Abstract
Objective
Folate receptor α (FRα) is a membrane protein expressed in various solid tumors but has limited expression in normal cells. Therefore, FRα is an attractive target for cancer treatment. This study aimed to investigate the relationship between FRα expression and the clinicopathological characteristics and survivals of cervical cancer.
Methods
This retrospective study included patients with cervical cancer who underwent primary surgery between 2000 and 2020 at our institution. Immunohistochemical staining of FRα was performed using an anti-folate-binding protein/FBP antibody. FRα-positive staining was defined as ≥5% of tumor staining and FRα-high as ≥50% tumor staining with ≥2+ intensity. The association between FRα expression and survival was assessed using multivariate Cox regression analysis, adjusting for established prognostic factors.
Results
Overall, 123 patients were identified, and 140 tumor samples, including 17 paired primary and metastatic samples, were evaluated. As histological types, 67 patients had squamous cell carcinoma (SCC), and 56 patients had non-SCC. All primary tumors were FRα-positive. High FRα expression was observed in 25% of the cases and differed according to histology (SCC vs. non-SCC, 14.9% vs. 37.5%, p=0.004). FRα expression was significantly higher in metastatic tumors than in primary (170 [IQR, 140–205] vs. 125 [IQR, 110–150], p=0.0006). High FRα expression was significantly associated with worse overall survival (hazard ratio, 6.73; 95% confidence interval, 2.21–20.53; p=0.001).
Conclusion
In cervical cancer, FRα expression was elevated in metastatic tumors and high expression was associated with a worse prognosis. Our study supports the development of FRα-targeted therapy for advanced cervical cancer.
Keywords: Folate Receptor Alpha, Cervical Cancer, Biomarkers
Synopsis
The association between folate receptor α (FRα) and cervical cancer remains unclear. High FRα expression was observed in 25% of the patients, which was more frequent in non-squamous histology. The FRα expression was significantly higher in the metastatic than in the primary tumors. FRα was an independent prognostic factor for poor overall survival.
INTRODUCTION
Cervical cancer is the fourth most common cancer among women worldwide [1]. Although the incidence of cervical cancer has been decreasing in Western countries due to the widespread use of vaccines against high-risk human papillomavirus (HPV), the incidence is still high in Asia, including Japan [2,3]. Squamous cell carcinoma (SCC) is the predominant histological type of cervical cancer, accounting for 80%–90% of cervical cancers. Other common types are adenocarcinoma (AC) and adenosquamous carcinoma (ASC), found in approximately 10%–25% and 5%–6% of the cases, respectively. No specific treatment has been established for each histological type. The standard treatment for metastatic or recurrent cervical cancer is systemic chemotherapy, but the prognosis is poor, with a median survival of 17 months [4,5]. When patients become refractory to first-line platinum-based chemotherapy, second-line and subsequent treatments have limited efficacy [6]. Therefore, novel treatment strategies need to be developed. Recent advances in molecular targeted therapy have improved the prognosis of other cancer types [7], and it is crucial to investigate new therapeutic targets to improve the prognosis of cervical cancer.
Folate receptor α (FRα) is a 38–40 kDa glycosyl-phosphatidylinositol-anchored membrane protein [8] encoded by FOLR1. FRα is considered to play a role in cell migration and invasion, and overexpression of this receptor is associated with tumor progression in preclinical models [9]. FRα is expressed over the entire surface of tumor cells in various cancer types, including ovarian cancer, triple-negative breast cancer (TNBC), endometrial cancer, and non-small cell lung cancer (NSCLC) [10,11,12]. In contrast, non-malignant tissues exhibit limited FRα expression. Therefore, FRα has been investigated as a potential target for cancer treatment, and various therapeutic developments are underway, including antibody-drug conjugates (ADCs), small molecules, and chimeric antigen receptor (CAR)-T therapy [13,14,15]. Mirvetuximab soravtansine, an ADC comprising an FRα-binding antibody, a cleavable linker, and the potent tubulin-targeting agent maytansinoid DM4, has demonstrated a tumor response in relapsed ovarian cancer with high FRα expression [16]. An FRα-targeted thymidylate synthase inhibitor has also shown an objective response in FRα-overexpressing ovarian cancer [17]. These FRα-targeted treatments may improve the prognosis of FRα-overexpressing tumors.
To date, no studies have evaluated the association between FRα expression and the clinicopathological features and prognosis of cervical cancer. A previous study by Liu et al. [18] has shown that 40% of SCCs exhibit moderate or high FRα expression. However, FRα expression in non-SCC patients and its prognostic role remain unclear. In this study, we aimed to evaluate FRα expression in various histological types of cervical cancer and its association with prognosis. We also compared FRα expression between primary and paired metastatic tumors to examine the stability of FRα expression status during disease progression.
