Correlation of p53 Expression with the Clinicopathological Parameters and Prognosis of Renal Cell Ca

Page 1

Research Article

Clinics of Oncology

ISSN: 2640-1037

Volume 4

Correlation of p53 Expression with the Clinicopathological Parameters and Prognosis of Renal Cell Carcinoma. A Revival of an Old-Topic

Celik B*

Department of Pathology, Antalya Hospital, Health Science University, Turkey

*Corresponding author:

Betul Celik,

Department of Pathology, Antalya Hospital, Health Science University, SBU Antalya Egitim Arastirma hastanesi, patoloji Bölümü 07000 Antalya/Turkey, E-mail: bet_celik@yahoo.com

Keywords:

Renal cell carcinoma; Clear cell; Prognosis; p53; Expression

1. Abstract

Received: 26 Mar 2021

Accepted: 07 Apr 2021

Published: 12 Apr 2021

Copyright:

©2021 Celik B, et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and build upon your work non-commercially.

Citation:

Celik B, Correlation of p53 Expression with the Clinicopathological Parameters and Prognosis of Renal Cell Carcinoma. A Revival of an Old-Topic. Clin Onco. 2021; 4(4): 1-5

junct to grading RCC.

1.1. Background: The prognostic value of p53 has been shown in many organs but there is still controversy regarding its value in Renal Cell Carcinoma (RCC). This study was aimed to investigate the prognostic and clinicopathological significance of p53 protein expression in RCC and its histological subtypes.

1.2. Materials and Methods: Tissues obtained from patients who undergone nephrectomy for RCC was included for the study at a single academic center. Anti-p53 antibody was applied to the tumor area immunohistochemically. The relationships of this antibody with prognostic factors and survival rates were evaluated with statistical analyses.

1.3. Results: The overall p53 expression was observed in 16.36% of cases. This rate was 19.5% for clear cell RCC. Chromophobe and papillary RCC cases were not hosted p53 expression. Our results showed that p53 positive expression was associated with low Fhurman (G1+G2) and high Fhurman (G3+G4) nuclear grades (p=0.031) but not the patient age (p=0.623), sex (p=0.131), tumor size (p=0.943), capsular invasion (p=0.720), sarcomatoid histology (p=0.321), Fhurman nuclear grades (p=0.220), Stage (p=0.135), and survival (p=0.1495) statistically. Albeit not statistically significant there was a tendency for p53 expression (p=0.060) in the clear cell type RCC and patients who died.

1.4. Conclusions: The p53 expression is correlated with higher grade tumors. Its expression is proportionally common in clear cell RCC than papillary or chromophobe RCC. Its presence can be ad-

2. Introduction

A few decades have been passed since the discovery of the protein p53. It had been first detected by virtue of its association with the SV40 large T cell antigen [1]. It has a protective effect that results in sustained proliferation, ie: acts as tumor suppressor protein and is the guardian of the genome. Since its discovery, thousands of articles have been published in nearly all disciplines [2, 3].

Non-mutated, wild-type p53 has a relatively short half-life. It is under the control of Murine Double Minute 2 (MDM2) [4]. While N-terminal domain of MDM2 binds to p53, promotes its translocation from the nucleus to the cytoplasm which leads to suppression of its activity, C-terminal domain targets proteasomal-mediated degradation of p53. Targeting the p53-MDM2 pathway and mutant p53 is the major goal in cancer treatment nowadays [5, 6].

Investigation of p53 in Renal Cell Carcinoma (RCC) dates back to the early 1990s. Earlier studies reported a very low level of p53 in RCC [7, 8, 9]. Recent studies, on the other hand, reveal different results [10, 11].

There are several clinicopathologic parameters which are useful in the evaluation of the prognosis of RCC. Besides cell type, nuclear grade, capsular invasion, stage, and tumor size, there are molecular biomarkers yet to be implemented in clinical practice such as Von Hippel Lindau (VHL), Vascular Endothelial Growth Factor (VEGF) and Carbonic Anhydrase IX (CAIX) [12]. Here in the present study, we aimed to examine p53 immunoreactivity

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in tissues obtained from patients with a diagnosis of RCC and to determine its relationship with the clinicopathological parameters and its potential for patient’s outcome.

