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ORIGINAL ARTICLE
Year : 2018  |  Volume : 14  |  Issue : 4  |  Page : 881-886

ATP7B rs9535826 is associated with gastrointestinal toxicity of platinum-based chemotherapy in nonsmall cell lung cancer patients


1 Department of Pharmacy; Department of Clinical Pharmacology, Xiangya Hospital, Central South University; Institute of Clinical Pharmacology, Central South University, Changsha, PR China
2 Department of Clinical Pharmacology, Xiangya Hospital, Central South University; Institute of Clinical Pharmacology, Central South University, Changsha, PR China

Date of Web Publication27-Jun-2018

Correspondence Address:
Xiang-Ping Li
87 Xiangya Road, Changsha, Hunan Province
PR China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrt.JCRT_890_17

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 > Abstract 


Aims: Platinum-based chemotherapy is considered as the first-line treatment for nonsmall cell lung cancer (NSCLC) patients. However, platinum resistance and toxicity are major obstacles to its clinical applications. The two P-type ATPases ATP7A and ATP7B have been identified to play an essential role in the transport of platinum. Their genetic polymorphisms may affect the treatment outcome and toxicity of platinum. In this study, we aimed to investigate the association of ATP7A and ATP7B genetic polymorphisms with clinical outcome and toxicity of platinum-based chemotherapy in NSCLC patients.
Subjects and Methods: Four hundred and twenty-seven NSCLC patients were enrolled. All patients have accepted platinum-based chemotherapy for at least two cycles. ATP7A (rs2227291 and rs6622665) and ATP7B (rs1061472 and rs9535826) polymorphisms were genotyped by allele-specific matrix-assisted laser desorption ionization-time-of-flight mass spectrometry. Chemotherapeutic response, overall survival time, and hematological and gastrointestinal toxicity were recorded and their associations with genetic factors were evaluated.
Results: ATP7A rs2227291 and rs6622665 deviated from Hardy–Weinberg equilibrium. Therefore, the two single-nucleotide polymorphisms were not taken into consideration. For ATP7B polymorphism, ATP7B rs9535826 was associated with gastrointestinal toxicity, and the GG genotype showed lower gastrointestinal toxicity (odds ratio = 0.30; 95% confidence interval = 0.10–0.90; P = 0.031).
Conclusion: The genotypes of ATP7B gene may be novel and significant biomarkers for predicting the gastrointestinal toxicity of platinum-based chemotherapy in NSCLC patients.

Keywords: ATP7A, ATP7B, clinical outcome, genetic polymorphism, nonsmall cell lung cancer, platinum-based chemotherapy


How to cite this article:
Li YQ, Zhang XY, Chen J, Yin JY, Li XP. ATP7B rs9535826 is associated with gastrointestinal toxicity of platinum-based chemotherapy in nonsmall cell lung cancer patients. J Can Res Ther 2018;14:881-6

How to cite this URL:
Li YQ, Zhang XY, Chen J, Yin JY, Li XP. ATP7B rs9535826 is associated with gastrointestinal toxicity of platinum-based chemotherapy in nonsmall cell lung cancer patients. J Can Res Ther [serial online] 2018 [cited 2019 Nov 23];14:881-6. Available from: http://www.cancerjournal.net/text.asp?2018/14/4/881/235102




 > Introduction Top


Lung cancer has been one of the leading causes for cancer-related death in the world.[1] In China, its morbidity and mortality rate was highest among all cancers.[2] In general, up to 80% newly lung cancer patients are histologically diagnosed as nonsmall cell lung cancer (NSCLC). Platinum-based chemotherapy was considered as the standard first-line therapy for NSCLC patients.[3] Unfortunately, the drug efficacy and toxicity remarkably varied among patients, which has become major obstacles to successful treatment.[4] If some biomarkers or forecasting model could be explored to predict individual response or toxicity of platinum-based chemotherapy, it would be very helpful to improve the clinical efficacy, promote personalized therapy, and alleviate the suffering of patients.