MATERIALS AND METHODS
1. Study population
We identified patients who underwent surgery as a primary treatment at the National Cancer Center Hospital (Tokyo, Japan) between January 2000 and December 2020. Among these patients, we further identified those who subsequently developed metastatic disease and underwent tumor biopsy for paired metastatic tumors. Patients with unavailable or insufficient primary tumor tissue were excluded from the study. We retrospectively collected clinical and pathological data, such as age, histology, clinical stage according to the International Federation of Gynecology and Obstetrics (FIGO) 2008 system [19], lymph node metastasis, adjuvant treatment, and survival time after surgery. All cases were reviewed, and pathological diagnoses were confirmed by at least two gynecological pathologists. Furthermore, given that the study period was approximately 20 years, the permanent slides of all cases were microscopically reviewed, and the final diagnoses were confirmed for the present study according to the 2014 World Health Organization classification of cervical cancer [20]. In this study, we separated usual-type endocervical adenocarcinoma and gastric-type adenocarcinoma (GAS) for subsequent analysis because these two types of adenocarcinoma reportedly have quite different etiologies and clinicopathological features [21,22]. This study was approved by the Institutional Review Board of the National Cancer Center (Tokyo, Japan) (No. 2014-393). Written informed consent was waived because of the retrospective design.
2. Immunohistochemical staining and evaluation
Hematoxylin and eosin-stained slides for each case were reviewed to obtain representative sections. New 4-μm-thick sections were prepared from formalin-fixed paraffin-embedded surgical specimens. FRα expression was evaluated by immunohistochemical staining using rabbit anti-folate binding protein/FBP antibody (ab67422; Abcam, Cambridge, UK) at a dilution of 1:200. Antigen retrieval was achieved in Target Retrieval Solution (pH 9) using a PT Link machine (Dako, Glostrup, Denmark). Immunohistochemical staining was performed using the Dako Autostainer Link 48 and EnVision Flex Mini kit (Dako), according to the manufacturer’s protocols. Briefly, deparaffinization, rehydration, and antigen retrieval (97°C, 20 minutes) were performed using PT-Link (Dako) in EnVision™ FLEX Target Retrieval Solution High pH 9.0 (Dako) for the antibody to FBP. Endogenous peroxidase was blocked using EnVision™ FLEX Peroxidase-Blocking Reagent (Dako) (5 minutes). Slides were then stained with Dako Link 48 Autostainer Immunostaining System (Agilent Technologies, Santa Clara, CA, USA) at room temperature for 60 min. EnVision Flex Mini-Kit HRP (K8023; Dako) was applied for 30 min; then, staining was visualized with EnVision Flex DAB-substrate chromagen (EnVision Flex Mini-Kit; Dako), which had been applied for 10 minutes. Slides were counterstained with hematoxylin (#SK203; Dako), dehydrated through graded ethanol solutions, cleared with xylene, and coverslipped. The H-score of FRα expression was calculated using the following formula: 3X+2Y+Z, where X, Y, and Z are the proportions of tumor cells showing strong (3+), moderate (2+), and weak (1+) staining intensities, respectively. The maximum H-score was 300 (strong staining of all tumor cells), and the minimum was 0 (no staining of any tumor cells). The immunohistochemistry results were defined as FRα-positive if ≥5% of tumor cells had FRα expression at ≥1+ intensity. The tumor tissues were scored for FRα expression as follows: high ≥50% of tumor cells ≥2+ staining intensity and low <50% of tumor cells ≥2+ staining intensity.
3. Association between FOLR1 mRNA expression and histological types of cervical cancer using The Cancer Genome Atlas (TCGA) dataset
FOLR1 mRNA expression data were obtained from the cBioPortal [23,24]. Of mRNA expression data available from 306 patients with cervical cancer, data for a total of 243 patients with either SCC (n=221) or AC (n=22) were analyzed. An analysis was performed on the log-transformed RNA-Seq by Expectation-Maximization V2-normalized data.
4. Statistical analysis
Continuous variables were reported as median, range, and interquartile range (IQR) and were compared using the Mann-Whitney U test. Categorical variables were reported as numbers and percentages and compared using the chi-square test. Disease-free survival (DFS) and overall survival (OS) were estimated using the Kaplan-Meier method. The log-rank test was used to compare the survival between the groups. DFS was defined as the time from surgery to the first relapse or death from any cause. OS was defined as the time from surgery to the death from any cause. We used a Cox proportional hazards model for univariate and multivariate analyses to identify the prognostic value of high FRα expression. All tests were two-tailed, and the significance level was set at α=0.05. Statistical analyses were performed using STATA (version 15.1; StataCorp, College Station, TX, USA) and GraphPad Prism version 8.0 (GraphPad Software, San Diego, California, USA).
