Download Prognostic Significance of Growth Hormone/Insulin Like Growth

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El Abd et al.
Journal of the Medical Research Institute
JMRI, 2006; Vol. 27 No.3: (204 -7)
Prognostic Significance of Growth Hormone/Insulin Like
Growth Factor-1/Insulin Axis in Colorectal Carcinoma
(1)
El-Abd E A, (2) EL-Kerm Y M, (3)Abdel Hammed A S, (4) El-Sewedy TS, (5)Assem N M,
Kazem A, (4) El-Sewedy S M
(6)
(1)
(5)
Radiobiology unit, (2) Oncology unit, (3) Surgery department, (4) Applied Medical Chemistry department,
Biochemistry department, (6) Pathology department, Medical Research Institute, Alexandria University, Egypt.
Abstract
Background
Insulin, insulin like growth factor (IGF) system, and growth hormone
(GH) play an important role in the development, proliferation,
differentiation, survival, metabolism, and transformation.
Aim of the work
This study aimed to explore the relation between insulin, IGF-1, GH and
the common prognostic factors in colorectal cancer.
Subjects and methods
The study included 47 subjects (30 colorectal cancer patients and 17
healthy volunteers). Serum insulin and GH were detected by
immunoradiometric assay (IRMA) while, IGF-1 was detected using
radioimmunoassay (RIA).
Results
Circulating IGF-1, insulin, and GH significantly increased in patients with
colorectal (CR) neoplasms than controls. IGF-1 showed the highest
diagnostic performance at cut off value of 116.5 ng/ml (area under the
ROC curve = 0.993, p = 0.000). A significant decrease in GH was
achieved by surgical intervention (p = 0.03). A stage dependent-significant
increase was detected with IGF-1 (p = 0.02). IGF-1 significantly decreased
(p = 0.02) with poorly differentiated tumors while GH significantly
increased (p = 0.01). Insignificant negative correlation was observed
between IGF-1 and each of GH and insulin reflecting failure of their feed
back mechanism/resistance and/or immunomodulation status.
Conclusion
As the prognosis of patients is predominantly influenced by the anatomic
extent of cancer and histologic grade, these results, provide evidence of
the prognostic role of GH/IGF-1 axis in CR neoplasms.
Keywords Colorectal neoplasms, IGF-1, GH, Insulin, prognosis, diagnostic
performance
Introduction
T he colorectal cancer ranks the sixth
of the male and the fifth of the
female cancer sites in Egypt (1) with a
mean age of 65 years.(2) Rectal
carcinomas are detected in younger
age than colonic carcinomas. (2) It is
reported that both sexes are equally
affected.(2) Colorectal cancer is
responsible for about 3.9% of all
cancer deaths in Egypt. (3) Dietary and
genetic factors, metabolic syndrome,
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certain diseases of the colon, aging,
physical inactivity, smoking, alcohol
intake, night shift work are the main
risk factors for colorectal cancer . (3)
The insulin-like growth factor (IGF),
family of ligandsbinding proteins and
receptors, is an important system
involved in regulation of a diverse
array of biological functions both
normal and pathologic including
transformation. (4) Many studies have
identified new signaling pathways
originating from the IGF-I receptor
that affect cancer cell proliferation,
adhesion, migration and cell death. (4, 5)
IGFs were suggested to increase
colonocyte turnover and hence indicate
poor prognosis in colorectal cancer.(6)
IGF is also a key player in the
signaling path that links insulin
resistance to colon cancer. (7) Insulin
resistance is characterized by compensatory hyperinsulinemia that affect
the bioavailability of IGF-1 via its
binding proteins. (7, 8) Currently, it has
been shown that circulating insulin, at
levels seen in insulin resistance,
acutely increases proliferation of
normal colorectal epithelial cells in
vivo in a dose-dependent manner. (9)
Moreover, extensive epidemiological
data support a link between growth
hormone (GH)/IGF-1 status and high
risk for colorectal cancer.(10, 11) It is
documented that IGF-1 is regulated by
GH levels.(12) Experimental evidences
implicate the involvement of the antiapoptotic environment created by
GH/IGF-1 in maintaining a long-term
survival of genetically damaged cells
resulting in acceleration of colorectal
carcinogenesis. (11)
Altogether, this study was conducted
to investigate the role of GH/IGF1/insulin axis in the prognosis of
colorectal carcinoma (CRC).
