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Chen L, Larsen B, Dermawan JK, Zarka MA. Cytomorphology of NUTM1-rearranged sarcoma involving pleural fluid. Diagn Cytopathol 2022; 50:E244-E247. [PMID: 35441831 DOI: 10.1002/dc.24968] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/08/2022] [Accepted: 04/12/2022] [Indexed: 12/18/2022]
Abstract
We describe an exceedingly rare cytology case of a NUTM1-rearranged sarcoma involving pleural fluid. A 48-year-old female presented with progressive abdominal pain. Computed tomography (CT) scan of the abdomen revealed a 5.6 cm soft tissue mass in the right hemi-abdomen. Needle core biopsy of the mass showed a small round cell tumor. Extensive work-up including next generation sequencing (NGS) demonstrated a NUTM1:MXI1 rearranged sarcoma. The patient was first treated with ifosfamide, carboplatin, and etoposide (ICE) chemotherapy. She responded initially and then progressed with multiple masses in the abdomen and pleural effusion. The cytology of the pleural effusion showed clusters and single small round blue cells. Some of them displayed rhabdoid morphology. Immunostains of NUT antibody on cell block demonstrated strong positivity of NUT. NUTM1-rearranged sarcoma is an emerging class of mesenchymal neoplasm and the cytomorphology of this neoplasm in liquid-based cytology (LBC) is yet to be described. We herein reported the first cytology case of NUTM1-rearranged sarcoma in pleural fluid.
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Affiliation(s)
- Longwen Chen
- Department of Pathology and Laboratory Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Brandon Larsen
- Department of Pathology and Laboratory Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Josephine K Dermawan
- Department of Pathology, Memorial Sloan Kettering Cancer Institute, New York, New York, USA
| | - Matthew A Zarka
- Department of Pathology and Laboratory Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA
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Pantanowitz L, Chivukula M. Serous fluid: Metastatic sarcomas, melanoma, and other non-epithelial neoplasms. Cytojournal 2022; 19:15. [PMID: 35510115 PMCID: PMC9063691 DOI: 10.25259/cmas_02_10_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 02/02/2022] [Indexed: 11/23/2022] Open
Abstract
While most tumors metastatic to the serous membranes are of epithelial origin, cytologists should be aware that non-epithelial neoplasms can also cause malignant effusions including sarcomas, melanomas, germ cell tumors, and, more rarely, brain tumors. The differential diagnosis of a malignant effusion is accordingly broad, especially for the small round blue cell tumors that includes not only mesenchymal tumors, but also non-mesenchymal tumors, such as neuroblastoma and Wilms tumor. Diagnosing non-epithelial malignancies in effusion specimens based entirely upon their cytomorphologic features is difficult because these neoplasms often exhibit considerable morphological overlap and their cytomorphology can differ from the original tumor. As malignant cells have a tendency to round up in body fluids these non-epithelial neoplasms can therefore mimic reactive mesothelial cells and metastatic adenocarcinoma. The use of ancillary studies including immunostaining, FISH, and molecular studies is thus often critical to reach a definitive diagnosis. This review article will be incorporated finally as one of the chapters in CMAS (CytoJournal Monograph/Atlas Series) #2. It is modified slightly from the chapter by the initial authors in the first edition of Diagnostic Cytopathology of Serous Fluids.
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Affiliation(s)
| | - Mamatha Chivukula
- Peninsula Pathologists Medical Group, Mills - Peninsula Hospitals, A Sutter Health Affiliate, South San Francisco, CA, USA,
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Jhala N, Arriola A, Pantanowitz L. Serous cavity metastasis: Evaluation of unknown primary. Cytojournal 2022; 19:16. [PMID: 35510111 PMCID: PMC9063508 DOI: 10.25259/cmas_02_11_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 09/02/2021] [Indexed: 11/04/2022] Open
Abstract
Malignant effusions can occur in patients with neoplasia. Once a metastatic diagnosis is confirmed, the primary site of origin of malignancy needs to be ascertained. This task can be challenging without a prior history of malignancy. In some patients their effusion may be the initial presentation of an underlying malignancy. Metastases usually present with a dual population of mesothelial and malignant cells. Combining cytomorphologic examination with ancillary testing such as immunocytochemistry can help identify the origin of the foreign malignant cell population. Helpful architectural clues include a single cell pattern, solid cell ball pattern, single file arrangement, papillary formation, psammoma bodies and background mucin. Useful cellular features include the presence of signet ring cells, small cells, pleomorphic and multinucleated giant cells, squamous cells, spindle cells and pigmentation. Rarely, despite an extensive work-up the primary site of origin for a malignant effusion may remain unresolved. This review article will be incorporated finally as one of the chapters in CMAS (CytoJournal Monograph/Atlas Series) #2. It is modified slightly from the chapter by the initial authors in the first edition of Cytopathologic Diagnosis of Serous Fluids.
