Disertasi

Patogenesis dan Kesintasan Satu Tahun Pasien Pancreatic Ductal Adenocarcinoma: Kajian Peran Cyclooxygenase-2, Nuclear Factor Kappa-B, Specificity Protein 1, dan Activator Protein-1. = The Role of Cyclooxygenase-2, Nuclear Factor Kappa-B, Specificity Protein 1, and Activator Protein-1 in the Pathogenesis and the One-Year Survival Rate of Patients with Pancreatic Ductal Adenocarcinoma.

Pancreatic ductal adenocarcinoma (PDAC) adalah jenis kanker pankreas yang memiliki survival rate rendah. Sekitar 90% pasien PDAC memiliki mutasi pada gen KRAS, yang diasosiasikan dengan peningkatan jaras inflamasi downstream dan protein utama yang terlibat adalah cyclooxygenase-2 (COX-2). Faktor transkripsi yang dapat meningkatkan ekspresi COX-2 adalah nuclear factor kappa-B (NF-κB), specificity protein 1 (Sp1), dan activator protein-1 (AP-1). Hubungan COX-2 dengan kesintasan masih kontradiktif dan penelitian yang menganalisis hubungan antara NF-κB, Sp1, dan AP-1 dengan kesintasan masih sedikit. Oleh karena itu, perlu dilakukan penelitian untuk menganalisis hubungan ekspresi NF-κB, Sp1, AP-1 dan COX-2 dengan kesintasan satu tahun pasien PDAC. Penelitian observasional multisenter ini menggunakan sampel jaringan PDAC dari RSUPN dr. Cipto Mangunkusumo (RSCM), RSUP Fatmawati, RS Dharmais, RS Persahabatan, RSUD Dr. Soetomo, RS St. Carolus, dan RSCM Kencana. Waktu penelitian adalah dari April 2020 sampai April 2022. Kriteria inklusinya adalah pasien PDAC yang menjalani reseksi atau biopsi dan jaringannya dibuat pada Januari 2014 hingga Desember 2019. Sebanyak 54 pasien diikutsertakan pada penelitian. Data klinis diperoleh dari rekam medis. Ekspresi protein dideteksi melalui pemeriksaan imunohistokimia. Terkait COX-2, dinilai pewarnaan di sitoplasma, sedangkan NF-κB yang dinilai adalah pewarnaan subunit RelA/ p65 di nukleus dan sitoplasma. Terkait Sp1, dinilai pewarnaan di nukleus dan untuk AP-1, dinilai pewarnaan subunit c-Jun di nukleus. Analisis kesintasan diawali dengan membuat kurva Kaplan-Meier yang diikuti dengan analisis mutivariat regresi Cox. Ekspresi COX-2 lebih tinggi pada jaringan kanker (88,6%) dibandingkan jaringan nonkanker (57,1%) di sebelahnya. Terdapat trend peningkatan ekspresi ketiga protein lainnya di jaringan kanker dibandingkan nonkanker, meskipun tidak bermakna. Terdapat korelasi sedang antara COX-2 dengan NF-κB, Sp1, dan AP-1 subunit c-Jun. Tidak ada perbedaan bermakna pada ekspresi COX-2, Sp1, dan c-Jun antara pasien dengan faktor risiko DM, obesitas, alkohol, merokok, pankreatitis kronik dan pasien tanpa faktor risiko tersebut. Akan tetapi, pasien dengan DM memiliki ekspresi NF-κB lebih rendah dibandingkan tanpa DM. Pasien dengan ekspresi NF-κB nuklear (aHR = 0,22; 95% CI 0,07–0,66; P = 0,007) dan sitoplasmik (aHR = 0,31; 95% CI 0,11 –0,90; P = 0,032) berhubungan secara independen dengan prognosis pasien PDAC yang lebih baik. Sebaliknya, pasien dengan ekspresi c-Jun berhubungan secara independen dengan prognosis pasien PDAC yang lebih buruk (aHR = 4,01; 95% CI 1,13–14,27; P = 0,032). Tidak ada hubungan antara ekspresi COX-2 dan Sp1 dengan kesintasan pasien PDAC. Peningkatan ekspresi COX-2, NF-κB, Sp1, dan AP-1 subunit c-Jun di jaringan kanker menandakan jaras inflamasi berperan pada patogenesis PDAC. Ekspresi NF-κB yang berhubungan dengan prognosis lebih baik menandakan jaras inflamasi tidak selalu memberikan efek negatif untuk pasien. Ekspresi NF-κB RelA/ p65 dan AP-1 subunit c-Jun berpotensi digunakan sebagai faktor prognostik pasien PDAC.
Kata kunci: c-Jun, COX-2, Kanker pankreas, NF-κB, Sp1.