Materials and methods
Subjects
This study included 47 participants
categorized as follow:
1. Thirty patients with CRC among
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El Abd et al.
those admitted to the medical research institute and
Dammanhour institute, Alexandria University, Egypt.
Patients were recruited according to the ethical rules
of Belmont report (13) and the following inclusion
criteria:
i. Age does not exceed 70 years
ii. Pathologically proved adenocarcimomas of A-C
Duke's stages
iii. Surgically resectable non-metastatic tumors
iv. No prior radiotherapy or chemotherapy
2. Seventeen healthy volunteers with no history of
malignant diseases or any current clinical manifestations as control group.
Pathological analysis
Post-surgical specimens were sent for routine pathological
assessment to determine the tumor type, grade, and stage.
Treatment and follow up
Treatment
Surgical treatment
30 cases with colorectal neoplasms; as proved by
preoperative sigmoidoscopy and biopsy were subjected to
colectomy (24 cases). Abdominoperineal operation was
performed in 6 cases.
Adjuvant therapy
Patients with CRC received adjuvant chemotherapy
(Mayo Clinic regimen) according to the stage, while
patients with rectal neoplasms received adjuvant radiotherapy.
Follow up
Patients were clinically followed up (twice per month)
and subjected to: routine laboratory and radiographic
investigations, and colonoscopy for suspected cases.
Samples
Blood samples were collected from healthy volunteers
and patients (before surgery). Additional blood samples
were collected after 14 days of surgical intervention and
before starting any adjuvant treatment. Serum were
separated and stored at -80ºC.
Methods
Serum GH and insulin were detected using ready-to-use
IRMA (immunoradiometric assay) kits while serum IGF1 was detected using ready-to-use RIA (radio-immunoassay)
kit (BioSource Europe S A, Belgium) according to the
manufacturer instructions. Reference range varied for
IGF-1 (ng/ml) according to age and gender. GH and
insulin normal ranges are <0.2-10 µIU/ml and 4-16
µIU/ml; respectively.
Statistical analysis
Statistical analysis was performed using SPSS version
11.5. Paired "t" test was used to compare before with after
readings, while unpaired "t" test was used to compare
between the study group and control group. Alpha was set
at < 0.05. Determination of the diagnostic performance of
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GH, insulin, and IGF-1 in CRC was done using the ROC
curve. The cut off level for diagnosis was chosen as the
point that maximizes the Youden index (Youden index =
sensitivity + specificity -1).
.
Results
The mean age of the patients and controls was 44.6 ± 12.3
and 45.3 ± 11.13 years (ranging from 23-64 and 25-62)
with male to female ratio of 1:2 and 1:1; respectively. The
pathological characteristics of patients with CRC are
shown in table 1. A significant increase was detected in
serum level of GH, IGF-1, and insulin in CRC (pre- and
post-operative) compared to control group (table 2). A
significant decrease in GH was achieved by surgery (table 2).
Table (1): Pathological characteristics of 30 patients with CRC
Parameter
Histologic type
Adenocarcimomas
Mucinous adenocarcimomas
Tumor grade
II
III
Duke's stage
B
C
Number (%)
24 (80)
6 (20)
13 (43.3)
17 (56.7)
19 (63.3)
11 (36.7)
Table (2). Serology of the studied groups.