RESULTS
1. Patient characteristics
A total of 123 patients were included in the analysis. Among them, 17 patients had paired metachronous metastatic tumor samples for which FRα expression could be assessed. Patient characteristics are shown in Table 1. The median age was 45 years (range, 26–72 years). There were 67 patients (54.5%) with SCC, 27 patients (22.0%) with AC, all of which had usual-type endocervical adenocarcinoma, 13 patients (10.6%) with ASC, 12 patients (9.8%) with GAS, and 4 patients (3.3%) with neuroendocrine carcinoma. Ninety-six patients (78%) had FIGO stage I disease while 27 (22%) had FIGO stage II disease. Lymph node metastasis was present in 45 patients (36.6%). For treatment, 44 patients (35.8%) received postoperative radiotherapy (RT), and 13 patients (10.6%) received postoperative concurrent chemoradiotherapy (CCRT).
Table 1. Patient characteristics.
| Characteristics | Total (n=123) | FRα-high (n=31) | FRα-low (n=92) | p-value | |
|---|---|---|---|---|---|
| Age (yr) | 45 (26–72) | 44 (30–67) | 46 (26–72) | 0.500 | |
| Histological types | 0.009 | ||||
| SCC | 67 (54.5) | 10 (32.3) | 57 (62.0) | ||
| AC | 27 (22.0) | 9 (29.0) | 18 (19.6) | ||
| GAS | 12 (9.8) | 5 (16.1) | 7 (7.6) | ||
| ASC | 13 (10.6) | 7 (22.6) | 6 (6.5) | ||
| NEC | 4 (3.3) | 0 (0) | 4 (4.4) | ||
| FIGO stage (2008) | 0.040 | ||||
| IA1 | 2 (1.6) | 2 (6.5) | 0 (0) | ||
| IB1 | 62 (50.4) | 13 (41.9) | 49 (53.3) | ||
| IB2 | 32 (26.0) | 7 (22.6) | 25 (27.2) | ||
| IIA1 | 5 (4.1) | 0 (0) | 5 (5.4) | ||
| IIA2 | 6 (4.9) | 2 (6.5) | 4 (4.3) | ||
| IIB | 16 (13.0) | 7 (22.6) | 9 (9.8) | ||
| Tumor size | 0.110 | ||||
| ≤4 cm | 67 (54.5) | 13 (41.9) | 54 (58.7) | ||
| >4 cm | 56 (45.5) | 18 (58.1) | 38 (41.3) | ||
| Lymph nodes metastasis | 0.780 | ||||
| Positive | 45 (36.6) | 12 (38.7) | 33 (35.9) | ||
| Negative | 78 (63.4) | 19 (61.3) | 59 (64.1) | ||
| LVSI | 0.016 | ||||
| Positive | 77 (62.6) | 25 (80.7) | 52 (56.5) | ||
| Negative | 46 (37.4) | 6 (19.4) | 40 (43.5) | ||
| Adjuvant RT/CCRT | 0.270 | ||||
| Yes | 57 (46.3) | 17 (54.8) | 40 (43.5) | ||
| No | 66 (53.7) | 14 (45.2) | 52 (56.5) | ||
Values are presented as median (range) or number (%).
AC, adenocarcinoma; ASC, adenosquamous carcinoma; CCRT, concurrent chemoradiotherapy; FIGO, International Federation of Gynecology and Obstetrics; FRα, folate receptor α; GAS, gastric-type adenocarcinoma; LVSI, lymphovascular space involvement; NEC, neuroendocrine carcinoma; RT, radiotherapy; SCC, squamous cell carcinoma.
2. Association between FRα expression and clinicopathological features
FRα expression was detected in all primary tumor samples. The median H-score of the primary tumor samples was 125 (IQR, 110–150). High FRα expression was found in 25% (31/123) of the primary tumor samples. Fig. 1A and B show representative images of FRα expression in SCC and AC, respectively. High FRα expression was associated with non-SCC (21 [67.7%] vs. 35 [38.0%]) and lymphovascular space involvement (LVSI) (25 [80.7%] vs. 52 [56.5%]) compared with low FRα expression. Other clinicopathological factors, including age (<45 vs. ≥45 years), tumor size (≤4 vs. >4 cm), stage (FIGO stage I vs. II), lymph node metastasis (positive vs negative), and adjuvant RT/CCRT (yes vs. no), were not significantly associated with high FRα expression.
Fig. 1. FRα-expression in different histological types of cervical cancer.
Representative intensity patterns for FRα expression in (A) SCC and (B) AC. (C) Difference in FOLR1 mRNA expression between SCC and AC using TCGA dataset. The dots depict the FOLR1 expression in each patient. The box represents the first quartile, median, and third quartile; whiskers represent the minimum/maximum values. Red and blue dots refer to AC and SCC, respectively.
AC, adenocarcinoma; FRα, folate receptor α; SCC, squamous cell carcinoma; TCGA, The Cancer Genome Atlas.
High FRα expression was more frequent in non-SCC than in SCC histology (non-SCC vs. SCC, 37.5% [21/56] vs. 14.9% [10/67]; p=0.004). Of note, 54% (7/13) of the patients with ASC and 42% (5/12) of those with GAS had high FRα expression (Table 2). According to TCGA dataset, FOLR1 mRNA expression was higher in AC than in SCC (log fold change −4.76, p<0.001; Fig. 1C).