ATP7A and ATP7B, the members of heavy metal transporting P-type ATPase, are known as copper transporters to transfer copper across the cellular membranes. Recently, an interesting possibility has emerged that ATP7A and ATP7B were also involved in the efflux of platinum.[5] The expressions of ATP7A and ATP7B were often increased in parallel with platinum resistance.[6],[7],[8],[9] Moreover, clinical studies also revealed that high ATP7A and ATP7B expression levels were associated with poor prognosis in the patients receiving platinum-based chemotherapy.[10],[11]

Pharmacogenomics studies indicated that single-nucleotide polymorphisms (SNPs) were important factors accounting for interindividual differences in drug efficacy and toxicity.[12] The SNPs of genes involved in apoptosis regulation, DNA damage repair, and drug transporter were significantly related to the drug toxicity and the clinical outcomes of platinum-based chemotherapy in NSCLC patients.[13],[14],[15],[16] Previously, it has been reported that ATP7A rs2227291 and ATP7B rs1061472, rs9535826 polymorphisms may be related to the response to chemotherapy.[17],[18],[19] However, no ATP7A or ATP7B genetic polymorphisms have been identified to be associated with the efficacy and toxicity of platinum-based chemotherapy in NSCLC patients.[20] Thus, in this study, ATP7A rs2227291, rs6622665 and ATP7B rs1061472, rs9535826 polymorphisms were genotyped to explore their associations with the efficacy and toxicity in 427 Chinese NSCLC patients receiving platinum-based chemotherapy.


 > Subjects and Methods Top


Patients

Four hundred and twenty-seven inpatients between 2010 and 2013 were enrolled in this study. The inclusion criteria in our study were as follows: (1) all patients were newly diagnosed as NSCLC by histological or cytological method, (2) all patients were primary lung cancers, (3) all patients received platinum-based chemotherapy for at least two cycles, including cisplatin/carboplatin + gemcitabine, cisplatin/carboplatin + navelbine, cisplatin/carboplatin + docetaxel, cisplatin/carboplatin + paclitaxel, and cisplatin/carboplatin + pemetrexed,[21] (4) they were up to the standard of Eastern Cooperative Oncology Group 0–2, and (5) organ function before chemotherapeutic treatment: liver function test (aspartate transaminase ≤1.5 × normal upper limit and alanine transaminase ≤1.5 × normal upper limit); blood test (leukocyte count ≥1.5 × 109/L, neutrophil count ≥1.5 × 109/L, and platelet count ≥100 × 109/L); kidney test (serum creatinine ≤1.5 × normal upper limit and creatinine clearance ≥60 mL/min); without recent (<3 months before the date of treatment) myocardial infarction, active congestive heart failure, or cardiac arrhythmia requiring medical treatment; without uncontrolled infectious diseases; and without other serious medical or psychological factors that might prevent adherence to the treatment schedule. The exclusion criteria were as follows: (1) pregnant or lactation period patients, (2) patients with brain metastases, (3) patients with active infection, and (4) prior surgical or radiation treatment for NSCLC. Clinical data of each patient were collected, such as sex, age, smoking status, lung cancer classification, lung cancer stage, chemotherapy regimens, chemotherapeutic response, and gastrointestinal and hematology side reactions. This study was approved by Xiangya Medical Ethics Committee, Central South University (No. CTXY-110008-2). We applied this study for clinical admission in the Chinese Clinical Trial Register (registration number: ChiCTR RO1200287). All patients wrote informed consent.

Clinical evaluation in non-small cell lung cancer patients

After the first two cycles of treatment, the response of patients to chemotherapy was evaluated according to the Response Evaluation Criteria in Solid Tumor Group guidelines.[22] In the current study, the patients with complete response (CR) or partial response (PR) were considered as drug sensitive, whereas patients with stable disease (SD) or progressive disease (PD) were defined as drug resistance. For survival analysis, only 302 patients were followed up because contact information of some patients was lacked. Moreover, the follow-up for the patients was updated in January 1, 2017. The overall survival (OS) time was calculated as the period between the date of pathological diagnosis and the date of death or last follow-up. Chemotherapy toxicity was mainly assessed twice a week for two to six cycles according to National Cancer Institute Common Terminology Criteria for Adverse Events version 3.0 (http://ctep.cancer.gov). The toxicities mainly focused in our study were gastrointestinal toxicity such as nausea and vomit and hematological toxicity including reduction of hemoglobin, leukopenia, neutropenia, and thrombocytopenia. Severe toxicity was defined as any Grade 3 or 4 toxicity, including Grade 3 or 4 hematologic toxicity and Grade 3 or 4 gastrointestinal toxicity. Hematology toxicity consisted of Grade 3 or 4 leukocytopenia, neutropenia, anemia, and thrombocytopenia while gastrointestinal toxicity referred to Grade 3 or 4 nausea and vomit.