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Affiliation(s)
- Nirag Jhala
- Department of Pathology and Laboratory Medicine, Temple University Hospital and Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA,
| | - Aileen Arriola
- Department of Pathology and Laboratory Medicine, Temple University Hospital and Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA,
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Ikeda K, Oboshi W, Hashimoto Y, Komene T, Yamaguchi Y, Sato S, Maruyama S, Furukawa N, Sakabe N, Nagata K. Characterizing the Effect of Processing Technique and Solution Type on Cytomorphology Using Liquid-Based Cytology. Acta Cytol 2021; 66:55-60. [PMID: 34644702 DOI: 10.1159/000519335] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 08/31/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Liquid-based cytology (LBC) is increasingly used for nongynecologic applications. However, the cytological preparation of LBC specimens is influenced by the processing technique and the preservative used. In this study, the influence of the processing techniques and preservatives on cell morphology was examined mathematically and statistically. METHODS Cytological specimens were prepared using the ThinPrep (TP), SurePath (SP), and AutoSmear methods, with 5 different preservative solutions. The cytoplasmic and nuclear areas of Papanicolaou-stained specimens were measured for all samples. RESULTS The cytoplasmic and nuclear areas were smaller in cells prepared using the 2 LBC methods, compared to that prepared using the AutoSmear method, irrespective of the preservative used. The cytoplasmic and nuclear areas of cells prepared using the SP method were smaller than those of cells prepared using the TP method, irrespective of the preservative used. There were fewer differences among the cytoplasmic areas of cells prepared with different preservative solutions using the TP method; however, the cytoplasmic areas of cells prepared using the SP method changed with the preservative solution used. CONCLUSIONS The most significant difference affecting the cytoplasmic and nuclear areas was the processing technique. The TP method increased the cytoplasmic and nuclear areas, while the methanol-based PreservCyt solution enabled the highest enlargement of the cell. LBC is a superior preparation technique for standardization of the specimens. Our results offer a better understanding of methods suitable for specimen preparation for developing precision AI-based diagnosis in cytology.
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Affiliation(s)
- Katsuhide Ikeda
- Pathophysiology Sciences, Department of Integrated Health Sciences, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Wataru Oboshi
- Department of Medical Technology and Sciences, School of Health Sciences at Narita, International University of Health and Welfare, Narita, Japan
| | - Yusuke Hashimoto
- Department of Medical Technology and Sciences, School of Health Sciences at Narita, International University of Health and Welfare, Narita, Japan
| | - Tetsuya Komene
- Department of Medical Technology and Sciences, School of Health Sciences at Narita, International University of Health and Welfare, Narita, Japan
| | - Yoshitaka Yamaguchi
- Department of Medical Technology and Sciences, School of Health Sciences at Narita, International University of Health and Welfare, Narita, Japan
| | - Shouichi Sato
- Department of Medical Technology and Sciences, School of Health Sciences at Narita, International University of Health and Welfare, Narita, Japan
| | - Sayumi Maruyama
- Pathophysiology Sciences, Department of Integrated Health Sciences, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Nozomi Furukawa
- Pathophysiology Sciences, Department of Integrated Health Sciences, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Nanako Sakabe
- Pathophysiology Sciences, Department of Integrated Health Sciences, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kohzo Nagata