3. Materials and Methods

Fifty-five cases of renal cell carcinoma, obtained from the files of Gazi University School of Medicine were examined retrospectively. All patients were treated by complete nephrectomy. The follow-up was available for 31 cases and ranged from 3 to 104 months. Tumor classification was made on the basis of guidelines from the 2016 WHO classification of tumors of the urinary system [13]. Histologic diagnosis, renal vein and renal sinus invasion or extension to fat were retracted from the pathology reports as well as re-evaluating the slides. Tumors with sarcomatoid features were also noted separately. Fhurman system for nuclear grading and Robson staging were employed [14]. For immunohistochemical detection of p53 gene, the formalin-fixed, paraffin-embedded tissues were taken on slides and de-waxed in xylene and rehydrated in graded alcohol. Antigen retrieval procedure was done by heating the sections in citrate buffer (pH 6.0) in a microwave oven after the endogenous peroxidase blocking. Anti-p53 monoclonal antibody (DO7, Dako) was applied, followed by a Streptavidin-Biotin complex. DAB (3'3-diaminobenzidine tetrahydrochloride) was used as the chromogen. P53 immunostaining status was scored as positive if more than 10% of the nuclei of neoplastic cells were positive and it was considered negative if less than 10% of the nuclei were stained.

The relationship of p53 protein with clinicopathologic parameters was analyzed using a chisquare test. Univariate analysis was performed with the Kaplan-Meier method and the log-rank test was used to assess the difference between subgroups.

4. Results

There were 21 female (%38) and 34 male (%62) aged 37 to 79 years (Mean 59.98). The range of tumor size was 1.4 to 19 cm (Mean 7,28 cm) and capsular invasions was observed in 32 (58.2%) of cases and vein invasions were seen in none cases. There were 20 (36.4%) Stage I, 17 (30.9%) Stage II, 16 (29.1%) Stage II, and 2 (3.6%) Stage IV cases. All cases we lost belonged to Stage III and patient loss was not related to metastatic disease. Distribution of cases based on stage, grade, and the results of the p53 staining in relation to clinicopathological parameters were presented in Table-1. Positive p53 staining was observed in 9 (19.5%) of the 46 clear cell RCC (ccRCC) (Figure 1). Positive p53 staining was not observed in none of 4 chromophobe and 5 papillary RCC. Each Fhurman nuclear grades had no statistical relationship with p53 (p=0.220) but when we subgroup cases as low and high grade, low (Fhurman G1+G2) and high (Fhurman G3+G4) nuclear grades were found to be correlated statistically with p53 staining (p=0.031). Patient age (p=0.623), sex (p=0.131), tumor size (p=0.943), capsular invasion (p=0.720), co-existed sarcomatoid histology (p=0.321), and Stage (p=0.135) were found not to be correlated with p53 staining statistically. Albeit not statistically significant, there was a tendency for frequent p53 expression in clear cell vs non-clear cell RCC (p=0.060).

Follow-up data for a minimum of 3 months and maximum of 104 months were available for 31 cases. The median time from operation to the end of study or to death was 44.0 months (mean:39.43). One patient died of acute myocardial infarction and was excluded from the survival analysis. Ten patients died of RCC at the end of clinical follow-up and median survival time was 8.3 months for these 10 patients (range 3 to 15). Although survival times be-

tween p53 positive and p53 negative groups were striking (31.88 vs 81.51 months respectively), the p53 gene expression was not found to be a significant predictor of survival (p=0.1495) statistically (Table 1). We also observed that p53 mutations were less common among survivors [5 out of 21 (23.8%) vs 4 out of 10 (40%) patients respectively] but it was not significant statistically.

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Figure 1: Diffuse p53 immunostaining in a Fhurman grade II tumor. Note the absence of p53 in the peritumoral kidney (right) and one obsolescence glomerulus (bottom right) (Anti-p53x20).

5. Discussion

Mutation of p53 gene leads to tumor formation and acts as an initiating factor in carcinogenesis as well as having influences on the prognosis of various malignant tumors. One well known tumor pathway is colon carcinogenesis. Studies in the 1990s observed a low level of p53 mutation in RCC [9, 15, 16]. In recent years, contrary findings have been observed: Gene expression profiles and mutation analyzes in RCC from Vinylidene chloride-exposed mice indicate dysregulation of the p53 pathway [17]. An in vitro study found that the regulatory role of the von Hippel-Lindau tumor suppressor gene (VHL) in which the knockdown of VHL increases chemo-resistance in the renal cancer cell lines (ACHN) is dependent on the activation of p53 [18]. Renal cancer cells escape death by p53 depletion and increasing p53 stability by transglutaminase 2 inhibition reduces tumor volume with the administration of a DNA-damaging anti-cancer drug such as doxorubicin [19]. Another in-vitro study confirms that inhibition of mTOR-induced apoptosis promotes RCC cell apoptosis through concurrent activation of p53 [20]. Indeed, more recent studies investigated the relation between treatment sensitivity and p53, and made p53 popular research interest for RCC again [10, 21, 22].

