Disertasi

Patogenesis dan Deteksi Penanda Prognosis Penurunan Sensitivitas Sel Adenokarsinoma Prostat terhadap Terapi Antiandrogen, melalui Telaah Persinyalan Reseptor Glukokortikoid, SGK-1, Wnt/-catenin, dan Sel Punca Kanker = Pathogenesis and Prognostic Biomarker Detection in Adenocarcinoma Prostate Cells Reduced Sensitivity to Antiandrogen, through the Study of Glucocorticoid Receptor Signaling, SGK-1 Wnt/-catenin, and Cancer Stem Cells.

Terapi kanker prostat masih menghadapi tantangan berupa relaps dan resistensi. Diduga salah satu penyebabnya adalah sel punca kanker (SPK). Potensi resistensi terhadap enzalutamid, antiandrogen generasi kedua yang relatif baru di Indonesia, perlu diketahui dengan mengidentifikasi SPK beserta jalur persinyalan molekularnya. Saat ini belum ada penelitian yang menganalisis secara bersamaan jalur persinyalan molekular AR (androgen reseptor), GR (glucocorticoid reseptor), SGK-1, dan Wnt/catenin, yang diduga berperan pada pembentukan SPK (CD133 dan CD44) setelah pemberian enzalutamid. Tujuan penelitian ini adalah mempelajari sifat SPK prostat dan jalur persinyalan yang terlibat dalam penurunan sensitivitas terhadap enzalutamid (in vitro), serta mengeksplorasi biomarker yang berpotensi menjadi prognosis pada pemberian antiandrogen (in vivo). Waktu penelitian Juli 2022–Desember 2023. Penelitian in vitro dilakukan di laboratorium terpadu FKUI dengan desain eksperimental menggunakan cell line adenokarsinoma prostat LNCaP yang dipajankan dengan enzalutamid selama 11 minggu. Penelitian in vivo menggunakan subjek 89 blok parafin pasien adenokarsinoma prostat sebelum pengobatan dari RSUPN Cipto Mangunkusumo, RS Medistra, RS Persahabatan, dan RS Fatmawati dengan desain kasus kontrol dalam pemberian terapi maksimal antihormonal (LHRH agonist dan antiandrogen generasi pertama). Kemudian blok parafin dilakukan pulasan imunohistokimia GR, SGK-1, Wnt/β-catenin, CD44 dan CD133 yang dihubungkan dengan kejadian castration resistant prostate cancer (CRPC) dalam dua tahun pengamatan. Pada penelitian in vitro didapatkan kecenderungan peningkatan jumlah SPK yang lebih tinggi pada kelompok pemberian enzalutamid (3,34 [±1,82]) dibanding kontrol (2,34 [±1,63]), p = 0,44. AR terekspresi lebih tinggi pada kelompok SPK 4,26 (0,76–5,83) dibandingkan non SPK 0,32 (0,24–1,73), p = 0,043. Kadar mRNA AR paling tinggi pada SPK pada kelompok enzalutamid (6,02 [±1,96]) p = 0,001. Pada penelitian in vivo rerata ekspresi CD44 lebih tinggi pada CRPC (177,6 [40–272]) dibanding non-CRPC (113,7 [30,8–261,8]), p =0,037. Ekspresi SGK-1 lebih tinggi pada kelompok CRPC (121 [15,2–245]) dibanding non-CRPC (102,8 [3,2–187]), p = 0,01. Ditemukan hubungan antara ekspresi SGK-1 tinggi dengan CRPC, p = 0,005, OR = 3,563 95%CI(1,458–8,706), sensitivitas 60%, spesifisitas 70,37%. Ditemukan hubungan antara tingginya minimal salah satu penanda SPK (CD44 atau CD133) dengan timbulnya CRPC, p = 0,044, OR = 2,843 95%CI (1,007–8,029), sensitivitas 82,85%, spesifisitas 37,03%. Simpulan: Terjadi peningkatan jumlah SPK dan mRNAAR sebagai respon pernurunan sensitifitas terhadap antiandrogen generasi kedua yaitu enzalutamide. Pasien yang mengalami CRPC dalam 2 tahun (early) setelah pemberian terapi maksimal antihormonal lebih sering memiliki kadar SGK-1 tinggi dan minimal salah satu penanda SPK (CD133 atau CD44) tinggi.
Kata kunci: Castration Resistant Prostate Cancer, enzalutamid, sel punca kanker


Prostate cancer therapy still faces some challenges, including relapse and resistance. The presence of cancer stem cells (CSCs) is suspected to be one of the causes. Enzalutamide is a second-generation antiandrogen regiment that is relatively new in Indonesia, so the resistance potential needs to be explored by CSC and its molecular signaling pathway identification. Currently, no study has simultaneously analyzed the molecular signaling pathways of AR (Androgen Receptor), GR (Glucocorticoid Receptor), SGK-1, and Wnt/β-catenin, which are thought to play a role in CSC (CD44 and CD133) formation after enzalutamide administration. This study aims to explain the characteristics of prostate CSCs and the signaling pathways involved in reduced sensitivity to enzalutamide (in vitro) and to explore potential prognostic biomarkers in antiandrogen administration (in vivo).This study was held from July 2022–December 2023. The in vitro study took place in the laboratorium terpadu FKUI with an experimental design using prostate cancer cell line LNCaP exposed to enzalutamide for 11 weeks. The in vivo study evaluated 89 paraffin blocks from prostate cancer patients treated with maximal ADT at Cipto Mangunkusumo General Hospital, Medistra Hospital, Persahabatan Hospital, and Fatmawati Hospital. Afterward, we conducted immunohistochemical staining of GR, SGK-1, Wnt/β-catenin, CD44, and CD133 expressions and correlated with CRPC incidence within two years. In vitro study showed tendency of cancer stem cells enhancement in treatment group (3.34 [±1.82]) than control group (2.34 [±1.63]), p = 0.44. AR expressions was higher in CSC group 4.26 (0.76–5.83) than non-CSC group 0.32 (0.24–1.73), p = 0.043. The highest AR mRNA levels were found in treated CSC group (6.02 [±1,96]) p = 0.001. In vivo study obtained higher mean of CD44 expressions in CRPC group (177.6 [40–272]) than nonCRPC group (113.7 [30.8–261.8]), p = 0.037. SGK-1 expression was higher in CRPC group (121 [15.2–245]) than non-CRPC group (102.8 [3.2–187]), p = 0.01. We also found association between high SGK-1 expressions and CRPC incidence, p = 0.005, OR = 3.563 95%CI (1.458–8.706), sensitivity 60%, specificity 70.37%. There was also an association between at least one marker (CD44 high or CD133 high) and CRPC incidence, p = 0.044, OR = 2.843 95%CI (1 .007–8.029), sensitivity 82.85%, specificity 37.03%. Conclusion: AR pathway is one of the enzalutamide resistance dominant pathways. CRPC patients within 2 years after maximal ADT therapy were more likely to have higher SGK-1 levels and at least one high CSC marker (CD44 or CD133).
Keywords: Cancer stem cell, Castration Resistant Prostate Cancer, enzalutamide