Enas M. Fouad¹, Abla S. Mahmoud², Rham Z. Ahmed³, Basant Sh El Shafaay⁴, Ramadan Mahmoud⁵, Gamal Osman⁵, Mohamed Farouk Amin⁵, Loay M. Gertallah^5*, Manar A. Bessar⁶

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¹ Lecturer of Pathology, Faculty of Medicine, Zagazig University, Zagazig, Egypt.
² Lecturer of Pathology, Faculty of Medicine, Beni-Suef University, Cairo, Egypt.
³ Lecturer of Medical Oncology, Faculty of Medicine, Zagazig University, Zagazig, Egypt.
⁴ Lecturer of Clinical Oncology & Nuclear Medicine, Faculty of Medicine, Zagazig, Egypt.
⁵ Lecturer of General Surgery, Faculty of Medicine, Zagazig University, Zagazig, Egypt.
⁶ Lecturer of Radiology, Faculty of Medicine, Zagazig University, Zagazig, Egypt.
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Abstract: Background: Breast cancer is considered the commonest and the most fatal female cancer worldwide. There is to an urgent need for discovering recent therapies to identify patient prognosis and improve treatment strategies. Fork-head Box C2 (FOXC2) is a transcription factor which is a key regulator of cancer stem cells (CSC) properties and epithelial mesenchymal transition (EMT) e.g. cancer initiation, metastatic capacity, and resistance to chemotherapy. FOXC2 roles in CSCs properties and EMT regulation in breast cancer needs detailed studies. YKL-40 is known as chitinase-3-like-1 belongs to a family of mammalian proteins that have an amino acid sequence which is similar to the 18-glycosyl hydrolase bacterial chitinases group. Recent studies have found aberrant YKL-40 elevated expression in cancer of various organs, so it may be used as a recent prognostic biomarker for patients with breast cancer. Former researchers have assessed the expression of FOXC2 & YKL-40 separately in cancer patients and relations to prognosis of patients; however, no studies assessed them together in breast cancer patients and the previous results were inconclusive. Accordingly, our study aimed at evaluation of immunohistochemical expressions of FOXC2 & YKL-40 in carcinoma of the breast in a trial to clarify the relation among their expressions, clinicopathological parameters and recurrence of the disease after successive therapy and patients’ prognosis. Methods: we have evaluated expressions of FOXC2 & YKL-40 in sections from 50 paraffin blocks of carcinoma of the breast using immunohistochemistry. We followed up our patients for 3 years for assessment of recurrence of the disease after successive therapy and survival rates. We analyzed the relationship between their combined expression clinicopathological and prognostic parameters. Results: high FOXC2 expression was associated with older age of the patient (p = 0.002), negative ER (p = 0.009), & PR (p = 0.008), positive HER2neu (p = 0.02), aggressive molecular subtype, higher grade of the tumor (p = 0.03), high incidence of distant metastasis (p = 0.011), high incidence of lymph node metastasis, higher KI labeling index, advanced stage, (p < 0.001). high YKL-40 expression was positively correlated with older age of the patient (p = 0.002), negative ER (p = 0.03), & PR (p = 0.04), positive HER2neu (p = 0.02), higher grade of the tumor (p = 0.003), high incidence of distant metastasis (p = 0.04), higher KI labeling index, aggressive molecular subtype, advanced stage, high incidence of lymph node metastasis (p < 0.001). We have found that patients with FOXC2 and YKL-40 overexpression have higher incidence of recurrence of the disease after therapy, poor RFS& OS rates (p < 0.001). Conclusion: Higher expression levels of FOXC2 & YKL-40 are markers of poor prognosis in breast cancer.

Keywords: Carcinoma of the Breast, FOXC2, YKL-40, Prognosis, Immunohistochemistry

Cite this paper: Fouad, E. , Mahmoud, A. , Ahmed, R. , Shafaay, B. , Mahmoud, R. , Osman, G. , Amin, M. , Gertallah, L. and Bessar, M. (2018) Prognostic and Clinicopathological Value of the Expression of FOXC2 & YKL-40 in Carcinoma of the Breast, an Immunohistochemical Study. Advances in Breast Cancer Research, 7, 211-230. doi: 10.4236/abcr.2018.73013.

