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| ORIGINAL ARTICLE |
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| Ahead of print publication |
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CXCR4 and RIF1 overexpression induces resistance of epithelial ovarian cancer to cisplatin-based chemotherapy
Lamiss Mohamed Abd Elaziz Sad1, Dareen Abdelaziz Mohamed2, Noha M Elanwar2, Assama Elkady1
1 Department of Clinical Oncology and Nuclear Medicine, Tanta University, Egypt
2 Department of Pathology, Faculty of Medicine, Tanta University, Egypt
| Date of Submission | 11-Jul-2019 |
| Date of Acceptance | 21-Jan-2020 |
| Date of Web Publication | 05-Nov-2020 |
Correspondence Address:
Lamiss Mohamed Abd Elaziz Sad,
Department of Clinical Oncology, Tanta University Hospital, Tanta
Egypt
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/jcrt.JCRT_480_19
Introduction: The chemoresistance of epithelial ovarian cancer (EOC) is a major problem. Thus, the search for novel biomarkers associated with cisplatin sensitivity is overwhelming. Previous studies have shown that CXC chemokine receptor 4 (CXCR4) is associated with tumor growth, angiogenesis, and distant metastases, and replication timing regulatory factor 1 (RIF1) is responsible for the repair of double-strand DNA breaks. This study, thus, aimed to identify the correlation between CXCR4 and RIF1 overexpression and cisplatin sensitivity in EOC.
Materials and Methods: Fifty-five EOC patients were recruited to assess the chemosensitivity of EOC to cisplatin-based chemotherapy at the Oncology Department in Tanta University Hospitals, Egypt.
Results: The results showed that patients with a higher CXCR4 and RIF1 expression exhibited a significantly lower chemosensitivity, worse overall survival, and poorer progression-free survival. The only prognostic associated with overall survival was CXCR4.
Conclusion: Our study showed that CXCR4 and RIF1expression levels are not associated only with poor prognostic features of epithelial ovarian cancer but also with its chemoresistance to cisplatin, and consequently, with worse overall survival and progression free survival.
Keywords: Cisplatin, CXCR4, epithelial ovarian cancer, predictive, RIF1
How to cite this URL:
Sad LM, Mohamed DA, Elanwar NM, Elkady A. CXCR4 and RIF1 overexpression induces resistance of epithelial ovarian cancer to cisplatin-based chemotherapy. J Can Res Ther [Epub ahead of print] [cited 2021 Jun 22]. Available from: https://www.cancerjournal.net/preprintarticle.asp?id=300106 |
| > Introduction | |  |
Ovarian cancer is the leading cause of gynecologic malignancy-related deaths in women. It is the most common type (90%) of epithelial tumors.[1] Despite ovarian epithelial malignancy being among the most chemosensitive malignancies and the availability of modern treatment modalities incorporating radical tumor debulking followed by platinum plus paclitaxel-based chemotherapy, the prognosis of the patients is poor and the 5-year survival rate is still 25%.[2]
Age, tumor histology, performance status, and residual tumor volume have been reported as independent prognostic factors for the survival of epithelial ovarian cancer (EOC) patients.[3],[4] Even in patients with similar disease status and receiving the same treatment, the survival rates still vary, the reason of which is still unknown. Recognizing new biological prognostic variables could help anticipate patients' treatment outcome.
G-protein-coupled chemokine receptor, CXC chemokine receptor 4 (CXCR4), exerts its action through binding to its ligand stromal cell-derived factor 1 (also called CXCL12), changing the backbone of cell and tumor migration. It has been shown to play a role in tumor growth and metastasis.[5],[6],[7] However, there is still a debate on the correlation between CXCR4 and survival.[8],[9],[10]
Cisplatin cytotoxicity occurs mainly during the active replication of DNA by forming cisplatin-containing DNA adducts, leading to double-stranded DNA breaks.[11] Replication timing regulatory factor 1 (RIF1) is responsible for the repair of DNA strand breaks and the regulation of replication time.[12],[13] In breast cancer, RIF1 was found to be unregulated and silencing of RIF1 increased cisplatin sensitivity in cervical cancer.[14],[15] The role of RIF1 in EOC is still under investigation.
In the present study, we aimed to evaluate CXCR4 and RIF1 expressions and their impacts on cisplatin-based therapy in EOC patients.
| > Materials and Methods | | |
Patients
Fifty-five individuals who diagnosed with EOC at the Oncology Department, Tanta University Hospital, Egypt, between January 2014 and January 2016 were included in the study. These patients were subjected to histopathological diagnoses at the Pathology Department of Tanta University Hospital, Egypt. These patients were staged according to the International Federation of Gynecology and Obstetrics.[16] Informed consent was taken from all patients. Chemotherapy was not allowed before surgery. Patients underwent surgical treatment followed by chemotherapy.
