Clinical Study Clinicopathological Impact of ABCC1/MRP1 and …downloads.hindawi.com/journals/bmri/2013/143202.pdf · 2019-07-31 · MRP and MRP expression adjusting for all known

Hindawi Publishing CorporationBioMed Research InternationalVolume 2013 Article ID 143202 7 pageshttpdxdoiorg1011552013143202

Clinical StudyClinicopathological Impact of ABCC1MRP1 andABCC4MRP4 in Epithelial Ovarian Carcinoma

Marina Bagnoli1 Giovanni L Beretta1 Laura Gatti1 Silvana Pilotti1

Paola Alberti1 Eva Tarantino1 Mattia Barbareschi2 Silvana Canevari1

Delia Mezzanzanica1 and Paola Perego1

1 Fondazione IRCSS Istituto Nazionale Tumori Via Venezian 1 20133 Milan Italy2 Department of Pathology S Chiara Hospital Largo Medaglie Oro 9 38122 Trento Italy

Correspondence should be addressed to Paola Perego paolaperegoistitutotumorimiit

Received 21 January 2013 Accepted 24 July 2013

Academic Editor Manoor Prakash Hande

Copyright copy 2013 Marina Bagnoli et alThis is an open access article distributed under the Creative Commons Attribution Licensewhich permits unrestricted use distribution and reproduction in any medium provided the original work is properly cited

Ovarian cancer is themain cause of death fromgynaecologicalmalignancies In spite of the efficacy of platinum-paclitaxel treatmentin patients with primary epithelial ovarian carcinoma platinum-based chemotherapy is not curative and resistance remains oneof the most important causes of treatment failure Although ABC transporters have been implicated in cellular resistance tomultiple drugs the clinical relevance of these efflux pumps is still poorly understood Thus we examined the prognostic role oftransporters of the MRP family (ie ABCC1MRP1 ABCC4MRP4) to gain insights into their clinical impacts A case material of127 patients with ovarian carcinoma at different stages and histotypes was used The expression of MRP1 and MRP4 was examinedby immunohistochemistry using tissuemicroarrays in tumor specimens collected at the time of initial surgery expressionWe foundan association between MRP1 expression and grading and we observed that MRP4 displayed an unfavourable impact on diseaserelapse in multivariate analysis (HR = 205 95 CI 101ndash411 119875 = 0045) These results suggest that in epithelial ovarian cancerMRP1may be amarker for aggressiveness because its expression was associated with tumor grade and support that MRP4may playan unfavourable role in disease outcome

1 Introduction

Ovarian cancer is themain cause of death from gynecologicalmalignancies and the majority of epithelial ovarian tumorsare diagnosed as advanced stage diseases [1] Recent studieshave shown that ovarian carcinoma is a complex disease thatgathers molecularly different tumors sharing the localiza-tion more than biological features [2] The management ofovarian carcinoma includes cytoreductive surgery followedby platinum (carboplatin or cisplatin) taxane chemotherapywhich has become a standard treatment for advanced stagedisease [3 4] In spite of the efficacy of the platinum-paclitaxelcombination with responses observed in at least three quar-ters of the patients the outcome is poor and responsesare incomplete The limited efficacy of chemotherapy maybe dependent on the expression of defence factors which

confer increased survival potential for tumor cells and as aconsequence a multidrug resistant phenotype [5]Thereforean analysis of the expression by tumor cells ofmembers of theATP Binding Cassette (ABC) efflux transporter superfamilymay be useful and could help in the choice of treatmentsdefined on the basis of the molecular features of the tumor

Whole-genome approaches have documented the exis-tence of a wide family of ABC transporters including 50different members that can be grouped into seven distinctclasses based on sequence similarities [6 7] Whereas it hasbeen clearly established that ABCB1 and ABCG2 do notconfer resistance to platinum compounds selected membersof the ABCCMRP family have been implicated in resistanceto platinum compounds and taxanes [8 9] The notion thatABC transporters are a large family of genes supports theneed for novel studies directed at clarifying the relationship