Table 2. FRα expression in primary tumors by histological types of cervical cancer.
| Variables | Histological type | |||||
|---|---|---|---|---|---|---|
| SCC (n=67) | AC (n=27) | GAS (n=12) | ASC (n=13) | NEC (n=4) | Total (n=123) | |
| H-score | 120 (110–140) | 125 (105–160) | 140 (132.5–167.5) | 150 (110–162.5) | 106 (63–117.5) | 125 (110–150) |
| FRα-high | 10 (14.9) | 9 (33.3) | 5 (41.7) | 7 (53.8) | 0 (0) | 32 (26) |
| FRα-low | 56 (83.6) | 18 (66.6) | 7 (58.3) | 6 (56.2) | 4 (100) | 91 (74) |
Values are presented as median (interquartile range) or number (%).
AC, adenocarcinoma; ASC, adenosquamous carcinoma; FRα, folate receptor α; GAS, gastric-type adenocarcinoma; NEC, neuroendocrine carcinoma; SCC, squamous cell carcinoma.
3. FRα expression in primary and metastatic tumors
First, we compared FRα expression between the primary and metastatic tumor samples in the total population. The median H-score of FRα expression in metastatic tumors was significantly higher than that in primary tumors (primary vs. metastatic, 125 [IQR, 110–150] vs. 170 [IQR, 140–205]; p=0.0006) (Fig. 2A). Twelve of the 17 (70%) metastatic tumors showed high FRα expression. Next, we analyzed FRα expression in patients with primary and paired metastatic tumor samples (n=17). The H-score of FRα expression in the paired metastatic tumors was higher than that in the primary tumors in 13/17 (76.5%) of the patients. Among the 13 patients with low FRα in the primary tumor, 8 patients (61.5%) had high FRα in the paired metastatic tumor (Fig. 2B). None of the patients were observed to display high FRα in the primary tumor in contrast to low FRα in the paired metastatic tumor. A representative case with low FRα expression in the primary tumor and high FRα in the lymph node metastasis is shown in Fig. 2C.
Fig. 2. FRα-expression in the primary and paired metastatic tumors.
(A) FRα expression in the total patient population. The dots depict the FRα expression in each patient. The box represents the first quartile, median, and third quartile; whiskers represent the minimum and maximum values. (B) FRα expression in primary and paired metastatic tumors. (C) Representative FRα-stained sections for primary and paired metastatic tumors.
FRα, folate receptor α.
4. Association between high FRα expression and survival
We evaluated the association between FRα expression in primary tumors and survival. The median follow-up period was 62.6 months (95% confidence interval [CI]=9.1–128.9 months). There was a significant difference in DFS between the FRα-high and FRα-low groups (hazard ratio [HR]=2.05; 95% CI=1.08–3.89; log-rank p=0.025). The estimated 5-year DFS was 55.8% (95% CI=36.0%–71.7%) in patients with high FRα expression and 75.3% (95% CI=64.7%–83.2%) in those with low FRα expression (Fig. 3A). There was also a significant difference in OS between the FRα-high and FRα-low groups (HR=4.12; 95% CI=1.62–10.46; log-rank p=0.0013). The estimated 5-year OS was 72.9% (95% CI=52.9%–85.4%) in patients with high FRα expression and 91.1% (95% CI=82.6%–95.7%) in patients with low FRα expression (Fig. 3B). Multivariable analysis included age, histology, FIGO stage, lymph node metastasis, LVSI, adjuvant RT/CCRT, and FRα expression and showed that high FRα expression was significantly associated with worse DFS (HR=2.26; 95% CI=1.08–4.72; p=0.031; Table S1) and OS (HR=6.73; 95% CI=2.21–20.53; p=0.001; Table 3).
Fig. 3. Kaplan-Meier analysis of DFS and OS according to FRα-high expression.
(A) DFS and (B) OS in patients with high FRα expression vs patients with low FRα expression.
DFS, disease-free survival; FRα, folate receptor α; OS, overall survival.
Table 3. Association between FRα expression and overall survival.
| Variables | Univariable | Multivariable | ||||
|---|---|---|---|---|---|---|
| HR | 95% CI | p-value | HR | 95% CI | p-value | |
| Age (continuous) | 1.00 | 0.96–1.05 | 0.87 | 1.02 | 0.97–1.07 | 0.51 |
| FIGO stage (I vs. II) | 1.49 | 0.53–4.19 | 0.45 | 0.73 | 0.25–2.15 | 0.57 |
| Lymph node metastasis (negative vs. positive) | 10.51 | 3.05–36.24 | <0.001 | 27.11 | 5.25–139.8 | <0.001 |
| Histological type (SCC vs. non-SCC) | 1.27 | 0.53–3.08 | 0.59 | 0.84 | 0.31–2.26 | 0.73 |
| LVSI (no vs. yes) | 3.24 | 0.94–11.18 | 0.063 | 1.01 | 0.25–4.07 | 0.99 |
| Adjuvant RT/CCRT (no vs. yes) | 2.74 | 1.03–7.30 | 0.044 | 0.28 | 0.08–1.03 | 0.055 |
| FRα expression (low vs. high) | 4.12 | 1.62–10.46 | 0.003 | 6.73 | 2.21–20.53 | 0.001 |
CCRT, concurrent chemoradiotherapy; CI, confidence interval; FIGO, International Federation of Gynecology and Obstetrics; FRα, folate receptor α; HR, hazard ratio; LVSI, lymphovascular space involvement; RT, radiotherapy; SCC, squamous cell carcinoma.