For chemotherapy, the patients were subjected to intravenous infusion of 175 mg/m 2 paclitaxel over 3 h plus carboplatin area under the curve 5–6 IV over 1 h on day 1; and the cycle was repeated after every 21 days for six cycles.
Patients who responded to cisplatin-based chemotherapy or those who did not progressed for more than 6 months off treatment were considered platinum sensitive, whereas patients who progressed during treatment or within 6 months from the treatment were considered platinum resistant.
Immunohistochemistry
Surgically extracted tissue specimens were fixed in 10% formalin and embedded in paraffin.
Immunohistochemical staining of the CXCR4 and RIF1 antibodies was done (1:100, Sigma-Aldrich). Four micrometers thick tissue sections were cut from paraffin-embedded blocks. Then, the tissue sections were baked at 60°C for 30 min followed by the incubation in xylene for 3 × 10 min, and graded ethanol to distilled water was used for rehydration. Then, the samples were heated in 1 mmol/L ethylenediaminetetraacetic acid for 20 min for antigen retrieval. Then, the samples were stained with goat serum in phosphate-buffered saline (PBS) buffer for 20 min at room temperature for blocking nonspecific staining. Then, the samples were incubated in 3% H2O2 for 10 min for quenching the endogenous peroxidase activity.
The slides were incubated first with rabbit polyclonal nonspecific RIF1 antibody or PBS control at 4°C overnight followed by biotinylated goat anti-rabbit antibody and peroxidase-conjugated streptavidin. To visualize staining, 3,3'-diaminobenzidine tetrahydrochloride substrate kit (Zhongshan Golden bridge) was used, according to the manufacturer's instructions.
The intensity of CXCR4 staining was scored as 0, 1, 2, and 3 indicating no staining, weak, moderate, and marked, respectively.
The percentage scores were graded as follows: 1 (1%–25%), 2 (26%–50%), 3 (51%–75%), and 4 (76%–100%). Final score by multiplying the scores of each tumor sample was found to be between 0 and 12, In our study, CXCR4 expression was classified either low (-, +) or high (++, +++) based on the amount of protein expression [Figure 1],[Figure 3], [Figure 5], [Figure 7], [Figure 9] [Figure 12]. | Figure 1: Clear cell carcinoma of the ovary showed high CXCR4 expression (×400)
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 | Figure 3: Endometrioid carcinoma of the ovary showed high RIF1 expression (×400)
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 | Figure 5: Serous carcinoma of the ovary showed high CXCR4 expression (×400)
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 | Figure 7: Undifferentiated carcinoma of the ovary showed high CXCR4 expression (×400)
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 | Figure 9: Endometrioid carcinoma of the ovary showed low CXCR4 expression (×400)
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 | Figure 12: Serous carcinoma of the ovary showed low CXCR4 expression (×200)
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Next, the RIF1 staining intensity was scored.[17] The RIF1 staining intensity was scored as 1, 2, 3, and 4 for <25%, ≥25% to 50%, ≥50% to 75%, and ≥75% to 100% positive cells, respectively. The staining intensity was scored as 0, 1, 2, and 3 for negative, weak, moderate, and strong, respectively. A final IRS score was then calculated by multiplying these two scores. The cutoff score was set to 4.0 according to receiver operating characteristic curves analysis. For the final score of <4 and ≥4, the tumor was considered to exhibit low RIF1 expression and high RIF1 expression, respectively [Figure 2], [Figure 6], [Figure 8], [Figure 10], [Figure 11], [Figure 13]. | Figure 2: Endometrioid carcinoma of the ovary showed high CXCR4 expression (×400)
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 | Figure 6: Serous carcinoma of the ovary showed high RIF1 expression (×100)
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 | Figure 8: Clear cell carcinoma of the ovary showed high RIF1 expression (×400)
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 | Figure 10: Endometrioid carcinoma of the ovary showed low RIF1 expression (×100)
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 | Figure 11: Mucinous carcinoma of the ovary showed high RIF1 expression (×400)
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 | Figure 13: Serous carcinoma of the ovary showed low RIF1 expression (×100)
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Statistical analysis
The correlation between patient characteristics and expression levels of both CXCR4 and RIF1 expression was evaluated using the Chi-square test. The survival was analyzed using the Kaplan–Meier method version 21. For univariate analysis of prognostic factors, the log-rank test was used. Statistical significance was defined at P < 0.05. For multivariate analysis, hazard ratios and their 95% confidence intervals were calculated using Cox's multivariate analysis for overall survival (OS) and progression-free survival (PFS).[18],[19]
| > Results | | |
CXCR4 and RIF1 expression was evaluated in 55 ovarian cancer patients. High and low expression of CXCR4 was observed in 30 (54.5%) and 25 (45.5%) patients, respectively. High and low expression of RIF1 was found in 47 (85.5%) and 8 (14.5%) patients, respectively [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13]. | Figure 4: Mucinous carcinoma of the ovary showed high CXCR4 expression (×400)
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[Table 1] summarizes the clinical characteristics of the patients with respect to CXCR4. High CXCR4 expression was significantly associated with bad performance, advanced stage (Stage III and IV), high grade, and chemoresistant cancer. | Table 1: Patients' characteristics according to CXC chemokine receptor 4
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In addition, we found that a high RIF1 level was associated with advanced stage (P = 0.028) and chemoresistant (P = 0.033) cancer, as shown in [Table 2]. | Table 2: Patients' characteristics according to replication timing regulatory factor 1
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The OS of the patients was 29.4% and 91.7% under high and low CXCR4 expression, respectively (P < 0.0001), whereas it was 36.7% and 85.7% under high and low RIF1, respectively (P = 0.017) [Figure 14] and [Figure 15].