References

[1]   Wang, J., Xu, Y., Li, L., Wang, L., Yao, R., Sun, Q. and Du, G. (2017) FOXC1 Is Associated with Estrogen Receptor Alpha and Affects Sensitivity of Tamoxifen Treatment in Breast Cancer. Cancer Medicine, 6, 275-287.

[2]   Wan, G., Xiang, L., Sun, X., Wang, X., Li, H., Ge, W. and Cao, F. (2017) Elevated YKL-40 Expression Is Associated with a Poor Prognosis in Breast Cancer Patients. Oncotarget, 8, 5382-5391.

[3]   Coates, A.S., Winer, E.P., Goldhirsch, A., Gelber, R.D., Gnant, M., Piccart-Gebhart, M., Thurlimann, B., et al. (2015) Tailoring Therapies—Improving the Management of Early Breast Cancer: St Gallen International Expert Consensus on the Primary Therapy of Early Breast Cancer 2015. Annals of Oncology, 26, 1533-1546.
https://doi.org/10.1093/annonc/mdv221

[4]   Acloque, H., Adams, M.S., Fishwick, K., Bronner-Fraser, M. and Nieto, M.A. (2009) Epithelial-Mesenchymal Transitions: The Importance of Changing Cell State in Development and Disease. The Journal of Clinical Investigation, 119, 1438-1449.
https://doi.org/10.1172/JCI38019

[5]   Han, B., Bhowmick, N., Qu, Y., Chung, S., Giuliano, A.E. and Cu, X. (2017) FOXC1: An Emerging Marker and Therapeutic Target for Cancer. Oncogene, 36, 3957-3963.
https://doi.org/10.1038/onc.2017.48

[6]   Pietila, M., Vijay, G.V., Soundararajan, R., Yu, X., Symmans, W.F., Sphyris, N. and Mani, S.A. (2016) FOXC2 Regulates the G2/M Transition of Stem Cell-Rich Breast Cancer Cells and Sensitizes Them to PLK1 Inhibition. Scientific Reports, 6, Article No. 23070.
https://doi.org/10.1038/srep23070

[7]   Rehli, M., Krause, S.W. and Andreesen, R. (1997) Molecular Characterization of the Gene for Human Cartilage gp-39 (CHI3L1), a Member of the Chitinase Protein Family and Marker for Late Stages of Macrophage Differentiation. Genomics, 43, 221-225.
https://doi.org/10.1006/geno.1997.4778

[8]   Fusetti, F., Pijning, T., Kalk, K.H., Bos, E. and Dijkstra, B.W. (2003) Crystal Structure and Carbohydrate-Binding Properties of the Human Cartilage Glycoprotein-39. The Journal of Biological Chemistry, 278, 37753-37760.
https://doi.org/10.1074/jbc.M303137200

[9]   Prakash, M., Bodas, M., Prakash, D., Nawani, N., Khetmalas, M., Mandal, A. and Eriksson, C. (2013) Diverse Pathological Implications of YKL-40: Answers May Lie in “Outside-In” Signaling. Cell Signal, 25, 1567-1573.
https://doi.org/10.1016/j.cellsig.2013.03.016

[10]   Johansen, J.S., Schultz, N.A. and Jensen, B.V. (2009) Plasma YKL-40: A Potential New Cancer Biomarker? Future Oncology, 5, 1065-1082.
https://doi.org/10.2217/fon.09.66

[11]   Liu, B., Han, S.M., Tang, X.Y., et al. (2014) Overexpressed FOXC2 in Ovarian Cancer Enhances the Epithelial-to-Mesenchymal Transition and Invasion of Ovarian Cancer Cells. Oncology Reports, 31, 2545-2554.
https://doi.org/10.3892/or.2014.3119