- Pathophysiology Sciences, Department of Integrated Health Sciences, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Sharma A, Thangaiah JJ, Shetty S, Policarpio-Nicolas MLC. Bone and soft tissue sarcomas in cerebrospinal fluid and effusion: A 20-year review at our institution. Cancer Cytopathol 2021; 129:776-787. [PMID: 34233079 DOI: 10.1002/cncy.22431] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 01/24/2021] [Accepted: 02/16/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND The literature on bone and soft tissue sarcomas (BSTSs) involving effusions and cerebrospinal fluid (CSF) is very limited. METHODS A computerized search for fluid cytology with a sarcoma diagnosis from 2000 to 2020 was performed. All available cases, including the clinical follow-up, were reviewed. RESULTS A total of 57 fluids specimens from 36 BSTSs were identified (9 rhabdomyosarcomas, 6 angiosarcomas, 5 epithelioid hemangioendotheliomas, 3 dedifferentiated liposarcomas, 2 chondrosarcomas, 1 extraskeletal myxoid chondrosarcoma, 3 Ewing sarcomas, 2 undifferentiated sarcomas, 3 osteosarcomas, 1 synovial sarcoma, and 1 hybrid low-grade fibromyxoid sarcoma/sclerosing epithelioid fibrosarcoma). There were 22 males and 14 females. The age range was 4 to 82 years (median, 45 years). Sites of involvement included pleural fluid (n = 38), peritoneal fluid (n = 14), and CSF (n = 5). Twenty-four cytology cases were available for review. The cytologic features were nonspecific and ranged from dyshesive to clusters of round, epithelioid, pleomorphic, and occasionally spindle-shaped malignant cells that could easily mimic other non-BSTS malignant tumors. The diagnosis of BSTS was made by comparison with a prior specimen and/or ancillary studies (molecular or immunohistochemical stains). The prognosis was poor because 95% of the patients died of their disease. CONCLUSIONS The incidence of BSTS in fluid cytology is extremely rare, and it can have cytologic features similar to those of non-BSTS malignancies. Although, in most cases, a comparison with a prior known BSTS specimen may suffice, the use of ancillary studies is extremely helpful in arriving at the correct diagnosis. However, in cases with no known prior malignancy, including BSTS in the differential diagnosis is prudent for preventing misdiagnosis.
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Affiliation(s)
- Anurag Sharma
- Department of Laboratory Medicine, Cleveland Clinic, Cleveland, Ohio
| | | | - Sindhu Shetty
- Department of Laboratory Medicine, Cleveland Clinic, Cleveland, Ohio
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Han LM, VandenBussche CJ, Abildtrup M, Chandra A, Vohra P. A Review of Effusion Cytomorphology of Small Round Cell Tumors. Acta Cytol 2021; 66:336-346. [PMID: 34218227 DOI: 10.1159/000516497] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 04/07/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Small round cell tumors (SRCTs) are a broad category of diverse malignant tumors composed of monotonous undifferentiated cells. Involvement of serous fluids by SRCT is rare; however, the identification of exfoliated malignant cells is a crucial component of management and has significant implications for treatment and prognosis. The most common effusion tumors with SRCT morphology include Ewing sarcoma, synovial sarcoma, rhabdomyosarcoma (RMS), small-cell neuroendocrine carcinoma (SCNC), and desmoplastic SRCT, and the cytomorphologic distinction between these tumors is challenging. The purpose of this article is to describe the morphologic features of the most common SRCT in fluids and propose helpful ancillary testing. SUMMARY Effusion SRCTs display similar primitive and undifferentiated morphologic features although each has subtle variations. Ewing sarcoma is a mesenchymal neoplasm and harbors characteristic translocations t(11;22) (EWSR1-FLI1) or t(21;22) (EWSR1-ERG). In fluids, Ewing sarcoma shows poorly differentiated cells of variable size with round to oval nuclei, prominent nucleoli, and scant cytoplasm. In contrast, synovial sarcoma typically involves extremities and expresses a fusion transcript in t(X;18) (SS18-SSX). This soft tissue neoplasm demonstrates uniform cells with irregular nuclear contours, characteristic nuclear folding, and scant cytoplasm. RMS is a neoplasm arising from skeletal muscle, and the alveolar subtype demonstrates a translocation in t(2;13) (PAX3-FOXO1). The malignant cells show a spectrum of small round cells and pleomorphic large cells with rhabdoid morphology. RMS cells characteristically express myogenin and MyoD1, markers of skeletal muscle differentiation. Although SCNC is not a classic SRCT, the morphology is similar. SCNC demonstrates tight clusters of malignant cells with nuclear molding and salt-and-pepper chromatin. This tumor classically has neuroendocrine differentiation and is positive for synaptophysin and chromogranin on immunohistochemistry. And last, desmoplastic SRCT typically presents as an intra-abdominal mass in young men and characteristically harbors the translocation t(11;22) (p13;q12) (EWSR1-WT1). Cytomorphologically, the tumor shows small monomorphic cells occasionally arranged as rosette-like structures. KEY MESSAGE The diagnosis of SRCT can be made in effusion samples and is best achieved with a combination of morphologic features, clinical history, and ancillary testing.