In the present study each Fhurman nuclear grade is not correlated with P53 expression. However, when we sub-grouped cases as low (Fhurman grade I+II) and high (Fhurman grade III+IV) grade, a statistically significant difference in p53 staining was noted (p<0.05). Kankaya et al grouped their cases as low and high grade and found similar results [23]. In the study of Mombini et al., the

cases were not classified as low and high grade but the calculation was made between these 2 grades because there was no grade 1 and grade 4 cases. They found statistically significant results between grade 2 and 3 in terms of p53 mutation [24]. Although the Fuhrman nuclear grading is applied in pathology practice widely, the utility of it has been questioned. When ccRRC was analysed, significant differences in survival were demonstrated between grade 1+2 and grade 3+4 [25]. As can be seen in our study modification of Fhurman grade (two- or three- tiered) may be more reliable for evaluating the pathologic status and prognosis of ccRCC. P53 mutation has been seen in conventional, papillary, and chromophobe RCC subtypes and the rate for ccRCC has been similar to our results: 20% [24]. Their study revealed higher p53 mutation in papillary and chromophobe tumors compared to ccRCC. Albeit not statistically significant, we observed opposite result: Frequent p53 expression in clear cell vs non-clear cell RCC was observed in our study (p=0.060). Other subtypes had no p53 expression in our study. This is interesting because instead of the deletion of 3p, seen in conventional RCC, there is a trisomy of chromosome 17, which harbors the p53 gene in papillary RCC. This coincidence made us hypothesized that p53 gene might be responsible in the development of papillary RCC. The relationship between papillary and chromophobe RCC and p53 is limited in the literature and there is a need to investigate it further [26, 27].

Seven cases in our study had sarcomatoid histology and 2 of them (28%) showed p53 staining. Oda et al reported that sarcomatoid areas more frequently showed p53 gene mutations (%79) than

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Clinicopathological characteristics n p53 p Positive (%) Negative (%) Sex 0.131 Male 34 8 (23.5) 26 (76.5) Female 21 1 (4.76) 20 (95.24) Age ≤ 50 34 3 (8.8) 31 (91.2) 0.623 >50 16 5 (31.2) 11 (68.8) Size ≤ 7 cm 32 6 (18.75) 26 (81.25) 0.943 > 7 cm 20 3 (15.0) 17 (85.0) Histological Type* 0.06 clear 46 9 (19.5) 37 (80.5) Non-clear 9 6 (100) Sarcomatoid areas 0.321 present 7 2 (28,6) 5 (71.4) absent 48 7 (14,6) 41 (85.4) Grade 0.22 I 4 4 (100) II 32 3 (9.4) 29 (90.6) III 14 4 (28.6) 10 (71.4) IV 5 2 (40) 3 (60) Low grade (GI+GII) 36 3 (8.3) 33 (91.7) 0.031 High grade (GIII+GIV) 19 6 (31.6) 13 (68.4) Stage 0.135 I 20 2 (10) 18 (90) II 17 2 (13.3) 13 (86.7) III 16 4 (25) 12 (75) IV 2 1 (50) 1 (50)
for overall cases.
Table 1: Patient and tumor characteristics in relation to the results of the p53 staining.
*p=0.17

carcinomatous areas (%14) in RCC [28]. High levels of p53 expression was also found in our study compared to carcinomatous histology, but it was not correlated statistically (p>0.05). Same as our result, Kanamaru et al reported that, in spite of a higher proliferative index and larger mean nuclear area, no substantial increase in p53 positivity in sarcomatoid components compared to basic components was seen [29]. We also observed that patients who died had more p53 mutations and patients who had p53 mutations had a shorter average survival time compared to others. The p53 positive cases had a mean survival time of 31.88 months, while negative cases had a mean survival time of 81,51 months. Almost same mean survival time (42 months) has been observed in p53 positive cases in a study: Only one of p53 positive cases was a survivor [30]. Another study found that p53 had an impact on disease progression [11]. A meta-analysis also supports these observations: A total of 2,013 patients from 22 studies showed that p53 positivity is associated with poor overall survival (HR = 2.17, 95% confidence [CI]: 1.51-3.13) and cancer-specific survival (HR = 1.59, 95% CI: 1.19-2.12), and was closely correlated with Fuhrman grade (III/IV vs. I/II: OR = 1.80, 95% CI: 1.24-2.63), not the sex or tumor size [22].