[12]   Xu, Y., Shao, Q., Yao, H., Jin, Y., Ma, Y. and Jia, L. (2014) Department of Gastrointestinal Surgery, Zhejiang Provincial People’s Hospital, Hangzhou, China Overexpression of FOXC1 Correlates with Poor Prognosis in Gastric Cancer Patients. Histopathology, 64, 963-970.
https://doi.org/10.1111/his.12347

[13]   Hollier, B.G., Tinnirello, A.A., Werden, S.J., Evans, K.W., Taube, J.H., Sarkar, T.R., Sphyris, N., Shariati, M., Kumar, S.V., Battula, V.L., Herschkowitz, J.I., Guerra, R., Chang, J.T., Miura, N., Rosen, J.M. and Mani, S.A. (2012) FOXC2 Expression Links Epithelial-Mesenchymal Transition and Stem Cell Properties in Breast Cancer. Cancer Research, 73, 1981-1992.
https://doi.org/10.1158/0008-5472.CAN-12-2962

[14]   Quan, Y., Zhe, Q., Zheng, C., Deng, W., Meng, F., Fu, Y., et al. (2014) Epithelial-Mesenchymal Transition-Associated miRNAs in Ovarian Carcinoma, with Highlight on the miR-200 Family: Prognostic Value and Prospective Role in Ovarian Cancer Therapeutics. Cancer Letters, 351, 173-181.
https://doi.org/10.1016/j.canlet.2014.05.022

[15]   Cui, Y.-M., Jiao, H.-L., Ye, Y.-P., Chen, C.-M., Wang, J.-X., Tang, N., et al. (2015) FOXC2 Promotes Colorectal Cancer Metastasis by Directly Targeting MET. Oncogene, 34, 4379-4390.

[16]   Watanabe, A., Suzuki, H., Yokobori, T., Altan, B., Kubo, N., Araki, K., et al. (2013) Forkhead Box Protein C2 Contributes to Invasion and Metastasis of Extrahepatic Cholangiocarcinoma, Resulting in a Poor Prognosis. Cancer Science, 104, 1427-1432.

[17]   Nishida, N., Mimori, K., Yokobori, T., et al. (2011) FOXC2 Is a Novel Prognostic Factor in Human Esophageal Squamous Cell Carcinoma. Annals of Surgical Oncology, 18, 535-542.
https://doi.org/10.1245/s10434-010-1274-y

[18]   Ivanov, K.I., et al. (2013) Phosphorylation Regulates FOXC2-Mediated Transcription in Lymphatic Endothelial Cells. Molecular and Cellular Biology, 33, 3749-3761.
https://doi.org/10.1128/MCB.01387-12

[19]   Li, Q., et al. (2015) Overexpression of Forkhead Box C2 Promotes Tumour Metastasis and Indicates Poor Prognosis in Colon Cancer via Regulating Epithelial-Mesenchymal Transition. American Journal of Cancer Research, 5, 2022-2034.

[20]   Zhou, Z., et al. (2015) FOXC2 Promotes Chemoresistance in Nasopharyngeal Carcinomas via Induction of Epithelial Mesenchymal Transition. Cancer Letters, 363, 137-145.
https://doi.org/10.1016/j.canlet.2015.04.008

[21]   Imayama, N., et al. (2015) FOXC2 Expression Is Associated with Tumour Proliferation and Invasion Potential in Oral Tongue Squamous Cell Carcinoma. Pathology & Oncology Research, 21, 783-791.
https://doi.org/10.1007/s12253-014-9891-6

[22]   Sano, H., Leboeuf, J.P., Novitskiy, S.V., et al. (2010) The Foxc2 Transcription Factor Regulates Tumor Angiogenesis. Biochemical and Biophysical Research Communications, 392, 201-206.
https://doi.org/10.1016/j.bbrc.2010.01.015

[23]   Cui, Y.M., Jiang, D., Zhang, S.H., et al. (2014) FOXC2 Promotes Colorectal Cancer Proliferation through Inhibition of FOXO3a and Activation of MAPK and AKT Signaling Pathways. Cancer Letters, 353, 87-94.
https://doi.org/10.1016/j.canlet.2014.07.008

[24]   Kim, S., Kasturi, D., Shahla, N., Frederick, C. and Meera, H. (2007) Prognostic Implications of Immunohistochemically Detected YKL-40 Expression in Breast Cancer. World Journal of Surgical Oncology, 5, 17.
https://doi.org/10.1186/1477-7819-5-17

[25]   Shao, R., Cao, Q.J., Arenas, R.B., Bigelow, C., Bentley, B. and Yan, W. (2011) Breast Cancer Expression of YKL-40 Correlates with Tumour Grade, Poor Differentiation, and Other Cancer Markers. British Journal of Cancer, 105, 1203-1209.
https://doi.org/10.1038/bjc.2011.347

[26]   Roslind, A., Knoop, A.S., Jensen, M.B., Johansen, J.S., Nielsen, D.L., Price, P.A. and Balslev, E. (2008) YKL-40 Protein Expression Is Not a Prognostic Marker in Patients with Primary Breast Cancer. Breast Cancer Research and Treatment, 112, 275-285.
https://doi.org/10.1007/s10549-007-9870-7

[27]   Jefri, M., Huang, Y.-N., Huang, W.-C., Tai, C.-S. and Chen, W.-L. (2015) YKL-40 Regulated Epithelial-Mesenchymal Transition and Migration/Invasion Enhancement in Non-Small Cell Lung Cancer. BMC Cancer, 15, 590.
https://doi.org/10.1186/s12885-015-1592-3

[28]   Hao, H., Wang, L., Chen, H., Xie, L., Bai, T., Liu, H. and Wang, D. (2017) YKL-40 Promotes the Migration and Invasion of Prostate Cancer Cells by Regulating Epithelial Mesenchymal Transition. American Journal of Translational Research, 9, 3749-3757.
http://www.ajtr.org

[29]   Ozdemir, E., Cicek, T. and Kaya, M.O. (2012) Association of Serum YKL-40 Level with Tumor Burden and Metastatic Stage of Prostate Cancer. Urology Journal, 9, 568-573.

[30]   Qin, G., Li, X., Chen, Z., Liao, G., Su, Y., Chen, Y. and Zhang, W. (2016) Prognostic Value of YKL-40 in Patients with Glioblastoma: A Systematic Review and Meta-Analysis. Molecular Neurobiology, 54, 3264-3270.

[31]   Low, D., Subramaniam, R., Lin, L., Aomatsu, T., Mizoguchi, A., Ng, A., DeGruttola, A.K., et al. (2015) Chitinase 3-like 1 Induces Survival and Proliferation of Intestinal Epithelial Cells during Chronic Inflammation and Colitis-Associated Cancer by Regulating S100A9. Oncotarget, 6, 36535-36550.
https://doi.org/10.18632/oncotarget.5440

[32]   Francescone, R.A., Scully, S., Faibish, M., Taylor, S.L., Oh, D., Moral, L., et al. (2011) Role of YKL-40 in the Angiogenesis, Radioresistance, and Progression of Glioblastoma. The Journal of Biological Chemistry, 286, 15332-15343.
https://doi.org/10.1074/jbc.M110.212514

[33]   Libreros, S. and Iragavarapu-Charyulu, V. (2015) YKL-40/CHI3L1 Drives Inflammation on the Road of Tumor Progression. Journal of Leukocyte Biology, 98, 931-936.
https://doi.org/10.1189/jlb.3VMR0415-142R

[34]   Kzhyshkowska, J., Yin, S., Liu, T., Riabov, V. and Mitrofanova, I. (2016) Role of Chitinase-Like Proteins in Cancer. Biological Chemistry, 397, 231-247.
https://doi.org/10.1515/hsz-2015-0269