In univariate analysis, the statistically significant factors were performance status (0.004), FIGO (P = 0.000), early versus late stage (P = 0.001), optimal debulking versus suboptimal debulking (P = 0.000), grade (P = 0.000), chemosensitive versus chemoresistant (P = 0.000), and expression levels of both CXCR4 and RIF1 (P < 0.000 and 0.017, respectively).
In multivariate analysis, only chemotherapy sensitivity and CXCR4 expression were statistically significant with OS, as shown in [Table 3].
The 3-year PFS was 36.5% and 84.4% for patients with high and low CXCR4 expression, respectively (P = 0.001), whereas it was 46.7% and 875% for patients with high and low RIF1 expression, respectively (P = 0.035) [Figure 16] and [Figure 17]. Univariate analysis revealed that the following clinical parameters correlated with improved PFS: performance status, FIGO staging (early), optimal debulking, well-differentiated tumor, chemotherapy sensitivity, and low expressions of CXCR4 and RIF1 [Table 4]. The multivariate analysis revealed that no factor was significantly associated with PFS [Table 4]. | Table 4: Univariate and multivariate analysis of progression-free survival
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| > Discussion | | |
In order to eradicate ovarian cancer, cisplatin is used which leads to improved OS through the formation of crosslinks.[11],[20] Nevertheless, EOC chemoresistance against cisplatin has been reported.[20],[21] Hence, identifying novel biomarkers that predict response to cisplatin-based chemotherapy is essential to tailor the treatment strategies for EOC patients.
Several human tumors, such as pancreatic, breast, ovarian, and non-small cell lung cancer, overexpress CXCR4.[9],[10],[22],[23] Angiogenesis, metastases, and poor prognosis have been shown to be associated with the overexpression of CXCR4;[9],[10],[11] however, its correlation with chemosensitivity to cisplatin has not yet been studied.
In addition, RIF1 is responsible for the regulation of telomere length and repair double-strand DNA breaks which is the cisplatin mode of action.[24],[25] RIF1 has been found to be upregulated in breast cancer, and knockdown of RIF1 in cervical cancer is associated with cisplatin sensitivity. Thus, it could be a potential therapeutic target in EOC.[9]
Therefore, we assessed the prognosis of EOC with these biomarkers (CXCR4 and RIF1 expressions) and their association with chemosensitivity to cisplatin.
In our study, we found that the high expression of CXC4 was associated with bad performance, advanced stage (stage III and IV), high grade, and chemoresistance which was similar to that reported by Li et al., 2014.[8]
Consistent with previous studies, the high expression of CXCR4 was associated with worse OS and PFS in the univariate analysis. Furthermore, the high expression of CXCR4 was the independent prognostic factor of OS but not PFS in the multivariate analysis.[8],[9]
Our study showed that high RIF1 expression is associated with advanced stage and chemoresistant EOC similar to that reported by Mei et al., 2017.[15],[26]
Corroborating previous studies, high RIF1 was associated with worse OS and PFS.[15],[26] However, its statistical significance for both OS and PFS was not revealed by multivariate analysis, which might be due to a small sample size.
| > Conclusions | | |
Our study showed that CXCR4 and RIF1 expression levels are not associated only with poor prognostic features of EOC but also with its chemoresistance to cisplatin, and consequently, with worse overall survival and PFS. Therefore, these factors might be used as novel biomarkers for tailoring the treatment.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17]
[Table 1], [Table 2], [Table 3], [Table 4]
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