2 BioMed Research International

between less characterized transporters and resistance Alsothe recent knowledge achieved by integrating biochemicaland molecular approaches indicates that the investigation ofexpression of ABC transporters in large collections of tumorspecimens should be pursued in an attempt to elucidate therole of such factors in tumor biology In fact ABC transporterexpression has been linked to tumor aggressiveness in differ-ent tumor types [10]

In a cellular study cells resistant to platinum compoundswere found to display increased levels ofMRP1 andMRP4 [9]In addition the available evidence supports that the effectsof transporters of the MRP subfamily on cell survival maybe indirect not necessarily implicating only efflux of thecytotoxic drugs [8] In this regardMRP4has been involved insignalling pathways which activate prosurvival mechanismsby virtue of its capability to pump cyclic nucleotides outsidethe cells [11]

Based on this background to document the role of MRP1and MRP4 in the clinical setting in ovarian carcinoma weinvestigated the role of MRPs as prognostic markers forthis tumor using archival material from tumor specimenscollected at surgery from epithelial ovarian carcinoma (EOC)patients

2 Material and Methods

21 Patients Tissue Specimens and Pathologic Data Thisstudy was performed on a tissue microarray (TMA) con-taining a series of formalin-fixed paraffin-embedded tissuescollected at surgery before any chemotherapeutic treatmentfrom 127 consecutive EOC patients who underwent surgicalresection at the S Chiara Hospital in Trento between 1992and 1999 [12] Histological sections and paraffin blockswere obtained from the Hospital Department of PathologyClinical data and follow-up information were available fromtheUnit of GynecologicOncology as specified in institutionalfollow-up procedures The use of tissue blocks and patientrecords was approved by the Institutional Review Board Allpatients gave informed consent for the therapy and for the useof specimens for research

Table 1 summarizes the patientsrsquo clinicopathological char-acteristics The average age of the patients was 58 yearsTumor staging was in accordance with International Feder-ation of Gynecology and Obstetrics (FIGO) criteria 31 ofpatients had stage I-II and 68 of patients had stage III-IVdisease Most tumors were of serous histotype (65) Forty-five percent of the cases were low grade (well moderatelydifferentiated) and 52 were high-grade tumors (poorlydifferentiated undifferentiated) Primary treatment for allpatients was surgery and based on the extent of residualdisease after primary surgery the patient population wasdivided into three groups no evident disease (NED)minimalresidual disease (mRD residual tumor smaller than 1 cm)and gross residual disease (GRD residual tumor equalgraterthan 1 cm) [13] Residual disease after surgical debulking wasdefined for 112 patients and was optimal (not evident diseaseor below 1 cm) in 52 of cases and equalgreater than 1 cm

Table 1 Patientrsquos clinical characteristics

Characteristics Patients (119899 = 127)N∘

Age years(mean median 58 range 23ndash84)

Tumor histotypeSerous 83 65Undifferentiated 12 10Clear cell 12 10Endometrioid 12 10Mucinous 6 4Others + mixed 2 1

Tumor stage (FIGO)I 24 19II 15 12III 64 50IV 23 18Not available 1 1

Tumor grade1 well differentiated 9 72 moderately differentiated 48 383 poorly differentiated 53 42Undifferentiated 12 10Not available 5 3

Amount of residual diseaseNED 47 37lt1 cm 19 15gt1 cm 46 36Not available 15 12

Frontline treatmentNone 8 6Platinum without taxanes 81 64Platinumpaclitaxel 35 28Other or not available 3 2

Response to frontline treatmentlowast

Complete 57 46Partial 21 18No response 21 18Not available 21 18

Abbreviations FIGO International Federation of Gynecological andObstet-rics staging system NED not evident disease lowastUntreated patients are notincluded

in 36 of cases After surgery 119 patients received front-line treatment with standard platinum-based therapeuticschedules (platinum without taxanes platinum and pacli-taxel) according to the time of accrualyear of diagnosis twopatients were treated with other chemotherapeutic agentseight patients (all stage I) received no chemotherapy andone patient had information missing Response to therapywas available for 99 patients Response was based on data