Our study had limitation. Many isoforms with a different function in tumor progression are present in RCC [31]. Although most commercially available p53 antibody detects the majority of mutations such as missense mutations, hotspot mutations, somatic mutations, germ line mutations, the present study didn’t seek all of these p53 mutations. Also case number for papillary and chromophobe RCC was limited to make a conclusion regarding p53 status. Another limitation is staging we applied. Our cases were consisted of archived materials in which American Joint Committee on Cancer (AJCC) Tumor Node Metastasis (TNM) system was not incorporated. Even so, the T and N status in the TNM system were evaluated separately in our study and revealed no significant result. Besides, The European Organization for Research and Treatment of Cancer investigated N status in a randomized phase III trial and found cancer in about 4% of resected nodes, and no difference in morbidity or long term outcomes with lymph node resection [32]. In conclusion, p53 expression is correlated with higher grade tumors (Fhurman grade I+II vs III+IV). Although there is no statistical significance, its expression is more common in patients who had ccRCC than those who had papillary or chromophobe RCC; p53 mutation is less common in patients who survived, and patients who had p53 mutation had a shorter survival time. Presence of p53 in RCC may indicate lower survival and can be used to predict survival of patients.

References

1. Lane DP, Crawford LV. T antigen is bound to a host protein in SV40-transformed cells. Nature. 1979; 278(5701): 261-3.

2. Dursun A, Akyol G, Celik B, et al. Expression of p53 protein in gas-

tric carcinoma. Association with the histopathologic characteristics, the presence of intestinal metaplasia and Helicobacter Pylori. Gazi Medical Journal. 1996: 115-9.

3. Alkibay T, Sınık Z, Ataoğlu Ö, Çelik B, Bozkırlı I. Prostat adenokanserinde p53 nükleer birikiminin yeri. Üroloji Bülteni. 1996; 7(2): 101-4.

4. Nguyen D, Liao W, Zeng SX, Lu H. Reviving the guardian of the genome: Small molecule activators of p53. Pharmacol Ther. 2017; 178: 92-108.

5. Qin JJ, Li X, Hunt C, Wang W, Wang H, Zhang R. Natural products targeting the p53-MDM2 pathway and mutant p53: Recent advances and implications in cancer medicine. Genes Dis. 2018; 5(3): 204-19.

6. Gupta A, Shah K, Oza MJ, Behl T. Reactivation of p53 gene by MDM2 inhibitors: A novel therapy for cancer treatment. Biomed Pharmacother. 2019; 109: 484-92.

7. Torigoe S, Shuin T, Kubota Y, Horikoshi T, Danenberg K, Danenberg PV. p53 gene mutation in primary human renal cell carcinoma. Oncol Res. 1992; 4(11-12): 467-72.

8. Suzuki Y, Tamura G, Satodate R, Fujioka T. Infrequent mutation of p53 gene in human renal cell carcinoma detected by polymerase chain reaction single-strand conformation polymorphism analysis. Jpn J Cancer Res. 1992; 83(3): 233-5.

9. Uchida T, Wada C, Shitara T, Egawa S, Mashimo S, Koshiba K. Infrequent involvement of p53 mutations and loss of heterozygosity of 17p in the tumorigenesis of renal cell carcinoma. J Urol. 1993; 150(4): 1298-301.

10. Zhang H, Zhao Y, Sun P, Zhao M, Su Z, Jin X, et al. p53β: a new prognostic marker for patients with clear-cell renal cell carcinoma from 5.3 years of median follow-up. Carcinogenesis. 2018; 39(3): 368-74.

11. Morshaeuser L, May M, Burger M, Otto W, Hutterer GC, Pichler M, et al. p53-expression in patients with renal cell carcinoma correlates with a higher probability of disease progression and increased cancer-specific mortality after surgery but does not enhance the predictive accuracy of robust outcome models. Urol Oncol. 2018; 36(3): 94.e15-21.

12. Rabjerg M. Identification and validation of novel prognostic markers in Renal Cell Carcinoma. Dan Med J. 2017; 64(10).

13. Moch H, Cubilla AL, Humphrey PA, Reuter VE, Ulbright TM. The 2016 WHO Classification of Tumors of the Urinary System and Male Genital Organs-Part A. Renal, Penile, and Testicular Tumours. Eur Urol. 2016; 70(1): 93-105.

14. Fuhrman SA, Lasky LC, Limas C. Prognostic significance of morphologic parameters in renal cell carcinoma. Am J Surg Pathol. 1982; 6(7): 655-63.

15. Bot FJ, Godschalk JC, Krishnadath KK, van der Kwast TH, Bosman FT. Prognostic factors in renal-cell carcinoma: immunohistochemical detection of p53 protein versus clinico-pathological parameters. Int J Cancer. 1994; 57(5): 634-7.