DISCUSSION
To our knowledge, this is the first study to examine FRα expression in various histological types and prognostic outcomes in cervical cancer. High FRα expression was found in 25% of the primary tumors, was significantly more frequent in non-SCC histology than in SCC histology, and was an independent poor prognostic factor. In addition, FRα expression was higher in metastatic tumors than in the corresponding primary tumors.
FRα overexpression has been reported in 76%–89% of serous ovarian cancer, 35%–74% of TNBC, 20%–50% of endometrial cancer, and 14%–74% of NSCLC patients [25,26]. In our study, 25% of the patients with cervical cancer showed high FRα expression. FRα expression differed by histological type and was higher in non-SCC than in SCC (38% vs. 15%). Using the TCGA dataset, we further confirmed that FOLR1 mRNA expression was higher in AC than in SCC. Previous studies in other cancer types have also shown that FRα expression varies according to histological type. A study of FRα expression in ovarian cancer revealed that FRα was expressed in 76% of high-grade serous carcinoma (HGSC) and 32% of clear cell carcinoma [27]. Furthermore, in a study involving NSCLC patients, FRα expression was found to be significantly higher in AC than in SCC [28]. Cervical adenocarcinoma has been increasing worldwide, especially among young women [2,29], and GAS incidence is not expected to decrease even after widespread HPV vaccination since GAS is regarded as HPV-independent [21,30]. Patients with AC and GAS of the cervix are more resistant to standard treatments and have a poorer prognosis than those with SCC [31,32]. Therefore, new therapeutic strategies are needed for patients with AC and GAS of the cervix, and FRα may become an attractive therapeutic target.
This study showed that high FRα expression was an independent factor for poor prognosis. The prognostic impact of FRα expression has been evaluated in various cancer types. Although a recent meta-analysis indicated that high expression of FRα was associated with poor survival [33], its prognostic impact remains controversial. According to a study of 91 patients with HGSC, high FRα expression was a predictive marker of chemoresistance and was associated with poor prognosis [34]. On the other hand, an ovarian tumor tissue analysis consortium study of 1,400 patients with HGSC showed that FRα expression was not associated with progression-free survival and OS [27]. Differences in patient populations, staining, and scoring methods may have affected these results. Indeed, larger studies are needed to confirm the prognostic impact of FRα expression in cervical cancer.
FRα expression was higher in metastatic tumors than in the corresponding primary tumors. Of note, 61% of the patients with low FRα expression in the primary tumor exhibited high FRα expression in the metastatic tumor. Martin et al. compared FRα expression in archival and post-recurrence biopsy samples of ovarian cancer; this study revealed that in 2 out of 5 patients (40%), the archival tumor samples displayed low FRα expression, whereas the post-recurrence biopsy samples displayed high FRα expression [16]. Thus, more patients may benefit from FRα-targeted therapy through the re-biopsy of metastatic tumors.
This study had several limitations. First, it was a retrospective study, and a relatively small number of patients were included from a single institution. Our cohort included a relatively lower frequency of SCC (62%) than what is found in the general population. According to the population-based cancer registry in Japan, patients with SCC comprised 75.5% of cervical cancer patients in 2005 [35]. Furthermore, because of the long enrollment period, changes in treatment strategies may have affected the prognosis. Therefore, the generalizability of the prognostic impact of FRα expression remains uncertain. Second, we found increased FRα expression in the paired metastatic tumors, but the mechanism was unclear. One possibility is that clonal selection occurred during tumor progression, whereas postoperative treatment, site of recurrence, and time to relapse may also be associated. Since only 17 patients had paired metastatic samples, we were unable to evaluate the potential effects of these factors. Third, the association of HPV status and genomic alterations with FRα expression was not evaluated. In ovarian, breast, and endometrial cancers, FRα expression has been reported to be higher in HGSC, TNBC, and non-endometrioid (type II) cancers [27,36,37], in which most tumors are known to have TP53 mutations. These results raised the hypothesis that genomic alterations, such as TP53 mutations, may be associated with FRα expression. Our results support this hypothesis because the frequency of TP53 mutation is higher in AC than in SCC in cervical cancer (AC vs. SCC, 20.9% vs. 5.6%) [38]. Further evaluation is required to confirm this hypothesis.
In conclusion, 25% of cervical cancers had high FRα expression, which was more prevalent in non-SCCs. High FRα expression was significantly associated with poor prognosis and was increased in metastatic tumors compared with primary tumors. FRα expression is a promising therapeutic target, and the development of FRα-targeted therapy may be desirable for the treatment of advanced cervical cancer.