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Affiliation(s)
- Lucy M Han
- Department of Pathology, University of California, San Francisco, California, USA
| | | | - Mads Abildtrup
- Department of Histopathology, King's College Hospital NHS Foundation Trust, London, UK
| | - Ashish Chandra
- Department of Cellular Pathology, St. Thomas' Hospital, London, UK
| | - Poonam Vohra
- Department of Pathology, University of California, San Francisco, California, USA,
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Kanber Y, Pusztaszeri M, Auger M. Immunocytochemistry for diagnostic cytopathology-A practical guide. Cytopathology 2021; 32:562-587. [PMID: 34033162 DOI: 10.1111/cyt.12993] [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: 01/12/2021] [Revised: 04/18/2021] [Accepted: 04/19/2021] [Indexed: 11/29/2022]
Abstract
Cytological specimens, which are obtained by minimally invasive methods, are an excellent source of diagnostic material. Sometimes they are the only material available for diagnosis as well as for prognostic/predictive markers. When cytomorphology is not straightforward, ancillary tests may be required for a definitive diagnosis to guide clinical management. Immunocytochemistry (ICC) is the most common and practical ancillary tool used to reach a diagnosis when cytomorphology is equivocal, to differentiate entities with overlapping morphological features, and to determine the cell lineage and the site of origin of a metastatic neoplasm. Numerous immunomarkers are available, and some are expressed in multiple neoplasms. To rule out entities within a differential diagnosis, the use of more than one marker, sometimes panels, is necessary. ICC panels for diagnostic purposes should be customised based on the clinical context and cytomorphology, and the markers should be used judiciously to preserve material for additional tests for targeted therapies in the appropriate setting. This review offers a practical guide for the use of ICC for diagnostic cytopathology, covering the most commonly encountered non-hematolymphoid diagnostic scenarios in various body sites.
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Affiliation(s)
- Yonca Kanber
- Department of Pathology, McGill University Health Center, McGill University, Montreal, QC, Canada
| | - Marc Pusztaszeri
- Department of Pathology, Jewish General Hospital, McGill University, Montréal, QC, Canada
| | - Manon Auger
- Department of Pathology, McGill University Health Center, McGill University, Montreal, QC, Canada
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Motoda N, Nakamura Y, Kuroki M, Yoneyama K, Isshiki S, Ohashi R, Naito Z. Exfoliation of Alveolar Rhabdomyosarcoma Cells in the Ascites of a 50-Year-Old Woman: Diagnostic Challenges and Literature Review. J NIPPON MED SCH 2019; 86:236-241. [DOI: 10.1272/jnms.jnms.2018_86-404] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Norio Motoda
- Department of Diagnostic Pathology, Nippon Medical School Musashi Kosugi Hospital
| | - Yuji Nakamura
- Department of Diagnostic Pathology, Nippon Medical School Musashi Kosugi Hospital
| | - Mutsumi Kuroki
- Department of Obstetrics and Gynecology, Nippon Medical School Musashi Kosugi Hospital
| | - Koichi Yoneyama
- Department of Obstetrics and Gynecology, Nippon Medical School Musashi Kosugi Hospital
| | - Saiko Isshiki
- Department of Radiology, Nippon Medical School Musashi Kosugi Hospital
| | - Ryuji Ohashi
- Department of Diagnostic Pathology, Nippon Medical School Musashi Kosugi Hospital
| | - Zenya Naito
- Department of Integrated Diagnostic Pathology, Nippon Medical School
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Ikeda K, Sato S, Chigira H, Shibuki Y, Hiraoka N. Characterizing the Effect of Automated Cell Sorting Solutions on Cytomorphological Changes. Acta Cytol 2019; 64:232-240. [PMID: 31234180 DOI: 10.1159/000500769] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 05/05/2019] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Liquid-based cytology has become a widely adopted, automated screening system for gynecologic and nongynecologic cytology. Automated screening systems function by distinguishing atypical cells based on their cytoplasmic and nuclear areas, densitometric measurement, and so on. However, the morphological influence of the washing solution has not been fully considered. Here, we examined the morphological effect and temporal change resulting from saving the cytologic samples in various solutions. METHODS Cytologic specimens were obtained from the ascites (AS) of patients with peritoneal cancer. Various solutions of a physiological saline, a Ringer's solution, a low-molecular dextran L injection, VOLUVEN 6% solution, MIXID L injection (ML), RPMI-1640 medium, and horse serum (HS) were added to aliquot sediments. All samples were refrigerated at 4°C, and aliquots were subsequently processed at specific time points (0, 1, 2, 4, 7, and 14 days). For all samples, cytoplasmic and nuclear size of the Papanicolaou-stained specimens were measured. RESULTS In terms of cytoplasmic and nuclear areas, samples stored in ML and HS showed no significant difference compared to the AS sample; in contrast, the other samples were significantly larger in both cytoplasmic and nuclear areas than the AS sample. In examining the temporal change among the solutions, we found that the cytoplasms and nuclei became small over the time course for all of the tested solutions. CONCLUSION We showed that cells swell in the solution after 1 h of storage and contract as time progresses. Together, our findings have important implications for how mathematical analysis is applied during the automated screening process.