Parameter
Controls
CRC Preoperative
(n = 17)
(n = 30)
CRC
Post-operative
(before
treatment)
(n = 23)
GH (µIU/ml)
Range
M ± SD
0-3
0.65 ± 0.02
1-40
9.4 ± 10.6^
1-11
3.5 ± 3.0^+
IGF-1 (ng/ml)
Range
M ± SD
27-107
53 ± 19.4
32-157
77.7 ± 36.7^
30.3-212
84 ± 52.2^
Insulin (µIU/ml)
Range
M ± SD
5.3-23.2
8.7 ± 4.6
6.5-37
13.3 ± 7.8^
6.5-37
16.6 ± 9.4^
CRC: colorectal cancer
^ Significant when compared with control (unpaired t test)
+ Significant when compared with pre-operative (paired t test)
The diagnostic performance of the three parameters was
tested using the ROC curve. IGF-1 showed the highest
diagnostic performance (table 3). IGF-1 significantly
increased with higher tumor stage (table 4). GH
significantly increased with higher tumor grade (poorly
differentiated) while, IGF-1 significantly decreased (table 4).
A negative correlation was observed between circulating
IGF-1 and insulin, however it did not reach a statistical
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El Abd et al.
level (r = - 0.481, p = 0.374). The same insignificant
correlation was detected between IGF-1 and GH (- 0.481,
p = 0.82).
Table (3): Diagnostic performance of serology in CRC.
Cut off
Factor
IGF-1
116.5 ng/ml
GH
1.5 µIU/ml
Insulin
15.55µIU/ml
Area under
the curve
Sensitivity
Specificity
P value
0.993
100
85
0.000
0.88
93
70
0.002
0.86
90
79
0.003
Table (4): Relation between tumor-related factors, GH, and
IGF-1 in CRC.
GH
IGF-1
M ± SD
M ± SD
9.2 ± 12.5
9.6 ± 7.9
66.5 ± 42.6
91.5 ± 33.0*
Prognostic factor
Stage
B
C
Grade
II
2.7 ± 1.4
III
15.2 ± 11.8*
* Significantly increased, P<0.05.
+
Significantly decreased, P<0.05.
98 ± 26.16
44 ± 30.48+
Discussion
Although Peters et al.(14) thought that the IGF-1 expression is of limited value in CRC, the current study
documents the prognostic value of GH/IGF-1 axis in CRC.
Prognosis in CRC is influenced by histologic grade in
most of the multivariate analyses (reviewed in 15). In our
study, IGF-1 was significantly decreased with loss of
differentiation (higher grade). Similar relation was
detected between IGF-1 and poorly differentiated tumors
in human breast cancer. (16)
In contrast, a significant increase in growth hormone was
observed with higher grade. Yang et al. (14) have shown a
significant inverse correlation between GHR (growth
hormone receptor; a member of the class I cytokine
receptor family) expression and tumor differentiation (P =
0.036). Therefore, the higher GH level towards loss of
differentiation parallels the increase in its receptor
expression pattern indicating a role for GH in CRC
physiology.
In all multivariate analyses, the anatomic extent
represents the most important prognostic factor after
tumor resection for cure (reviewed in 15). Our results
identified a significant increase in IGF-1 level in
advanced stage (C). In a study of 713 CRC cases, IGF-1positive CRC reached statistical significance only in
limited tumor stages (pT1/pT2; P<0.01) . (17) This may be
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explained by interobserver and technical variability [IHC
(immunohistochemistry) versus RIA].
In addition, results of our study elucidated the possible
diagnostic potential (as reflected by diagnostic
performance tested by ROC curve analysis) of GH/IGF-1/
insulin axis in identifying patients with or more likely to
develop CRC.
Previous studies had contradictory results regarding the
correlation between higher levels of IGF-I and increased
risk of CRC (reviewed in 18). In a meta-analysis of 677
CRC patients and 1673 controls; there was a positive
association between elevated levels of circulating IGF-I
and CRC risk (OR: 1.58; 95% CI: 1.11–2.27). (19)
However, on conducting multivariate meta-regression
analysis, this positive association remained but was not
statistically significant (p = 0.09).
GH/IGF-1 axis presumed to play a role in neoplastic
pathology. (20., 21) More persuasive evidence came from the
association of polymorphic variation in the growth
hormone gene (GH1) and risk of colorectal cancer,
suggesting that lifetime exposure may be an important
determinant of risk. (22) In addition, several studies have
shown increased colon cancer in acromegaly (reviewed in
7). It is also evident that in response to growth factors
such as IGF-I, insulin, and heregulin, HIF-1 (hypoxia
inducible factor-1) protein synthesis is increased. (23, 24)
HIF-1 activates more than 100 genes bridging the IGF-1
signaling pathways in cell cycle, angiogenesis, motility,
invasion, drug resistance, growth, proliferation, apoptosis
and survival. (25)
The insulin resistance-colon cancer hypothesis was also
supported by several studies (reviewed in 7). However,
the results did not establish causality, but they have
advanced this hypothesis to a level that justifies rigorous
studies to provide proof of it.
Modulation of GH by surgery might indicate that the
tumor represents the major source of circulating GH and
the optimum time to detect this modulation effect is 14
days after surgery.
The absence of negative feedback mechanism (as
indicated by insignificant negative relation) may indicate
a hormone resistance status. During the past 20 years, it
was clear that there is a rout of communication between
protein hormones and immunity (reviewed in 26). This
communication is activated when inflammatory processes
induced by pro-inflammatory cytokines which antagonize
the function of a variety of hormones in cancer cells,
leading to endocrine resistance.
In conclusion, the GH/IGF-1 axis has diagnostic and
prognostic value in CRC. Moreover, it represents a new
therapeutic target that should be considered. More
detailed well-designed studies to validate relation between
inflammations, immunity, hormone resistance and molecular
changes during transformation are mandatory.
El Abd et al.
Acknowledgement
We wish to thank Al-Hanash A and El-Tieb M for
collecting samples, data and financing part of this work.
References
1.
2.
Statistical report for NCI 2004.
El-Bolkainy T N, Sakr M A, Nouh A A, Ali El-Din N
H. A Comparative Study of Rectal and Colonic
Carcinoma: Demographic, Pathologic and TNM Staging
Analysis. J Egyptian NCI 2006; 18: 258-63.
3.
El-Attar I. Colo-rectal cancer: Magnitude of the problem.
4.
Annual cancer conference of the Egyptian NCI, cairo
2005
LeRoith D, Roberts CT Jr. The insulin-like growth factor
system and cancer. Cancer Lett 2003; 195: 127-37.
5.
6.
7.
8.
9.
Adhami V M, Afaq F, Mukhtar H. Insulin-like growth
factor-I axis as a pathway for cancer chemoprevention.
Clin Cancer Res 2006; 12: 5611- 14.
Fu P, Thompson JA, Leeding KS, Bach LA. Insulin-like
growth factors induce apoptosis as well as proliferation
in LIM 1215 colon cancer cells. J cell Biochem 2007;
100: 58-68.
Komninou D, Ayonote A, Richie J P, Rigas B. Insulin
resistance and its contribution to colon carcinogenesis.
Exp Biol Med 2003; 228:396–405.
Sandhu M S, Dunger D B, Giovannucci E L. Insulin,
insulin-like growth factor-I (IGF-I), IGF binding
proteins, their biologic interactions, and colorectal
cancer. J Natl Cancer Inst 2002; 94: 972–80.
Tran T T, Naigamwalla D, Oprescu A I, Lam L, McKeown-
Eyssen G, Bruce R W, et al. Hyperinsulinemia, but not
other factors associated with insulin resistance, acutely
enhances colorectal epithelial proliferation in vivo.
Endocrinol 2006; 147: 1830–7.
10. Perry JK, Emerald BS, Mertani HC, Lobie PE. The
oncogenic potential of growth hormone. Growth Horm
IGF Res 2006; 16: 277-89.