ACKNOWLEDGEMENTS
The authors are grateful to Nao Nakamura and Kyoko Onozawa for their secretarial assistance. We would like to thank Editage (www.editage.com) for English language editing.
Footnotes
Presentation: This manuscript has been presented at the American Association of Cancer Research Annual Meeting 2021.
Conflict of Interest: Shu Yazaki, Yuki Kojima, Hiroshi Yoshida, Shigemasa Takamizawa, Rui Kitadai, Tatsunori Shimoi, Kazuki Sudo, Ayumi Saito, Hitomi Sumiyoshi Okuma, Maki Tanioka, Masaya Uno, Mitsuya Ishikawa and Tomoyasu Kato have nothing to disclose. Tadaaki Nishikawa reports personal fees from Takeda Pharmaceutical Company, Eisai, and AstraZeneca, outside the submitted work. Emi Noguchi reports personal fees from Pfizer, Taiho, Eli Lilly, AstraZeneca, Chugai, and Eisai, outside the submitted work. Yasuhiro Fujiwara reports personal fees from AstraZeneca, Chugai, Daiichi Sankyo, Bristol-Myers, SRL, and Santen, outside the submitted work. Yuichiro Ohe reports grants and personal fees from AstraZeneca, Amgen, Bristol-Myers Squibb, Chugai, Eli Lilly, Janssen, Kyorin, Nippon Kayaku, Novartis, Ono Pharmaceutical Company, MSD, Pfizer, Taiho, and Takeda Pharmaceutical Company, personal fees from Boehringer Ingelheim and Celtrion, and grants from Kissei, outside the submitted work. Kan Yonemori reports personal fees from Pfizer, AstraZeneca, Eisai, Takeda Pharmaceutical Company, Chugai, Ono Pharmaceutical Company, Novartis, and Daiichi Sankyo, outside the submitted work. We received no funding support.
- Conceptualization: Y.S., K.Y., Y.H.
- Data curation: Y.S.
- Formal analysis: Y.S., K.Y.
- Methodology: Y.H.
- Project administration: K.Y.
- Supervision: Y.K.
- Writing - original draft: Y.S., K.Y., Y.H.
- Writing - review & editing: T.S., K.R., N.T., S.T., S.K., S.A., O.H.S., T.M., N.E., U.M., I.M., K.T., F.Y., O.Y., Y.K.
SUPPLEMENTARY MATERIAL
Association between FRα expression and disease-free survival
References
- 1.Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018;68:394–424. doi: 10.3322/caac.21492. [DOI] [PubMed] [Google Scholar]
- 2.Yagi A, Ueda Y, Kakuda M, Tanaka Y, Ikeda S, Matsuzaki S, et al. Epidemiologic and clinical analysis of cervical cancer using data from the population-based Osaka Cancer Registry. Cancer Res. 2019;79:1252–1259. doi: 10.1158/0008-5472.CAN-18-3109. [DOI] [PubMed] [Google Scholar]
- 3.Bray F, Jemal A, Grey N, Ferlay J, Forman D. Global cancer transitions according to the Human Development Index (2008-2030): a population-based study. Lancet Oncol. 2012;13:790–801. doi: 10.1016/S1470-2045(12)70211-5. [DOI] [PubMed] [Google Scholar]
- 4.Tewari KS, Sill MW, Long HJ, 3rd, Penson RT, Huang H, Ramondetta LM, et al. Improved survival with bevacizumab in advanced cervical cancer. N Engl J Med. 2014;370:734–743. doi: 10.1056/NEJMoa1309748. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Kitagawa R, Katsumata N, Shibata T, Kamura T, Kasamatsu T, Nakanishi T, et al. Paclitaxel plus carboplatin versus paclitaxel plus cisplatin in metastatic or recurrent cervical cancer: the open-label randomized phase III trial JCOG0505. J Clin Oncol. 2015;33:2129–2135. doi: 10.1200/JCO.2014.58.4391. [DOI] [PubMed] [Google Scholar]
- 6.Boussios S, Seraj E, Zarkavelis G, Petrakis D, Kollas A, Kafantari A, et al. Management of patients with recurrent/advanced cervical cancer beyond first line platinum regimens: where do we stand? A literature review. Crit Rev Oncol Hematol. 2016;108:164–174. doi: 10.1016/j.critrevonc.2016.11.006. [DOI] [PubMed] [Google Scholar]
- 7.Kris MG, Johnson BE, Berry LD, Kwiatkowski DJ, Iafrate AJ, Wistuba II, et al. Using multiplexed assays of oncogenic drivers in lung cancers to select targeted drugs. JAMA. 2014;311:1998–2006. doi: 10.1001/jama.2014.3741. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Luhrs CA, Slomiany BL. A human membrane-associated folate binding protein is anchored by a glycosyl-phosphatidylinositol tail. J Biol Chem. 1989;264:21446–21449. [PubMed] [Google Scholar]
