Gill AJ, Samra J, Mittal A. Gene expression profiling of pancreatic ductal adenocarcinomas in response to neoadjuvant chemotherapy. Cancer Med 2023; 12:18050-18061. [PMID: 37533202 PMCID: PMC10523964 DOI: 10.1002/cam4.6411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 07/09/2023] [Accepted: 07/25/2023] [Indexed: 08/04/2023] Open
Abstract
AIM Pancreatic ductal adenocarcinoma (PDAC) has the lowest survival rate of all major cancers. Chemotherapy is the mainstay systemic therapy for PDAC, and chemoresistance is a major clinical problem leading to therapeutic failure. This study aimed to identify key differences in gene expression profile in tumors from chemoresponsive and chemoresistant patients. METHODS Archived formalin-fixed paraffin-embedded tumor tissue samples from patients treated with neoadjuvant chemotherapy were obtained during surgical resection. Specimens were macrodissected and gene expression analysis was performed. Multi- and univariate statistical analysis was performed to identify differential gene expression profile of tumors from good (0%-30% residual viable tumor [RVT]) and poor (>30% RVT) chemotherapy-responders. RESULTS Initially, unsupervised multivariate modeling was performed by principal component analysis, which demonstrated a distinct gene expression profile between good- and poor-chemotherapy responders. There were 396 genes that were significantly (p < 0.05) downregulated (200 genes) or upregulated (196 genes) in tumors from good responders compared to poor responders. Further supervised multivariate analysis of significant genes by partial least square (PLS) demonstrated a highly distinct gene expression profile between good- and poor responders. A gene biomarker of panel (IL18, SPA17, CD58, PTTG1, MTBP, ABL1, SFRP1, CHRDL1, IGF1, and CFD) was selected based on PLS model, and univariate regression analysis of individual genes was performed. The identified biomarker panel demonstrated a very high ability to diagnose good-responding PDAC patients (AUROC: 0.977, sensitivity: 82.4%; specificity: 87.0%). CONCLUSION A distinct tumor biological profile between PDAC patients who either respond or not respond to chemotherapy was identified.
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Affiliation(s)
- Sumit Sahni
- Northern Clinical School, Faculty of Medicine and HealthUniversity of SydneySt LeonardsNew South WalesAustralia
- Northern Clinical School, Kolling Institute of Medical ResearchUniversity of SydneySt LeonardsNew South WalesAustralia
- Australian Pancreatic CentreSydneyNew South WalesAustralia
| | - Christopher Nahm
- Western Clinical School, Faculty of Medicine and HealthUniversity of SydneySt LeonardsNew South WalesAustralia
| | - Mahsa S. Ahadi
- Northern Clinical School, Faculty of Medicine and HealthUniversity of SydneySt LeonardsNew South WalesAustralia
- Northern Clinical School, Kolling Institute of Medical ResearchUniversity of SydneySt LeonardsNew South WalesAustralia
- Department of Anatomical Pathology, NSW Health PathologyRoyal North Shore HospitalSydneyNew South WalesAustralia
| | - Loretta Sioson
- Northern Clinical School, Faculty of Medicine and HealthUniversity of SydneySt LeonardsNew South WalesAustralia
- Northern Clinical School, Kolling Institute of Medical ResearchUniversity of SydneySt LeonardsNew South WalesAustralia
- Department of Anatomical Pathology, NSW Health PathologyRoyal North Shore HospitalSydneyNew South WalesAustralia
| | - Sooin Byeon
- Northern Clinical School, Faculty of Medicine and HealthUniversity of SydneySt LeonardsNew South WalesAustralia
- Northern Clinical School, Kolling Institute of Medical ResearchUniversity of SydneySt LeonardsNew South WalesAustralia
| | - Angela Chou
- Northern Clinical School, Faculty of Medicine and HealthUniversity of SydneySt LeonardsNew South WalesAustralia
- Northern Clinical School, Kolling Institute of Medical ResearchUniversity of SydneySt LeonardsNew South WalesAustralia