BioMed Research International 3

from medical records instrumental evaluation and Ca 125levels and was scored as complete (57 cases) partial (diseasereduced by 50) (21 cases) or absent (21 cases) accordingto the WHO standard criteria [14] Remission was definedafter completion of first-line treatment as disappearance ofall clinical radiological and biochemical evidence of EOCFollow-up time was based on patient date of death or thelast information available in themedical recordsThemedianof follow-up period for all patients was 89 months Timeto progression (TTP) was calculated as the time in monthsfrom the date of surgery until the first evidence (clinicalinstrumental or biological) of disease progression

22 Immunohistochemistry MRP expression was exam-ined by immunohistochemistry (IHC) on formalin-fixedparaffin-embedded sections of EOC TMA Briefly afterxylene deparaffinization and alcohol rehydration sectionswere subjected to antigen retrieval in 10mM pH 60 citratebuffer at 95∘C for 6min and 15min in autoclave forMRP4 andMRP1 respectively Endogenous peroxidasewas quenched byincubating the slide with 3H

2O2for 10min After washing

slides were incubated in saturating solution (PBS 1 BSA) for30min at room temperature (RT) followed by 1-hour incuba-tion at RT with primary rat monoclonal anti-MRP1 (MRPr1MONOSAN) orMRP4 (M4 I-80 MONOSAN) antibody at a1 20 dilution Afterwashing slideswere incubated for 30minat room temperature with biotinylated anti-rat secondaryantibody (1 200 Dako SpA Milan Italy) followed by HPR-streptavidin for 30min at room temperature The peroxidasereaction was developed with 3 31015840-diaminobenzidine (Dako)and sections were counterstained with hematoxylin Slidesincubated with secondary antibody alone provided negativecontrolsThe IHC experimental protocol was set up using theIGROV-1 cell line which expressesMRP1 andMRP4 proteinsas observed through Western blotting

Staining was recorded by a semiquantitative gradingsystem Samples were defined as positive when 10 of cellsdisplayed reactivity Slides were evaluated by two indepen-dent observers blinded to patient characteristics and out-come All cases with discrepant evaluations were discussedduring observation with a double-headed microscope and aconsensus was reached

23 StatisticalMethods andDataAnalysis Subsets of patientswere grouped based on similar clinical-pathological parame-ters (see Tables 1 2 3 4 and 5) Fisherrsquos test or 1205942 test wasused to analyze the distribution of MRP positive cases inrelation to clinical and pathological category variables Theeffects of MRPsrsquo expression on time to progression (TTP)were investigated first by univariate analysis through theinspection of Kaplan-Meyer curves and differences betweencurves were assessed for statistical significance using the log-rank test

A Cox univariate model was used to estimate the hazardratio (HR) for each prognostic variable considered Multi-variable analysis using a Cox regression model was used toevaluate the prognostic impact of MRPs expression in thecontext of concomitant effects of other known prognostic

factors Frontline therapy was used as a stratification factoraccounting for its possible nonproportional effect The 119875 val-ues of all statistical tests were 2 sided For all analyses differ-ences were considered significant at119875 lower than 005 Analy-ses were performed with the GraphPad Software version 303and R statistical language (URL httpwwwR-projectorg)

3 Results

31 Expression of MRP1 and MRP4 in Primary EpithelialOvarian Carcinoma To investigate the expression of ABCtransporters in ovarian cancer tissues tumor specimens wereanalyzed by IHC In tumor specimens the MRP1 and MRP4specific staining mainly displayed a cytoplasmic localizationconsistent with localization at subcellular membranes (Fig-ures 1 and 2) The cytoplasmic immunoreactivity frequentlydisplayed a granular aspect similar to what is observed in celllines using immunofluorescence (data not shown)Overall inspecimens the staining intensity was more intense for MRP1than for MRP4 a feature that may reflect tumor biology

Thirty percent of assessable tumors were MRP1 reactiveand 23 were MRP4 reactive An analysis of the associationbetweenMRP1 orMRP4 expression and known clinical prog-nostic factors indicated a statistically significant associationbetween tumor grade and MRP1 expression (1205942 = 847 119875 =0037 Table 2) No correlation with other clinicopathologicalcharacteristics was observed

MRP1 and MRP4 expression was concurrently assessablefor 101 cases AmongMRP1 negative tumors only 14 (10 outof 84) were MRP4 positive whereas among MRP1 positivecases 47 (13 out of 36) were MRP4 positive (1205942 = 105119875 = 00011) Then the fraction of tumors positive for bothtransporters was 14 (13 out of 101 cases Table 3)

32 Relationship between Prognostic Variables and MRP1 orMRP4 In an attempt to define the prognostic impact ofMRP1 and MRP4 on TTP we performed univariate analysesto seek for associations Since a low number (119899 = 9) oftumors with a G1 grade was available in the present casematerial analyses were carried out without including suchcases (Table 4) As expected the analyses indicated thatknown clinical prognostic factors (such as advanced stage III-IV versus I-II) histotype (serous versus others) and residualtumor after surgical debulking were associated with shorterTTP in high-grade EOC informative cases (Table 4) Usingthis approach we found that neither MRP1 nor MRP4 wassignificantly associated with TTP

We then appliedmultivariable Cox regressionmodel withMRP1 and MRP4 expression adjusting for all known clinicaland pathological prognostic factors In this model well-established clinical prognostic factors (stage and residualdisease) maintained their unfavourable prognostic impactMRP1 did not display any prognostic impact whereas thatof MRP4 was unfavourable (HR = 205 95 CI 101ndash411119875 = 0045)


Table 2 Patientrsquos clinical and pathological characteristics according to MRP1 and MRP4 expression as assessed by immunohistochemistry

Clinical parametersTotal(119899 = 127)

MRP1 expression MRP4 expression

Negative (119899 = 84) Positive (119899 = 36) Missing(119899 = 7) 119875

lowastNegative (119899 = 80) Positive (119899 = 24) Missing

(119899 = 23) 119875lowast

N∘ N∘ N∘ N∘ Age years 0245 0971le55 40 75 13 25 2 33 77 10 23 12gt55 44 66 23 34 5 47 77 14 23 11

Tumor histotype 0617 0686Serous 53 68 25 32 5 52 74 18 26 13Undifferentiated 9 82 2 18 1 7 87 1 13 4Clear cell 8 67 4 33 10 83 2 17Endometrioid 8 67 4 33 6 67 3 33 3Mucinous 5 100 1 3 100 3Others 1 50 1 50 2 100

Tumor stage (FIGO) 0178 0172I + II 30 79 8 21 1 30 83 6 17 3III 40 69 18 31 6 36 78 10 22 18IV 13 57 10 43 13 62 8 38 2Missing 1 1

Tumor grade 0037 08211 7 78 2 22 5 83 1 17 32 37 80 9 20 2 32 74 11 26 53 27 55 22 45 4 31 74 11 59 11Undifferentiated 9 82 2 18 1 7 87 1 13 4Missing 4 1 5

Amount of residualdisease 032 029

NED 33 75 11 25 3 31 82 7 18 9lt1 cm 12 67 6 33 1 10 62 6 38 3gt1 cm 27 60 18 40 1 26 70 11 30 9Missing 12 1 2 13 2

NED not evidence of disease lowast119875 values evaluated on MRP1 and MRP4 expression and available clinical and pathological parameters

4 Discussion

Preclinical evidence supports that the expression of MRP1and MRP4 is increased in ovarian carcinoma cells character-ized by resistance to platinum compounds [9] Furthermorewe have previously shown that lung cancer CD133+ cellswhich are spared by cisplatin treatment in xenografted lungcancer models are enriched in ABC transporters includingMRP1 and MRP4 [15] Thus the present study was designedto examine the expression of MRP1 and MRP4 on archivalmaterial from EOC patients with known clinical history IHCwas chosen as a method with the specific aim to set up proce-dures potentially useful for prospective clinical studies firstand then for routine analysis of tumor specimens Also weelected to use TMA because they provide a high-throughputtechnique for the molecular profiling of tissue specimensstrengthened by the availability of sequentially sliced samples

from the same master block to test the expression of therelevant macromolecules [16]