- 9.Siu MK, Kong DS, Chan HY, Wong ES, Ip PP, Jiang L, et al. Paradoxical impact of two folate receptors, FRα and RFC, in ovarian cancer: effect on cell proliferation, invasion and clinical outcome. PLoS One. 2012;7:e47201. doi: 10.1371/journal.pone.0047201. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.O’Shannessy DJ, Somers EB, Smale R, Fu YS. Expression of folate receptor-α (FRA) in gynecologic malignancies and its relationship to the tumor type. Int J Gynecol Pathol. 2013;32:258–268. doi: 10.1097/PGP.0b013e3182774562. [DOI] [PubMed] [Google Scholar]
- 11.Necela BM, Crozier JA, Andorfer CA, Lewis-Tuffin L, Kachergus JM, Geiger XJ, et al. Folate receptor-α (FOLR1) expression and function in triple negative tumors. PLoS One. 2015;10:e0122209. doi: 10.1371/journal.pone.0122209. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Tamura N, Fujiwara Y, Hashimoto T, Shiraishi H, Kitano S, Shimizu T, et al. Correlation between the expression of folate receptor alpha (FRα) and clinicopathological features in patients with lung adenocarcinoma. Lung Cancer. 2020;145:152–157. doi: 10.1016/j.lungcan.2020.05.002. [DOI] [PubMed] [Google Scholar]
- 13.Kim M, Pyo S, Kang CH, Lee CO, Lee HK, Choi SU, et al. Folate receptor 1 (FOLR1) targeted chimeric antigen receptor (CAR) T cells for the treatment of gastric cancer. PLoS One. 2018;13:e0198347. doi: 10.1371/journal.pone.0198347. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Moore KN, Martin LP, O’Malley DM, Matulonis UA, Konner JA, Perez RP, et al. Safety and activity of mirvetuximab soravtansine (IMGN853), a folate receptor alpha-targeting antibody-drug conjugate, in platinum-resistant ovarian, fallopian tube, or primary peritoneal cancer: a phase I expansion study. J Clin Oncol. 2017;35:1112–1118. doi: 10.1200/JCO.2016.69.9538. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Banerji U, Ingles Garces AH, Michalarea V, Ruddle R, Raynaud FI, Riisnaes R, et al. An investigator-initiated phase I study of ONX-0801, a first-in-class alpha folate receptor targeted, small molecule thymidylate synthase inhibitor in solid tumors. J Clin Oncol. 2017;35:2503. [Google Scholar]
- 16.Martin LP, Konner JA, Moore KN, Seward SM, Matulonis UA, Perez RP, et al. Characterization of folate receptor alpha (FRα) expression in archival tumor and biopsy samples from relapsed epithelial ovarian cancer patients: a phase I expansion study of the FRα-targeting antibody-drug conjugate mirvetuximab soravtansine. Gynecol Oncol. 2017;147:402–407. doi: 10.1016/j.ygyno.2017.08.015. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Banerjee SN, Ingles Russo AI, Biondo A, Funingana IG, Little M, Prout T, et al. A phase I trial a FR alpha targeted thymidylate synthase inhibitor CT900 exploring four schedules of treatment in expansion cohorts of patients with high-grade serous ovarian cancer. J Clin Oncol. 2020;38:6043. [Google Scholar]
- 18.Liu C, Ding L, Bai L, Chen X, Kang H, Hou L, et al. Folate receptor alpha is associated with cervical carcinogenesis and regulates cervical cancer cells growth by activating ERK1/2/c-Fos/c-Jun. Biochem Biophys Res Commun. 2017;491:1083–1091. doi: 10.1016/j.bbrc.2017.08.015. [DOI] [PubMed] [Google Scholar]
- 19.Pecorelli S, Zigliani L, Odicino F. Revised FIGO staging for carcinoma of the cervix. Int J Gynaecol Obstet. 2009;105:107–108. doi: 10.1016/j.ijgo.2009.02.009. [DOI] [PubMed] [Google Scholar]
- 20.Kurman RJ, Carcangiu ML, Young RH, Herrington CS. WHO classification of tumours of female reproductive organs. Lyon: International Agency for Research on Cancer; 2014. [Google Scholar]
- 21.Pirog EC, Lloveras B, Molijn A, Tous S, Guimerà N, Alejo M, et al. HPV prevalence and genotypes in different histological subtypes of cervical adenocarcinoma, a worldwide analysis of 760 cases. Mod Pathol. 2014;27:1559–1567. doi: 10.1038/modpathol.2014.55. [DOI] [PubMed] [Google Scholar]
- 22.Kojima A, Shimada M, Mikami Y, Nagao S, Takeshima N, Sugiyama T, et al. Chemoresistance of gastric-type mucinous carcinoma of the uterine cervix: a study of the Sankai Gynecology Study Group. Int J Gynecol Cancer. 2018;28:99–106. doi: 10.1097/IGC.0000000000001145. [DOI] [PubMed] [Google Scholar]