16. Suzuki Y, Tamura G. Mutations of the p53 gene in carcinomas of the

clinicsofoncology.com 4 Volume 4 Issue 3 -2021 Research Article

urinary system. Acta Pathol Jpn. 1993; 43(12): 745-50.

17. Hayes SA, Pandiri AR, Ton TV, Hong HHL, Clayton NP, Shockley KR,et al. Renal Cell Carcinomas in Vinylidene Chloride-exposed Male B6C3F1 Mice Are Characterized by Oxidative Stress and TP53 Pathway Dysregulation. Toxicol Pathol. 2016; 44(1): 71-87.

18. Zhao Z, Chen C, Lin J, Zeng W, Zhao J, Liang Y, et al. Synergy between von Hippel-Lindau and P53 contributes to chemosensitivity of clear cell renal cell carcinoma. Mol Med Rep. 2016; 14(3): 2785-90.

19. Kang JH, Lee JS, Hong D, Lee SH, Kim N, Lee WK, et al. Renal cell carcinoma escapes death by p53 depletion through transglutaminase 2-chaperoned autophagy. Cell Death Dis. 2016; 7: e2163.

20. Liu QJ, Shen HL, Lin J, Xu XH, Ji ZG, Han X, et al. Synergistic roles of p53 and HIF1α in human renal cell carcinoma-cell apoptosis responding to the inhibition of mTOR and MDM2 signaling pathways. Drug Des Devel Ther. 2016; 10: 745-55.

21. Li VD, Li KH, Li JT. TP53 mutations as potential prognostic markers for specific cancers: analysis of data from The Cancer Genome Atlas and the International Agency for Research on Cancer TP53 Database. J Cancer Res Clin Oncol. 2019; 145(3): 625-36.

22. Wang Z, Peng S, Jiang N, Wang A, Liu S, Xie H, et al. Prognostic and clinicopathological value of p53 expression in renal cell carcinoma: a meta-analysis. Oncotarget. 2017; 8(60): 102361-70.

23. Kankaya D, Kiremitci S, Tulunay O, Baltaci S. Gelsolin, NF-κB, and p53 expression in clear cell renal cell carcinoma: Impact on outcome. Pathol Res Pract. 2015; 211(7): 505-12.

24. Mombini H, Givi M, Rashidi I. Relationship between expression of p53 protein and tumor subtype and grade in renal cell carcinoma. Urol J. 2006; 3(2): 79-81.

25. Ficarra V, Martignoni G, Maffei N, Brunelli M, Novara G, Zanolla L, et al. Original and reviewed nuclear grading according to the Fuhrman system: a multivariate analysis of 388 patients with conventional renal cell carcinoma. Cancer. 2005; 103: 68-75.

26. Gad S, Lefèvre SH, Khoo SK, Giraud S, Vieillefond A, Vasiliu V, et al. Mutations in BHD and TP53 genes, but not in HNF1beta gene, in a large series of sporadic chromophobe renal cell carcinoma. Br J Cancer. 2007; 96(2): 336-40.

27. Abbosh P, Sundararajan S, Millis SZ, Hauben A, Reddy S, Geynisman DM, et al. Molecular and Genomic Profiling to Identify Actionable Targets in Chromophobe Renal Cell Cancer. Eur Urol Focus. 2018; 4(6): 969-71.

28. Oda H, Nakatsuru Y, Ishikawa T. Mutations of the p53 gene and p53 protein overexpression are associated with sarcomatoid transformation in renal cell carcinomas. Cancer Res. 1995; 55(3): 658-62.

29. Kanamaru H, Li B, Miwa Y, Akino H, Okada K. Immunohistochemical expression of p53 and bcl-2 proteins is not associated with sarcomatoid change in renal cell carcinoma. Urol Res.1999; 27(3): 169-73.

30. Ebru T, Fulya OP, Hakan A, Vuslat YC, Necdet S, Nuray C, et al. Analysis of various potential prognostic markers and survival data in clear cell renal cell carcinoma. Int Braz J Urol. 2017; 43(3): 440-54.

31. Song W, Huo SW, Lü JJ, Liu Z, Fang XL, Jin XB, Yuan MZ. Expression of p53 isoforms in renal cell carcinoma. Chin Med J (Engl). 2009; 122(8): 921-6.

32. Blom JH, van Poppel H, Marechal JM, Jacqmin D, Schroder FH, de Prijck L, et al. Radical nephrectomy with and without lymph-node dissection: final results of European Organization for Research and Treatment of Cancer (EORTC) randomized phase 3 trial 30881. Eur Urol. 2009; 55: 28-34.

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