Predictive markers of chemoresistance in advanced stages epithelial ovarian carcinoma
Introduction
Worldwide, ovarian cancer is the sixth most common cancer in women, with more than 230,000 new cases per year [1]. The mortality is high, with 141,000 deaths per year and a 5-year survival rate of 44.4% (35% for stage III and 22% for stage IV disease) [1]. This poor prognosis is partially explained by the fact that 75% of patients are diagnosed at advanced stages (FIGO classification stage IIIC or IV) [2], [3]. Therapeutic management of advanced epithelial ovarian cancer (EOC) is usually based on complete cytoreduction surgery (debulking), followed by chemotherapy. When a complete cytoreduction is not feasible or reasonable because of the morbidity induced by extensive surgery, neoadjuvant chemotherapy can be proposed, followed by debulking surgery after 3 or 4 courses of chemotherapy, without impairing the prognosis [4]. In this alternative approach, the first surgery, usually a laparoscopy, has the following objectives: to confirm the EOC diagnosis with biopsies and to evaluate the possibility of an initial complete surgical cytoreduction. Then, adjuvant chemotherapy is performed. The first-line chemotherapy for EOC is a combination of carboplatin (an alkylating agent) and paclitaxel (an antimicrotubule agent) [5], [6], which induces an initial response in 65 to 80% of patients [7]. However, the majority of patients who respond to primary chemotherapy will develop recurrent disease. From a practical standpoint, when the relapse occurs during the first year after chemotherapy cessation, the patient is said to be “platinum resistant,” and a different line of chemotherapy must be considered. Conversely, when the relapse occurs beyond the first two years after chemotherapy cessation, the patient is said to be “platinum sensitive”. The exact disease-free period that defines platinum sensitivity remains varied in the literature [8].
Three major research concepts can facilitate an understanding of EOC chemoresistance. The first concept is the tumor cell as an autonomous entity that is subject to stochastic mutations and selection pressure by chemotherapy. Tumor cells might employ DNA repair mechanisms such as nucleotide excision repair (NER) to escape platinum-induced apoptosis. Therefore, the enzyme ERCC1 is a key protein in platinum resistance [9]. Second, Meads et al. oppose the concept of de novo resistance such as environment-mediated drug resistance (EMDR), compared to the acquired resistance that develops over time as a result of sequential genetic changes that ultimately culminate in complex therapy-resistant phenotypes [10]. According to this model, the tumor cells are surrounded by a specialized stroma that induces transient EMDR through soluble factors (IL-6, IL-8 and BMP2) and adhesion between tumor cells and stromal fibroblasts or extracellular matrix components [11], [12], [13]. Third, the hypothesis of cancer initiating cells (CIC) within the tumor could partially explain chemoresistance. These cells are defined by the functional properties of self-renewal and differentiation. In EOC, CIC have been characterized by cell surface markers (CD44, CD117, CD133) or functional properties (label-retaining cells, side population, ALDH1 activity) [14], [15], [16], [17], [18]. CIC remain mostly in a dormant state and thus escape conventional chemotherapies that target cycling cells. All of these models help to explain the survival of a small, chemoresistant contingency of cells during chemotherapy, also known as residual disease, which is responsible for recurrences.
We hypothesized that a dynamic analysis of the expression changes of potential markers associated with drug resistance (MADR) before and after chemotherapy would predict platinum resistance. The principal objective was to identify chemoresistance-predictive markers in advanced EOC patients who were treated with neoadjuvant therapy. The secondary objective was to identify a cell population enriched after chemotherapy both in vivo and in vitro by selecting markers from the three main approaches to chemoresistance: the stochastic autonomous tumor cell model, cancer initiating cells and the EMDR.
Section snippets
Patients
From our pathology database, we first selected 298 women who were diagnosed with epithelial ovarian carcinoma between January 2004 and July 2011 at Tenon Hospital, Paris. Firstly, the patients underwent exploratory laparoscopy before chemotherapy to evaluate the extent of the carcinomatosis. Debulking surgery was performed when complete cytoreduction was feasible. When it was not feasible due to the extent of the carcinomatosis and the morbidity associated with a complete resection, the
Patient characteristics
Of the 32 patients in our final cohort, 17 were chemoresistant and 15 were chemosensitive. The overall survival (OS) was significantly shorter in the chemoresistant group, compared to the chemosensitive group, with median values of 26 months and not reached, respectively (p < 0.001), and 5-year overall survival rates of 16.9% and 88.9%, respectively. Age, gravidity, parity, menopausal status, BMI, FIGO staging at diagnosis and pathologic findings did not significantly differ between the
Discussion
Herein, we identified an enriched CD44 + tumor cell population after chemotherapy both in vitro and in vivo. The absence of CD44 enrichment was correlated with chemoresistance and OS in patients. In vitro, we observed a population of chemotherapy-resistant CD44 + cells. Decreased ALDH1 expression was associated with a shorter RFS. In contrast, IL-8 enrichment was associated with chemoresistance and a shorter overall survival. We observed enriched IL-6 and ERCC1 expression after chemotherapy, but
Conflicts of interest
The authors report no conflict of interest. This work was supported by INSERM (financial support for the conduct of the research) and not sponsored by any external financial support, including the pharmaceutical industry.
Acknowledgments
No acknowledgments.
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