- 23.Cerami E, Gao J, Dogrusoz U, Gross BE, Sumer SO, Aksoy BA, et al. The cBio cancer genomics portal: an open platform for exploring multidimensional cancer genomics data. Cancer Discov. 2012;2:401–404. doi: 10.1158/2159-8290.CD-12-0095. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Gao J, Aksoy BA, Dogrusoz U, Dresdner G, Gross B, Sumer SO, et al. Integrative analysis of complex cancer genomics and clinical profiles using the cBioPortal. Sci Signal. 2013;6:pl1. doi: 10.1126/scisignal.2004088. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Scaranti M, Cojocaru E, Banerjee S, Banerji U. Exploiting the folate receptor α in oncology. Nat Rev Clin Oncol. 2020;17:349–359. doi: 10.1038/s41571-020-0339-5. [DOI] [PubMed] [Google Scholar]
- 26.Cheung A, Bax HJ, Josephs DH, Ilieva KM, Pellizzari G, Opzoomer J, et al. Targeting folate receptor alpha for cancer treatment. Oncotarget. 2016;7:52553–52574. doi: 10.18632/oncotarget.9651. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Köbel M, Madore J, Ramus SJ, Clarke BA, Pharoah PD, Deen S, et al. Evidence for a time-dependent association between FOLR1 expression and survival from ovarian carcinoma: implications for clinical testing. An Ovarian Tumour Tissue Analysis consortium study. Br J Cancer. 2014;111:2297–2307. doi: 10.1038/bjc.2014.567. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Nunez MI, Behrens C, Woods DM, Lin H, Suraokar M, Kadara H, et al. High expression of folate receptor alpha in lung cancer correlates with adenocarcinoma histology and EGFR [corrected] mutation. J Thorac Oncol. 2012;7:833–840. doi: 10.1097/JTO.0b013e31824de09c. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Smith HO, Tiffany MF, Qualls CR, Key CR. The rising incidence of adenocarcinoma relative to squamous cell carcinoma of the uterine cervix in the United States--a 24-year population-based study. Gynecol Oncol. 2000;78:97–105. doi: 10.1006/gyno.2000.5826. [DOI] [PubMed] [Google Scholar]
- 30.Kojima A, Mikami Y, Sudo T, Yamaguchi S, Kusanagi Y, Ito M, et al. Gastric morphology and immunophenotype predict poor outcome in mucinous adenocarcinoma of the uterine cervix. Am J Surg Pathol. 2007;31:664–672. doi: 10.1097/01.pas.0000213434.91868.b0. [DOI] [PubMed] [Google Scholar]
- 31.Mabuchi S, Okazawa M, Matsuo K, Kawano M, Suzuki O, Miyatake T, et al. Impact of histological subtype on survival of patients with surgically-treated stage IA2-IIB cervical cancer: adenocarcinoma versus squamous cell carcinoma. Gynecol Oncol. 2012;127:114–120. doi: 10.1016/j.ygyno.2012.06.021. [DOI] [PubMed] [Google Scholar]
- 32.Eifel PJ, Burke TW, Morris M, Smith TL. Adenocarcinoma as an independent risk factor for disease recurrence in patients with stage IB cervical carcinoma. Gynecol Oncol. 1995;59:38–44. doi: 10.1006/gyno.1995.1265. [DOI] [PubMed] [Google Scholar]
- 33.Liu Y, Lian T, Yao Y. A systematic review and meta-analysis of higher expression of folate receptor alpha (FOLR1) predicts poor cancer prognosis. Biomarkers. 2020;25:367–374. doi: 10.1080/1354750X.2020.1771420. [DOI] [PubMed] [Google Scholar]
- 34.Chen YL, Chang MC, Huang CY, Chiang YC, Lin HW, Chen CA, et al. Serous ovarian carcinoma patients with high alpha-folate receptor had reducing survival and cytotoxic chemo-response. Mol Oncol. 2012;6:360–369. doi: 10.1016/j.molonc.2011.11.010. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Yamagami W, Nagase S, Takahashi F, Ino K, Hachisuga T, Aoki D, et al. Clinical statistics of gynecologic cancers in Japan. J Gynecol Oncol. 2017;28:e32. doi: 10.3802/jgo.2017.28.e32. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.Brown Jones M, Neuper C, Clayton A, Mariani A, Konecny G, Thomas MB, et al. Rationale for folate receptor alpha targeted therapy in “high risk” endometrial carcinomas. Int J Cancer. 2008;123:1699–1703. doi: 10.1002/ijc.23686. [DOI] [PubMed] [Google Scholar]
- 37.O’Shannessy DJ, Somers EB, Maltzman J, Smale R, Fu YS. Folate receptor alpha (FRA) expression in breast cancer: identification of a new molecular subtype and association with triple negative disease. Springerplus. 2012;1:22. doi: 10.1186/2193-1801-1-22. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.Hirose S, Murakami N, Takahashi K, