|Year : 2014 | Volume
| Issue : 4 | Page : 1052-1056
Prognostic significance of metastasis associated in colon cancer 1 (MACC1) expression in patients with gallbladder cancer
Lijian Chen1, Jianjun Wang2, Lixia Fu1, Bingtai Zhang3, Huanhu Zhang4, Bin Ye1
1 Department of Gastroenterology, Lishui City Central Hospital and the Fifth Affiliated Hospital of Wenzhou Medical University, Lishui, P.R. China
2 Department of General Surgery, Guangfu Hospital of Jinhua, Jinhua, P.R. China
3 Department of General Surgery, Shanxi Medical University Second Hospital, Taiyuan, P.R. China
4 Department of Gastroenterology, Shanxi Medical University Second Hospital, Taiyuan, P.R. China
|Date of Web Publication||9-Jan-2015|
Department of Gastroenterology, Lishui City Central Hospital and the Fifth Affiliated Hospital of Wenzhou Medical University, 289 Kuocang Road, Lishui, Zhejiang - 323000
Source of Support: None, Conflict of Interest: None
Background: The clinical significance of metastasis associated in colon cancer 1 (MACC1), in human gallbladder cancer, is not yet established. This study was performed to assess the expression of MACC1 in benign and malignant gallbladder lesions, and to assess its clinicopathological significance.
Materials and Methods: Tissue samples from resected gallbladder cancer (n = 70) and cholelithiasis (n = 70) were evaluated for MACC1 expression by immunohistochemical staining. Their expression was correlated with different clinicopathological parameters.
Results: Cytoplasmic MACC1 expression was significantly higher (58.6%) in gallbladder cancer than in chronic cholecystitis (27.1%, P < 0.001). High MACC1 levels were associated with lymph node metastasis (P < 0.05), tumor node metastasis (TNM) stage (P < 0.01), and perineural invasion (P < 0.01), but not with sex, age, history of gallstones or histological grade (P > 0.05). The univariate Kaplan-Meier analysis showed that a positive MACC1 expression was associated with decreased overall survival (P < 0.001). The multivariate Cox regression analysis showed that MACC1 expression and the histopathological subtypes were independent risk factors for disease-free survival.
Conclusion: The expression of MACC1 might be closely related to carcinogenesis, clinical biological behaviors, and prognosis of gallbladder adenocarcinoma.
材料与方法：通过对切除胆囊癌组织标本（n = 70）和胆石症标本（N = 70）进行免疫组化染色，评价MACC1基因的表达。他们的表达与不同的临床病理参数相关。
Keywords: Gallbladder cancer, immunohistochemistry, metastasis associated in colon cancer 1
|How to cite this article:|
Chen L, Wang J, Fu L, Zhang B, Zhang H, Ye B. Prognostic significance of metastasis associated in colon cancer 1 (MACC1) expression in patients with gallbladder cancer. J Can Res Ther 2014;10:1052-6
|How to cite this URL:|
Chen L, Wang J, Fu L, Zhang B, Zhang H, Ye B. Prognostic significance of metastasis associated in colon cancer 1 (MACC1) expression in patients with gallbladder cancer. J Can Res Ther [serial online] 2014 [cited 2019 Jun 20];10:1052-6. Available from: http://www.cancerjournal.net/text.asp?2014/10/4/1052/137977
| > Introduction|| |
Gallbladder cancer (GBC) is the most common biliary tract malignancy and the seventh most common gastrointestinal cancer. ,, According to data from the Surveillance Epidemiology and End Results (SEER) program, the incidence of GBC is estimated at 2.5 per 100,000 persons. Despite the relatively lower incidence rate, GBC-associated mortality is higher than that of other cancers.  The median survival of GBC patients is less than one year; this is due to the early spread of tumors via the lymphatic, perineural, and hematogenous routes, as well as direct invasion into the liver. , Therefore, the development of novel and effective therapeutic strategies for GBC, as well as an increased understanding of the biomarkers and their effects on the therapeutic responses may improve patient prognosis.
Metastasis associated in colon cancer-1 (MACC1), a key regulator of the hepatocyte growth factor (HGF)/metabolic (Met) signaling pathway, has a wide range of biological functions, including angiogenesis, growth, differentiation, cellular motility, and invasion.  Consistent with these critical roles, MACC1 has been characterized as an oncogene in hepatocellular carcinoma (HCC), lung adenocarcinoma, gastric carcinoma and colorectal cancer. ,,, The clinicopathological analysis showed that high MACC1 expression correlated with poor prognosis in a variety of solid cancers, and increased MACC1 expression was determined to be an independent prognostic biomarker.  In addition, MACC1 was also demonstrated to be of predictive value for therapy response.  However, the significance of MACC1 expression in the prognosis of GBC has not been fully evaluated.