Pancreatic Ductal Adenocarcinoma (PDAC) is the most common type of pancreatic cancer with poor survival rates due to delays in diagnosis. About 90% of PDAC patients have a mutation in the KRAS gene, which is associated with increased activation of the inflammatory pathways. Cyclooxygenase-2 (COX-2) is a protein involved in the inflammatory pathway. Transcription factors such as nuclear factor kappa-B (NF-κB), specificity protein 1 (Sp1), and activator protein-1 (AP-1) regulate the expression of COX-2. Studies investigating the role of COX-2 expression as a prognostic factor had shown conflicting results, and few studies had investigated the prognostic values ofNF-κB, Sp1, and AP-1 expressions. Therefore, this study aims to investigate the associations between the COX-2, NF-κB, Sp1, and AP-1 tissue expressions and the 1-year survival rate in PDAC patients. This observational multicenter study used PDAC tissue samples obtained from dr. Cipto Mangunkusumo Hospital (RSCM), Fatmawati Central General Hospital, Dharmais National Cancer Hospital, Persahabatan Central General Hospital, Dr. Soetomo General Academic Hospital, St. Carolus Hospital, dan RSCM Kencana. The study was conducted from April 2020 to April 2022. The inclusion criteria were PDAC patients with tissue samples obtained from tumor resection or biopsy from January 2014 to December 2019. A total of 54 patients were included in this study. Clinical data were obtained from the medical record. Protein expression was assessed through immunohistochemistry. COX-2 staining was evaluated in the cytoplasm of the cells. For NF-κB evaluation, its RelA/ p65 subunit staining was assessed in both the nucleus and cytoplasm of the cells. Sp1 staining was evaluated in the nucleus of the cells. For AP-1 evaluation, its c-Jun subunit staining was assessed in the nucleus of the cells. Survival analysis was performed by creating Kaplan-Meier curves, followed by multivariate Cox regression analysis. COX-2 expression was higher in cancerous tissues (88.6%) than in the normal tissues (57.1%). There were also trends of increased expressions in the other three proteins, but they were not significant. There were moderate correlations between the four proteins. There were no significant differences in the expressions of COX-2, Sp1, and AP-1 between PDAC patients with and without risk factors (DM, obesity, alcohol, smoking, chronic pancreatitis). However, patients with DM had higher rates of positive NF-κB expression than those without DM. Positive nuclear (aHR = 0.22; 95% CI 0.07–0.66; P = 0.007) or cytoplasmic (aHR = 0.31; 95% CI 0.11 –0.90; P = 0.032) NF-κB expressions were independently associated with a better prognosis in PDAC patients. In contrast, positive c-Jun expression was independently associated with a worse prognosis in PDAC patients (aHR = 4.01; 95% CI 1.13–14.27; P = 0.032). The increased expression of the four proteins in cancerous tissues indicated that the inflammatory pathway was involved in the pathogenesis of PDAC. The association of positive NF-κB expression with better patient prognosis suggests that certain inflammatory pathways may have a beneficial effect. Tissue expressions of NF-κB RelA/p65 and the c-Jun subunit of AP-1 may potentially be used as prognostic factors.
Keywords: c-Jun, COX-2, NF-κB, Pancreatic cancer, Sp1.