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Affiliation(s)
- Katsuhide Ikeda
- Department of Medical Technology and Sciences, School of Health Sciences at Narita, International University of Health and Welfare, Narita, Japan,
| | - Shouichi Sato
- Department of Medical Technology and Sciences, School of Health Sciences at Narita, International University of Health and Welfare, Narita, Japan
| | - Hiroshi Chigira
- Department of Pathology and Clinical Laboratory, National Cancer Center Hospital, Tokyo, Japan
| | - Yasuo Shibuki
- Department of Pathology and Clinical Laboratory, National Cancer Center Hospital, Tokyo, Japan
| | - Nobuyoshi Hiraoka
- Department of Pathology and Clinical Laboratory, National Cancer Center Hospital, Tokyo, Japan
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Renshaw AA, Gould EW. Effusion cytology of epithelioid rhabdomyosarcoma. Diagn Cytopathol 2019; 47:1042-1044. [PMID: 31017725 DOI: 10.1002/dc.24194] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 04/03/2019] [Accepted: 04/05/2019] [Indexed: 11/09/2022]
Abstract
We report a case of epithelioid rhabdomyosarcoma in a pleural effusion. In contrast to most rhabdomyosarcomas in effusions, the cells presented as cohesive clusters of atypical cells with abundant eosinophilic cytoplasm which mimicked an adenocarcinoma. Immunohistochemistry was positive for epithelial membrane antigen and muscle markers and negative for keratins.
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Affiliation(s)
- Andrew A Renshaw
- Department of Pathology, Miami Cancer Institute and Baptist Hospital, Baptist Health of South Florida Healthcare System, Miami, Florida
| | - Edwin W Gould
- Department of Pathology, Miami Cancer Institute and Baptist Hospital, Baptist Health of South Florida Healthcare System, Miami, Florida
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Role of Forkhead Box Class O proteins in cancer progression and metastasis. Semin Cancer Biol 2017; 50:142-151. [PMID: 28774834 DOI: 10.1016/j.semcancer.2017.07.007] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 07/24/2017] [Accepted: 07/30/2017] [Indexed: 01/10/2023]
Abstract
It is now widely accepted that several gene alterations including transcription factors are critically involved in cancer progression and metastasis. Forkhead Box Class O proteins (FoxOs) including FoxO1/FKHR, FoxO3/FKHRL1, FoxO4/AFX and FoxO6 transcription factors are known to play key roles in proliferation, apoptosis, metastasis, cell metabolism, aging and cancer biology through their phosphorylation, ubiquitination, acetylation and methylation. Though FoxOs are proved to be mainly regulated by upstream phosphatidylinositol-4,5-bisphosphate 3-kinase (PI3 K)/Akt signaling pathway, the role of FoxOs in cancer progression and metastasis still remains unclear so far. Thus, with previous experimental evidences, the present review discussed the role of FoxOs in association with metastasis related molecules including cannabinoid receptor 1 (CNR1), Cdc25A/Cdk2, Src, serum and glucocorticoid inducible kinases (SGKs), CXCR4, E-cadherin, annexin A8 (ANXA8), Zinc finger E-box-binding homeobox 2 (ZEB2), human epidermal growth factor receptor 2 (HER2) and mRNAs such as miR-182, miR-135b, miR-499-5p, miR-1274a, miR-150, miR-34b/c and miR-622, subsequently analyzed the molecular mechanism of some natural compounds targeting FoxOs and finally suggested future research directions in cancer progression and metastasis.
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