Using immunohistochemistry, here we investigated MACC1 expression levels in benign and malignant lesions of the gallbladder and studied the clinicopathological significance of its expression in the prognosis of GBC.
| > Materials and methods|| |
Patients and clinicopathological data
The study was approved by the Ethics Committee of our hospital, and all the patients provided informed consent. Samples from 70 patients with pathologically confirmed GBC, after surgery, were collected from 2008 to 2012, at the Department of General Surgery in our hospital. None of the patients received either chemotherapy or radiotherapy before surgery. The patients comprised of 21 males and 49 females, with an average age of 70.6 years. According to the American Joint Committee on Cancer (AJCC) staging system, two (2.9%), nine (12.9%), 12 (17.1%), 36 (51.4%), and 11 (15.7%) patients were diagnosed with stage 0, I, II, III, and IV disease, respectively. Additionally, 26 cases were diagnosed with lymph node metastases. In addition, 70 patients with cholelithiasis, who underwent simple cholecystectomy, were included as the controls. All diagnoses of GBC, cholelithiasis, and lymph node metastasis were confirmed by histopathological examination, and all tissue samples were fixed in 4% formalin immediately after removal and embedded in paraffin for immunohistochemical staining.
Immunohistochemical analysis and evaluation of MACC1 expression
Immunohistochemical staining was performed using the standard immunoperoxidase staining procedure, and MACC1 expression in the specimens was evaluated according to the methods described by Li et al.  The intensity of staining in the tumor cells was scored independently by two investigators who were blinded to the clinical and pathological parameters. When the immunohistochemical (IHC) readings were different, the slides were re-reviewed and a consensus score was applied. The sections were semi-quantitatively scored according to the extent of immunoreactivity, as follows: 0, 0% immunoreactive cells; 1, <5% immunoreactive cells; 2, 5 - 50% immunoreactive cells; and 3, >50% immunoreactive cells. Additionally, the staining intensity was scored semi-quantitatively as follows: 0, negative; 1, weak; 2, intermediate; and 3, strong. The final immunoreaction score was defined as the sum of both parameters (extension and intensity) and the samples were classified as negative (0), weakly stained (1 - 2), moderately stained (3), and strongly stained (4 - 6). For statistical purposes, only the 'moderate' and 'strong' final immunoreaction scores were considered positive and the other final scores were considered negative.
The data were analyzed using SPSS 19.0 (Statistical Package for the Social Sciences version 19.0). The inter-relationship of MACC1 expression with the histology or clinical factors was analyzed using the χ2 independence or Fisher's exact test. The Kaplan-Meier test was used for univariate survival analysis. The Cox proportional hazard model was used for multivariate analysis and for determining the 95% confidence interval. P < 0.05 was considered statistically significant.
| > Result|| |
MACC1 expression in benign and malignant lesions of the gallbladder
To determine the potential role of MACC1 in GBC progression, we evaluated MACC1 expression in the GBC and cholelithiasis tissues by IHC [Figure 1]a-e. MACC1 was mainly located in the cytoplasm. Approximately 58.6% (41/70) of the GBC cases had positive MACC1 staining in the tumor cells. In contrast, only 27.1% (21/70) of the cases had positive staining in the cholelithiasis tissues [Figure 1], P < 0.001].
|Figure 1: MACC1 is overexpressed in the GBC tumors and is reversely associated with the prognosis of cancer patients. MACC1 was predominantly localized in the cell cytoplasm (black arrow, positive staining; scale bar, 100 um). (a) Negative staining in normal glandular epithelium. (b) Weak staining in the well-differentiated adenocarcinoma. (c) Strong staining in the poorly differentiated adenocarcinoma. (d) Strong staining in lymph metastasis. (e) The immunohistochemistry staining scores of MACC1 expression in the cholelithiasis and GBC samples. (f) The Kaplan-Meier analysis for overall survival of GBC patients with a positive or negative MACC1 expression score|
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The association of MACC1 expression with the clinicopathological characteristics of gallbladder adenocarcinoma
As shown in [Table 1], MACC1 overexpression was found to be significantly correlated with lymph node metastasis (P < 0.05), the TNM stage (P < 0.01), and the perineural invasion (P < 0.001), indicating the potential role of MACC1 expression in promoting aggressive phenotypes in GBC. However, MACC1 expression exhibited no significant association with the histological grade or other clinicopathological characteristics, such as, gender, age, or history of gallstones (P > 0.05).
|Table 1: Association of MACC1 expression with the clinicopathological characteristics of GBC |
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Correlation between MACC1 expression and survival in patients with gallbladder cancer
Among the 70 GBC patients, the survival information of 68 patients was obtained through phone calls. Twenty-seven patients survived for over one year and 41 patients survived for less than one year, with an average survival time of 11.8 months. The patients who survived for less than one year were found to have significantly higher MACC1 expression than patients who survived for over one year [Table 2]. The Kaplan-Meier survival analysis revealed that the histological grade (P < 0.001), TNM stage (P < 0.01), presence of lymph node metastasis (P < 0.01), and perineural invasion (P < 0.01) were significantly associated with the average survival time. The average survival time for MACC1-negative patients was significantly higher than that for patients with positive MACC1 expression (P < 0.001) [Table 3], [Figure 1]f. To obtain a more precise estimate about the prognosis, the Cox proportional hazard regression model was applied. The results confirmed that the MACC1 expression as well as the histopathological subtypes was negatively correlated with the postoperative survival, suggesting that high MACC1 expression is a risk factor [Table 4].
|Table 2: Correlation between patient survival time and the expression of MACC1 |
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|Table 3: Univariate analyses showing the overall survival rate for patients with GBC |
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|Table 4: Multivariate analysis showing the overall survival rate for patients with GBC |
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| > Discussion|| |
Gallbladder cancer involves a highly invasive, rapidly proliferating tumor. Unfortunately, the most aggressive conventional treatments for this tumor are still associated with poor survival. , Therefore, it is necessary to identify the prognostic biomarkers that are independently correlated with tumor aggressiveness. This study documents MACC1 immunostaining in gallbladder carcinomas for the first time, and shows that high cytoplasmic MACC1 expression is found in approximately 58.6% of the cases.
Metastasis associated in colon cancer-1 (MACC1), which is located on chromosome 7, has been originally identified through genome-wide expression analyses, when comparing primary and metastatic colon cancers.  MACC1 comprises 852 amino acids and contains multiple functional domains, including an Src-homology 3 (SH3)-domain together with a proline-rich motif (PXXP), enabling MACC1 for protein-specific interactions. , MACC1 was first identified as a colon cancer oncogene that promoted metastasis and proliferation, and was associated with peritoneal dissemination and a higher stage of TNM classification in colorectal carcinomas.  Recent studies have also linked MACC1 upregulation to cancer development and progression in other solid tumors. In hepatocellular cancer, MACC1 was validated as a prognostic biomarker for tumor progression and survival, including in the early stage and in alpha-fetoprotein (AFP)-normal patients, and also as a predictive biomarker for therapy response.  In gastric cancer, MACC1 contributed to a poor prognosis by promoting tumor cell proliferation and invasion as well as epithelial-mesenchymal transition (EMT).  On the basis of these findings, it is implicated that MACC1 plays an important role in the carcinogenesis processes.  In this study, our results showed that 58.6% (41/70) of GBC tumors expressed MACC1 compared to only 27.1% (21/70) of the paired cholelithiasis samples, which is consistent with the results of Xie's  study on hepatocellular carcinoma.
No reports suggest that MACC1 may be a useful prognostic and survival indicator for GBC. To further support the role of MACC1 in GBC, we analyzed the correlation between MACC1 expression and the clinicopathological features of 70 GBC patients and its prognosis. Our study indicated that positive MACC1 expression was significantly correlated with the presence of lymph node metastasis, perineural invasion, and the TNM stage. Kaplan-Meier univariate survival analysis showed that high MACC1 expression is negatively correlated with the overall survival of patients with GBC. More importantly, the Cox multivariate analysis showed that MACC1 expression was an independent factor in predicting the overall survival time for GBC patients. These findings indicate the potential role of MACC1 in promoting the aggressive phenotypes of GBC, and the possible utility of MACC1 expression levels as prognostic biomarkers of GBC.
In conclusion, our data, for the first time, suggest that MACC1 overexpression is associated with advanced tumor progression and poor clinical outcome for GBC patients. MACC1 might be a novel prognostic marker of GBC.
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[Table 1], [Table 2], [Table 3], [Table 4]