Given the function of drug transporters and their capa-bility to extrude from cells toxins drugs and physiologicalsubstrates [8] a clear definition of their prognostic role is notstraightforward to achieve The available evidence supportsthat the ABC transporters MRP1 and MRP4 were shown todisplay an unfavorable prognostic impact on neuroblastoma[17 18] Also in this tumor type a prognostic value for MRP1has been clearly documented by carrying out a prospectivestudy [18]

In the present retrospective study the prognostic impactwas evaluated in terms of progression-free survival whichby being an earlier end point than overall survival wasconsidered more appropriate when modelling the prognosticsignificance of drug transporters which are expected toinfluence treatment outcome and to control drug efficacy


Table 3 MRP1 versus MRP4 expression in EOC as assessed byimmunohistochemical staining

MRP1expression

MRP4 expression 1205942

(P-value)Negative80

Positive24

Not available23

Negative

84 63(86)lowast 10 (14) 11

Positive36 15 (54) 13 (47) 8 10536

Not available7 2 1 4 00011

lowastRaw percentages are reported and refer to the only case valuable for bothMRPs

Table 4 Univariate analysis of the prognostic impact of clinicalcovariates and MRPs on progression-free survival in high-gradeEOC

119875lowast HR (95 CI)

StageIII-IV versus I-II lt00001 778 385ndash157

HistotypeSerous versusothers 0011 19 116ndash312

Surgical debulkingSOD versus OD lt00001 34 209ndash552

Age at diagnosisgt55 versus le55 048 117 076ndash18

MRP1 expressionPositive versusnegative 086 096 06ndash153


lowast

119875 value determined using log-rank test HR hazard ratio CI confidenceinterval SOD suboptimal debulking (residual disease gt1 cm) OD optimaldebulking (residual disease not evident or lt1 cm)

Indeed overall survivalmay be dependent on amultiplicity ofvariables not necessarily on expression of drug transportersIn fact EOC patients resistant to first-line chemotherapy(around 30) as well as patients that experienced diseaserelapse after successful first-line chemotherapy (around 70of sensitive patients) [19] receive further chemotherapy reg-imen including different agents with a variable pattern ofrecognition by ABC transporters

Considering disease relapse as the clinical end pointof our analysis an unfavorable role for the expression ofMRP4 was also observed in this case material whereas thisbehaviour was not found for MRP1 Here we also found anassociation between MRP1 expression and tumor grade Thisobservation is at least in part in keeping with a paper report-ing expression ofMRP1 in aggressive ovarian carcinoma [20]In fact significantly increased MRP1 protein expression was

Table 5 Multivariable analysis of the prognostic impact of clinicalcovariates and MRPs on progression free survival in high-gradeEOC




Surgical debulkingSOD versus OD 0016 222 116ndash426




lowastP value determined using log rank test HR hazard ratio CI confidenceinterval SOD suboptimal debulking (residual disease gt1 cm) OD optimaldebulking (residual disease not evident or lt1 cm)

observed in high-grade tumors similar to the present studyHowever the case material used by Faggad and coauthorsis not representative of the standard clinical behaviour ofthis disease regarding survival rate and prognostic impactof clinical variables (eg stage) Here we did not find anassociation between disease stage and MRP1 and patientswith higher expression of MRP1 protein did not exhibitsignificantly decreased overall survival (data not shown)Although our data validate only in part the previous findingsthe discrepancies may be due to the different features of thetwo casematerials However the bottom line of these findingsis that less differentiated cells express the MRP1 protein Ofnote MRP1 levels have been shown to correlate with gradingin untreated hepatocellular carcinoma [21] The associationbetween MRP1 and grading suggests an aggressive nature oftheMRP1 expressing tumors Since less differentiated tumorsare expected to be endowed with the greatest proliferationpotential thereby being chemoresponsive the unfavourablerole of MRP1 may be difficult to assess Thus the prospectivecollection of a more homogeneous case material with respectto this pathologic parameter (ie grading) may be helpful indesigning the prognostic role of MRP1 in disease relapse

5 Conclusion

In the present study using a case material containing ovariancarcinoma specimens we found an association betweenMRP1 and grading and we observed that MRP4 displayed anunfavourable role in disease outcome However additionaleffort is required to better understand the precise mechanismby which MRP1 and MRP4 may influence tumor biologyand drug resistance in an attempt to rationally develop


(a) (b)

Figure 1MRP1 immunostaining in specimens of ovarian carcinoma Immunostaining decoratesmost of tumor cells of an ovarian carcinomaMRP1 displayed a cytoplasmic localization consistent with cellular localization at subcellular membranes Cytoplasmic immunoreactivityfrequently displayed a granular aspect

(a) (b)

(c)

Figure 2 MRP4 immunostaining in specimens of ovarian carcinoma MRP4 displayed a cytoplasmic localization consistent with cellularlocalization at subcellular membranes Cytoplasmic immunoreactivity frequently displayed a granular aspect


therapeutic options including combination therapies basedon the use of modulators of ABC transporters [22] or drugsthat are not substrates for such efflux pumps [8]

Acknowledgment

This work was partially supported by the AssociazioneItaliana per la Ricerca sul Cancro Milan

References

[1] V Guarneri F Piacentini E Barbieri and P F Conte ldquoAchieve-ments and unmet needs in the management of advancedovarian cancerrdquo Gynecologic Oncology vol 117 no 2 pp 152ndash158 2010

[2] S Vaughan J I Coward R C Bast Jr et al ldquoRethinkingovarian cancer recommendations for improving outcomesrdquoNature Reviews Cancer vol 11 no 10 pp 719ndash725 2011

[3] R C Bast Jr B Hennessy and G B Mills ldquoThe biologyof ovarian cancer new opportunities for translationrdquo NatureReviews Cancer vol 9 no 6 pp 415ndash428 2009

[4] F Muggia ldquoPlatinum compounds 30 years after the intro-duction of cisplatin implications for the treatment of ovariancancerrdquo Gynecologic Oncology vol 112 no 1 pp 275ndash281 2009

[5] J-P Gillet T Efferth and J Remacle ldquoChemotherapy-inducedresistance by ATP-binding cassette transporter genesrdquo Biochim-ica et Biophysica Acta vol 1775 no 2 pp 237ndash262 2007

[6] MMGottesman T Fojo and S E Bates ldquoMultidrug resistancein cancer role of ATP-dependent transportersrdquoNature ReviewsCancer vol 2 no 1 pp 48ndash58 2002

[7] P Borst R Evers M Kool and J Wijnholds ldquoA family ofdrug transporters the multidrug resistance-associated pro-teinsrdquo Journal of the National Cancer Institute vol 92 no 16pp 1295ndash1302 2000

[8] J I Fletcher M Haber M J Henderson and M D NorrisldquoABC transporters in cancermore than just drug efflux pumpsrdquoNature Reviews Cancer vol 10 no 2 pp 147ndash156 2010

[9] G L Beretta V Benedetti G Cossa et al ldquoIncreased levelsand defective glycosylation of MRPs in ovarian carcinoma cellsresistant to oxaliplatinrdquo Biochemical Pharmacology vol 79 no8 pp 1108ndash1117 2010

[10] G D Leonard T Fojo and S E Bates ldquoThe role of ABCtransporters in clinical practicerdquo Oncologist vol 8 no 5 pp411ndash424 2003

[11] Y Sassi Y Hara A-M Lompre and J-S Hulot ldquoMulti-drugresistance protein 4 (MRP4ABCC4) and cyclic nucleotidessignaling pathwaysrdquo Cell Cycle vol 8 no 7 pp 962ndash963 2009

[12] D Aldovini F Demichelis C Doglioni et al ldquoM-CAM expres-sion as marker of poor prognosis in epithelial ovarian cancerrdquoInternational Journal of Cancer vol 119 no 8 pp 1920ndash19262006

[13] M L Berman ldquoFuture directions in the surgical managementof ovarian cancerrdquoGynecologic Oncology vol 90 no 2 pp S33ndashS39 2003