- Department of Anatomical Pathology, NSW Health PathologyRoyal North Shore HospitalSydneyNew South WalesAustralia
| | - Sarah Maloney
- Northern Clinical School, Faculty of Medicine and HealthUniversity of SydneySt LeonardsNew South WalesAustralia
- Northern Clinical School, Kolling Institute of Medical ResearchUniversity of SydneySt LeonardsNew South WalesAustralia
| | - Elizabeth Moon
- Northern Clinical School, Faculty of Medicine and HealthUniversity of SydneySt LeonardsNew South WalesAustralia
- Northern Clinical School, Kolling Institute of Medical ResearchUniversity of SydneySt LeonardsNew South WalesAustralia
| | - Nick Pavlakis
- Northern Clinical School, Faculty of Medicine and HealthUniversity of SydneySt LeonardsNew South WalesAustralia
- Northern Clinical School, Kolling Institute of Medical ResearchUniversity of SydneySt LeonardsNew South WalesAustralia
- Northern Sydney Cancer Center, Royal North Shore HospitalSt LeonardsNew South WalesAustralia
- Northern Cancer InstituteSt LeonardsNew South WalesAustralia
| | - Anthony J. Gill
- Northern Clinical School, Faculty of Medicine and HealthUniversity of SydneySt LeonardsNew South WalesAustralia
- Northern Clinical School, Kolling Institute of Medical ResearchUniversity of SydneySt LeonardsNew South WalesAustralia
- Department of Anatomical Pathology, NSW Health PathologyRoyal North Shore HospitalSydneyNew South WalesAustralia
| | - Jaswinder Samra
- Northern Clinical School, Faculty of Medicine and HealthUniversity of SydneySt LeonardsNew South WalesAustralia
- Northern Clinical School, Kolling Institute of Medical ResearchUniversity of SydneySt LeonardsNew South WalesAustralia
- Australian Pancreatic CentreSydneyNew South WalesAustralia
- Upper Gastrointestinal Surgical UnitRoyal North Shore Hospital and North Shore Private HospitalSt LeonardsNew South WalesAustralia
| | - Anubhav Mittal
- Northern Clinical School, Faculty of Medicine and HealthUniversity of SydneySt LeonardsNew South WalesAustralia
- Northern Clinical School, Kolling Institute of Medical ResearchUniversity of SydneySt LeonardsNew South WalesAustralia
- Australian Pancreatic CentreSydneyNew South WalesAustralia
- Upper Gastrointestinal Surgical UnitRoyal North Shore Hospital and North Shore Private HospitalSt LeonardsNew South WalesAustralia
- The University of Notre Dame AustraliaSydneyNew South WalesAustralia
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Immunophenotype of Measurable Residual Blast Cells as an Additional Prognostic Factor in Adults with B-Cell Acute Lymphoblastic Leukemia. Diagnostics (Basel) 2022; 13:diagnostics13010021. [PMID: 36611312 PMCID: PMC9818326 DOI: 10.3390/diagnostics13010021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 12/16/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
Measurable residual disease (MRD) is a well-known independent prognostic factor in acute leukemias, and multicolor flow cytometry (MFC) is widely used to detect MRD. MFC is able not only to enumerate MRD accurately but also to describe an antigen expression profile of residual blast cells. However, the relationship between MRD immunophenotype and patient survival probability has not yet been studied. We determined the prognostic impact of MRD immunophenotype in adults with B-cell acute lymphoblastic leukemia (B-ALL). In a multicenter study RALL-2016 (NCT03462095), 267 patients were enrolled from 2016 to 2022. MRD was assessed at the end of induction (day 70) in 94 patients with B-ALL by six- or 10-color flow cytometry in the bone marrow specimens. The 4 year relapse-free survival (RFS) was lower in MRD-positive B-ALL patients [37% vs. 78% (p < 0.0001)]. The absence of CD10, positive expression of CD38, and high expression of CD58 on MRD cells worsened the 4 year RFS [19% vs. 51% (p = 0.004), 0% vs. 51% (p < 0.0001), and 21% vs. 40% (p = 0.02), respectively]. The MRD immunophenotype is associated with RFS and could be an additional prognostic factor for B-ALL patients.
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Zhang Y, Liu Q, Cui M, Wang M, Hua S, Gao J, Liao Q. Comprehensive Analysis of Expression, Prognostic Value, and Immune Infiltration for Ubiquitination-Related FBXOs in Pancreatic Ductal Adenocarcinoma. Front Immunol 2022; 12:774435. [PMID: 35046938 PMCID: PMC8761623 DOI: 10.3389/fimmu.2021.774435] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 11/22/2021] [Indexed: 11/13/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is one of the most refractory human malignancies. F-box only proteins (FBXO) are the core components of SKP1-cullin 1-F-box E3 ubiquitin ligase, which have been reported to play crucial roles in tumor initiation and progression via ubiquitination-mediated proteasomal degradation. However, the clinical implications and biological functions of FBXOs in PDAC have not been fully clarified. Herein we perform a comprehensive analysis for the clinical values and functional roles of FBXOs in PDAC using different public databases. We found that FBXO1 (CCNF), FBXO20 (LMO7), FBXO22, FBXO28, FBXO32, and FBXO45 (designated six-FBXOs) were robustly upregulated in PDAC tissues, which predicted an adverse prognosis of PDAC patients. There was a significant correlation between the expression levels of six-FBXOs and the clinicopathological features in PDAC. The transcriptional levels of six-FBXOs were subjected to the influence of promoter methylation levels. There were more than 40% genetic alterations and mutations of six-FBXOs, which affected the clinical outcome of PDAC patients. Furthermore, the expression of six-FBXOs was associated with immune infiltrations and activated status, including B cells, CD8+ T cells, CD4+ T cells, NK cells, macrophages, and dendritic cells. The functional prediction revealed that the six-FBXOs were involved in ubiquitination-related pathways and other vital signaling pathways, such as p53, PI3K/Akt, and Hippo pathway. Therefore, six-FBXOs are the promising prognostic biomarkers or potential targets for PDAC diagnosis and treatment.
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Affiliation(s)
- Yalu Zhang
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Qiaofei Liu
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Ming Cui
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Mengyi Wang
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Surong Hua
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Junyi Gao
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Quan Liao
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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Kamakura M, Uehara T, Iwaya M, Asaka S, Kobayashi S, Nakajima T, Kinugawa Y, Nagaya T, Yoshizawa T, Shimizu A, Ota H, Umemura T. LGR5 expression and clinicopathological features of the invasive front in the fat infiltration area of pancreatic cancer. Diagn Pathol 2022; 17:21. [PMID: 35123536 PMCID: PMC8818226 DOI: 10.1186/s13000-022-01203-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 01/20/2022] [Indexed: 12/24/2022] Open
Abstract
Abstract
Background
Leucine-rich repeat-containing G-protein-coupled receptor 5 (LGR5) is a strong cancer stem cell marker in colorectal cancer; however, there are many unclear aspects of LGR5 expression in pancreatic cancer. It has been reported that the interaction between tumor cells and stroma at the fat infiltration site has a significant effect on pancreatic cancer prognosis. Therefore, we report a clinicopathological study of LGR5 expression at the fat invasion front in pancreatic cancer.
Methods
LGR5 expression was analyzed in 40 pancreatic ductal adenocarcinoma cases with RNAscope, which is a newly developed high-sensitivity in situ hybridization method. Epithelial-mesenchymal transition (EMT) was analyzed by the expression of E-cadherin and vimentin via immunohistochemistry.
Results
LGR5-positive dots were identified in all cases, especially with glandular formation. In the fat invasion front, a high histological grade showed significantly reduced LGR5 expression compared with a low histological grade (p=0.0126). LGR5 expression was significantly higher in the non-EMT phenotype group than in EMT phenotype group (p=0.0003). Additionally, LGR5 expression was significantly lower in cases with high vascular invasion than in those with low vascular invasion (p=0.0244).
Conclusions
These findings suggest that decreased LGR5 expression in the fat invasion front is associated with more aggressive biological behavior in pancreatic ductal adenocarcinoma, with higher tumor grade, EMT phenotype, and higher vascular invasion.
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