11. Jenkins PJ, Mukherjee A, Shalet SM. Does growth
hormone cause cancer? Clin Endocrinol 2006; 64: 11521. comments 122-4.
12. Pavelic J, Matijevic T, Iknezevic J. Biological and
physiological aspects of action of insulin-like growth
factor peptide family. Indian J Med Res 2007; 125: 511-22.
13. Belmont Report: Ethical Principles and Guidelines for
the Protection of Human Subjects of Research.
Washington, D.C.: U.S. Government Printing Office.
14. Peters G, Gongoll S, Langner C, Mengel M, Piso P,
Klempnauer J, Rüschoff J, Kreipe H, von Wasielewski
R. IGF-1R, IGF-1 and IGF-2 expression as potential
JMRI, 2006; Vol.27 No.3: (204 - 7)
٤
prognostic and predictive markers in colorectal-cancer.
Virchows Arch 2003; 443: 139-45.
15. Hermanek P, Sobin L H. Colorectal carcinoma. In:
Hermane k, Gospodarowicz MK, Henson DE et al.
editors. Prognostic factors in cancer. Germany:
Springer-verlag, 1995; 64-79.
16. Eppler E, Zapf J, Bailer N, Falkmer UG, Falkmer S,
Reinecke M. IGF-I in human breast cancer: low
differentiation stage is associated with decreased IGF-I
content. Eur J Endocrinol 2002; 146: 813-21.
17. Yang X, Liu F, Xu Z, Chen C, Li G, Wu X, Li J. Growth
hormone receptor expression in human colorectal
cancer. Dig Dis Sci 2004; 49: 1493-8.
18. Donovan E A, Kummar S. Role of insulin-like growth
factor-1R system in colorectal carcinogenesis. Crit Rev
Oncol Hematol 2007 Oct 30; [Epub ahead of print]
19. Renehan AG, Zwahlen M, Minder C, O'Dwyer ST,
Shalet SM, Egger M. Insulin-like growth factor (IGF)-I,
IGF binding protein-3, and cancer risk: systematic
review and meta-regression analysis. Lancet 2004; 363:
1346–53.
20. Yu H, Rohan T. Role of insulin like growth factors
family in cancer development and progression. J Natl
Cancer Inst 2000; 92: 1472-89.
21. Schernhammer ES, Holly JM, Hunter DJ, Pollak MN,
Hankinson SE, Schernhammer ES, et al. Insulin-like
growth factor-I, its binding proteins (IGFBP-1 and
IGFBP-3), and growth hormone and breast cancer risk in
The Nurses Health Study II. Endocr Relat Cancer 2006;
13: 583-92.
22. Le Marchand L, Donlon T, Seifried A, Kaaks R,
Rinaldi S, Wilkens LR. Association of a common
polymorphism in the human GH1 gene with colorectal
neoplasia. J Natl Cancer Inst 2002; 94: 454–60.
23. Fukuda R, Hirota K, Fan F, Jung YD, Ellis LM,
Semenza GL. Insulin-like growth factor 1 induces
hypoxia-inducible factor 1-mediated vascular endothelial
growth factor expression, which is dependent on MAP
kinase and phosphotidylinositol 3-kinase signaling in
colon cancer cells. J Biol Chem 2002; 277: 38205–11.
24. Laughner E, Taghavi P, Chiles K, Mahon PC, Semenza
GL. HER2 (neu) signaling increases the rate of hypoxiainducible factor 1 (HIF-1) synthesis: novel
mechanism for HIF-1-mediated vascular endothelial
growth factor expression. Mol Cell Biol 2001; 21: 3995–
4004.
25. Grimberg A. Mechanisms by which IGF-1 may
promote cancer. Cancer Boil Ther 2003; 2: 630-35.
26. Kelley K W, Weigent D A, Kooijman R. Protein
hormones and immunity. Brain Behav Immun 2007; 21:
384–92. Epub 2007 Jan 2. Review.
Elsaid and Elkerm
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