[14] A B Miller B Hoogstraten M Staquet and A WinklerldquoReporting results of cancer treatmentrdquo Cancer vol 47 no 1pp 207ndash214 1981

[15] G Bertolini L Roz P Perego et al ldquoHighly tumorigenic lungcancer CD133+ cells display stem-like features and are sparedby cisplatin treatmentrdquo Proceedings of the National Academy of

Sciences of the United States of America vol 106 no 38 pp16281ndash16286 2009

[16] A Aguilar-Mahecha S Hassan C Ferrario and M BasikldquoMicroarrays as validation strategies in clinical samples tissueand protein microarraysrdquo OMICS vol 10 no 3 pp 311ndash3262006

[17] MDNorris J Smith K Tanabe et al ldquoExpression ofmultidrugtransporter MRP4ABCC4 is a marker of poor prognosis inneuroblastoma and confers resistance to irinotecan in vitrordquoMolecular Cancer Therapeutics vol 4 no 4 pp 547ndash553 2005

[18] M Haber J Smith S B Bordow et al ldquoAssociation of high-level MRP1 expression with poor clinical outcome in a largeprospective study of primary neuroblastomardquo Journal of ClinicalOncology vol 24 no 10 pp 1546ndash1553 2006

[19] P Harter F Hilpert S Mahner F Heitz J Pfisterer and AD Bois ldquoSystemic therapy in recurrent ovarian cancer currenttreatment options and new drugsrdquo Expert Review of AnticancerTherapy vol 10 no 1 pp 81ndash88 2010

[20] A Faggad S Darb-Esfahani R Wirtz et al ldquoExpression ofmultidrug resistance-associated protein 1 in invasive ovariancarcinoma implication for prognosisrdquo Histopathology vol 54no 6 pp 657ndash666 2009

[21] S Vander BorghtM Komuta L Libbrecht et al ldquoExpression ofmultidrug resistance-associated protein 1 in hepatocellular car-cinoma is associated with a more aggressive tumour phenotypeandmay reflect a progenitor cell originrdquo Liver International vol28 no 10 pp 1370ndash1380 2008

[22] L Gatti G L Beretta G Cossa F Zunino and P PeregoldquoABC transporters as potential targets for modulation of drugresistancerdquo Mini-Reviews in Medicinal Chemistry vol 9 no 9pp 1102ndash1112 2009

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Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom


between less characterized transporters and resistance Alsothe recent knowledge achieved by integrating biochemicaland molecular approaches indicates that the investigation ofexpression of ABC transporters in large collections of tumorspecimens should be pursued in an attempt to elucidate therole of such factors in tumor biology In fact ABC transporterexpression has been linked to tumor aggressiveness in differ-ent tumor types [10]

In a cellular study cells resistant to platinum compoundswere found to display increased levels ofMRP1 andMRP4 [9]In addition the available evidence supports that the effectsof transporters of the MRP subfamily on cell survival maybe indirect not necessarily implicating only efflux of thecytotoxic drugs [8] In this regardMRP4has been involved insignalling pathways which activate prosurvival mechanismsby virtue of its capability to pump cyclic nucleotides outsidethe cells [11]

Based on this background to document the role of MRP1and MRP4 in the clinical setting in ovarian carcinoma weinvestigated the role of MRPs as prognostic markers forthis tumor using archival material from tumor specimenscollected at surgery from epithelial ovarian carcinoma (EOC)patients

2 Material and Methods

21 Patients Tissue Specimens and Pathologic Data Thisstudy was performed on a tissue microarray (TMA) con-taining a series of formalin-fixed paraffin-embedded tissuescollected at surgery before any chemotherapeutic treatmentfrom 127 consecutive EOC patients who underwent surgicalresection at the S Chiara Hospital in Trento between 1992and 1999 [12] Histological sections and paraffin blockswere obtained from the Hospital Department of PathologyClinical data and follow-up information were available fromtheUnit of GynecologicOncology as specified in institutionalfollow-up procedures The use of tissue blocks and patientrecords was approved by the Institutional Review Board Allpatients gave informed consent for the therapy and for the useof specimens for research