Single-nucleotide polymorphism selecting, DNA extraction, and genotyping

For ATP7A gene, two tag SNPs (rs2227291, rs6622665) located in 5 kb upstream and downstream regions were selected to investigate in this study. For ATP7B gene, two SNPs (rs1061472, rs9535826) located in 5 kb upstream and downstream regions were selected to investigate in this study. These loci were selected based on the data of HapMap project Phase II database of Chinese population. Tagger program of Haploview [23] (version 4.2 Cambridge, MA, USA) was performed to select these SNPs by the pairwise tagging with default settings (pairwise r2 threshold 0.8). The DNA for genotyping was separated from 5 mL venous blood with the DNeasy Blood and Tissue Kit (QIAGEN, Shanghai, China) or Genomic DNA Purification Kit (Promega, Madison, WI, USA) following the standard protocols. SNPs were genotyped by allele-specific matrix-assisted laser desorption ionization-time-of-flight mass spectrometry [24] (Sequenom, San Diego, California, USA) and primers were designed by AssayDesigner 3.1 software (Sequenom, San Diego, California, USA). Polymorphisms calls were analyzed with Sequenom's Spectro Typer 4.0 software (Sequenom, San Diego, California, USA).[25]

Statistical analysis

The associations of different genotypes with chemotherapy response and toxicities were evaluated with Fisher's exact Chi-square test. Age, sex, smoking status, histological types, tumor, node, and metastasis stage, and chemotherapeutic regimen were considered as covariates, and unconditional logistic regression was conducted to calculate the adjusted odds ratio (OR) with 95% confidence intervals (95% CI). The Kaplan–Meier method was applied for plotting the survival curves and calculating OS time, and the log-rank test was performed to compute P value. The prognostic value of potential factors for survival time was estimated by multivariate analysis with the Cox proportional hazards models. The P value was two-sided and P < 0.05 was considered statistically significant. All association analyses were conducted by three models including additive, dominant, and recessive. The additive model represented the additive effects of SNPs. If D is a minor allele and d is the major allele, the additive model means DD versus Dd versus dd. The dominant model means (DD, Dd) versus dd, and the recessive model means DD versus (Dd, dd). All statistical analyses were performed by PLINK version 1.07 (Cambridge, MA, USA) and SPSS 13.0 (SPSS Inc., Chicago, Illinois, USA).


 > Results Top


The clinical characteristics of non-small cell lung cancer patients and single-nucleotide polymorphism frequencies

The clinical characteristics of the 427 NSCLC patients were summarized [Table 1]. Three hundred and twenty-eight males (76.8%) and 99 females (23.2%) were enrolled in the study. The median age at diagnosis for NSCLC was 55 years (ranged 22–75 years). Most patients were in the advanced stages of cancer: 417 patients (97.7%) were classified as Stage III–IV. All patients received platinum-based chemotherapy for at least two cycles. Among these, 82.7% of patients were treated with chemotherapy regimens based on cisplatinum while the others (17.3%) received carboplatin-based chemotherapy regimens. Prior clinical studies have revealed equal efficacy for the two platinum compounds.[26],[27] In addition, there was no significant difference in chemotherapeutic response, gastrointestinal toxicity, and hematologic toxicity between the two drugs in this study (P = 0.747, P = 0.875, and P = 0.653, respectively).
Table 1: Basic clinical characteristics of nonsmall cell lung cancer patients

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As shown in [Table 2], the minor allele frequencies of four SNPs (ATP7A rs2227291, ATP7A rs6622665, ATP7B rs1061472, and ATP7B rs9535826) were 0.28, 0.04, 0.38, and 0.47, respectively. The call rates of the SNPs were ranged from 96.02% to 97.89%. ATP7A rs2227291 and rs6622665 deviated from Hardy–Weinberg equilibrium; thus, the two SNPs were not taken into consideration.
Table 2: Result of genotype and Hardy–Weinberg equilibrium

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Association between the polymorphisms and treatment outcome in non-small cell lung cancer patients

Of the 427 patients, 212 (49.65%) were considered as platinum responders (CR + PR), and 215 (50.35%) were detected to be platinum nonresponders (SD + PD). No statistically significant difference was found between the SNPs and chemotherapeutic response [Table 3].
Table 3: Association of ATP7B polymorphisms with platinum-based chemotherapeutic responses in nonsmall cell lung cancer patients