Table 1 summarizes the patientsrsquo clinicopathological char-acteristics The average age of the patients was 58 yearsTumor staging was in accordance with International Feder-ation of Gynecology and Obstetrics (FIGO) criteria 31 ofpatients had stage I-II and 68 of patients had stage III-IVdisease Most tumors were of serous histotype (65) Forty-five percent of the cases were low grade (well moderatelydifferentiated) and 52 were high-grade tumors (poorlydifferentiated undifferentiated) Primary treatment for allpatients was surgery and based on the extent of residualdisease after primary surgery the patient population wasdivided into three groups no evident disease (NED)minimalresidual disease (mRD residual tumor smaller than 1 cm)and gross residual disease (GRD residual tumor equalgraterthan 1 cm) [13] Residual disease after surgical debulking wasdefined for 112 patients and was optimal (not evident diseaseor below 1 cm) in 52 of cases and equalgreater than 1 cm

Table 1 Patientrsquos clinical characteristics

Characteristics Patients (119899 = 127)N∘

Age years(mean median 58 range 23ndash84)

Tumor histotypeSerous 83 65Undifferentiated 12 10Clear cell 12 10Endometrioid 12 10Mucinous 6 4Others + mixed 2 1

Tumor stage (FIGO)I 24 19II 15 12III 64 50IV 23 18Not available 1 1

Tumor grade1 well differentiated 9 72 moderately differentiated 48 383 poorly differentiated 53 42Undifferentiated 12 10Not available 5 3

Amount of residual diseaseNED 47 37lt1 cm 19 15gt1 cm 46 36Not available 15 12

Frontline treatmentNone 8 6Platinum without taxanes 81 64Platinumpaclitaxel 35 28Other or not available 3 2

Response to frontline treatmentlowast

Complete 57 46Partial 21 18No response 21 18Not available 21 18

Abbreviations FIGO International Federation of Gynecological andObstet-rics staging system NED not evident disease lowastUntreated patients are notincluded

in 36 of cases After surgery 119 patients received front-line treatment with standard platinum-based therapeuticschedules (platinum without taxanes platinum and pacli-taxel) according to the time of accrualyear of diagnosis twopatients were treated with other chemotherapeutic agentseight patients (all stage I) received no chemotherapy andone patient had information missing Response to therapywas available for 99 patients Response was based on data










3 Results












(119899 = 23) 119875lowast








4 Discussion







MRP1expression


(P-value)Negative80

Positive24

Not available23

Negative

84 63(86)lowast 10 (14) 11

Positive36 15 (54) 13 (47) 8 10536











lowast














5 Conclusion



(a) (b)


(a) (b)

(c)




Acknowledgment


References





























of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of

























3 Results












(119899 = 23) 119875lowast








4 Discussion







MRP1expression


(P-value)Negative80

Positive24

Not available23

Negative

84 63(86)lowast 10 (14) 11

Positive36 15 (54) 13 (47) 8 10536











lowast














5 Conclusion



(a) (b)


(a) (b)

(c)




Acknowledgment


References





























of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of






















(119899 = 23) 119875lowast








4 Discussion







MRP1expression


(P-value)Negative80

Positive24

Not available23

Negative

84 63(86)lowast 10 (14) 11

Positive36 15 (54) 13 (47) 8 10536











lowast














5 Conclusion



(a) (b)


(a) (b)

(c)




Acknowledgment


References





























of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of


















MRP1expression


(P-value)Negative80

Positive24

Not available23

Negative

84 63(86)lowast 10 (14) 11

Positive36 15 (54) 13 (47) 8 10536











lowast














5 Conclusion



(a) (b)


(a) (b)

(c)




Acknowledgment


References





























of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of

















(a) (b)


(a) (b)

(c)




Acknowledgment


References





























of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of


















Acknowledgment


References





























of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of





















of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















Documents

Clinical Study Clinicopathological Impact of ABCC1/MRP1 and …downloads.hindawi.com/journals/bmri/2013/143202.pdf · 2019-07-31 · MRP and MRP expression adjusting for all known