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Follow-up OS was available for 302 patients. At the end of the observation period, 280 (92.7%) patients were deceased. The median follow-up time was 21.2 months (ranged 2.8–72.5 months). The results of Kaplan–Meier survival test were presented in [Figure 1]. There was no significant association between OS and genotypes either in Kaplan–Meier survival test or in Cox multivariate survival analysis [Table 4].
Figure 1: Kaplan–Meier survival analysis in 302 nonsmall cell lung cancer patients. (a) ATP7B rs1061472; (b) ATP7B rs9535826

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Table 4: Cox multivariate regression survival analysis of potential prognostic factors in 302 nonsmall cell lung cancer patients

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Association between the polymorphisms and gastrointestinal toxicity and hematologic toxicity

One hundred and one patients (23.7%) suffered severe hematologic toxicity, and severe gastrointestinal toxicity was observed in 44 patients (10.3%). The relationships between ATP7B polymorphisms and platinum-induced toxicities were given [Table 5] and [Table 6]. We found that ATP7B rs9535826 was associated with gastrointestinal toxicity in the recessive model. The GG genotype appeared to be a significantly protective factor for gastrointestinal toxicity (OR = 0.30; 95% CI = 0.10–0.90; P = 0.031) [Table 5]. No statistically significant difference was observed between SNPs and platinum-induced hematologic toxicities [Table 6].
Table 5: Association of ATP7B polymorphisms with platinum-induced gastrointestinal toxicity in nonsmall cell lung cancer patients

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Table 6: Association of ATP7B polymorphisms with platinum-induced hematologic toxicity in nonsmall cell lung cancer patients

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 > Discussion Top


In the current study, we investigated the association of ATP7A and ATP7B genetic polymorphisms with clinical outcome and toxicities of platinum-based chemotherapy in NSCLC patients. We found that ATP7B rs9535826 was associated with gastrointestinal toxicity. On the basis of our findings, the genotypes of ATP7B may be novel and useful biomarker for predicting the outcomes of platinum-based chemotherapy in NSCLC patients.

ATP7A and ATP7B proteins shared high similarity in structure and function. Both two have eight transmembrane domains and several intramembrane domains. A special component was the N-terminal metal-binding domain (NMBD), containing six copper-binding sites consisted by GMxCxxC sequence. Similar to Cu, Pt could bind to the CXXC motifs of the NMBD, mediating the platinum transport.[28] Therefore, ATP7A and ATP7B could be involved in the transport of platinum drugs. More importantly, both in vivo and in vitro experiments have proved that the expression levels of ATP7A and ATP7B were associated with platinum resistance in NSCLC.[6],[7],[8],[9]

Although the associations of ATP7A and ATP7B expressions with platinum resistance have been extensively studied, it was not definite on the roles of ATP7A or ATP7B polymorphisms in platinum resistance or toxicity. In our study, ATP7A rs2227291 and rs6622665 deviated from Hardy–Weinberg equilibrium. Therefore, the two SNPs were not taken into consideration. For ATP7B polymorphism, He et al. reported that ATP7B rs1061472 was significantly associated with carboplatin/taxane-induced gastrointestinal toxicity in ovarian cancer patients.[18] However, this result was inconsistent with the current study. We found that ATP7B rs9535826 was associated with gastrointestinal toxicity in NSCLC patients. The inconsistency may be resulted from differences in tumor types, sample sizes, chemotherapy regimens, and assessment methods. Although rs9535826 was located in intron regions, more and more studies proved that introns may play an important role in gene expression, especially the No. 1 intron.[29],[30] Due to the lack of mechanism researches about the association between ATP7B polymorphisms and toxicity, we postulated that ATP7B rs9535826 located in No. 1 intron might increase the cellular accumulation of platinum drugs, especially in small intestinal gland cells, which may eventually lead to gastrointestinal reactions such as nausea and vomit.


 > Conclusions Top


Taken together, our findings have been valuable for providing the potential biomarkers to platinum-based chemotherapy in NSCLC patients. However, the study also had limitations such as limited sample sizes. The validation of our results requires replication studies in other independent participants. Moreover, further research is needed on how ATP7B genetic polymorphisms affect platinum resistance and toxicity.

Acknowledgment

We first thank all the supported funds from the Hunan Provincial Natural Science Foundation of China (2016JJ2152). We also thank all patients who participated in the study.

Financial support and sponsorship

This study was financially supported by the Hunan Provincial Natural Science Foundation of China (2016JJ2152).

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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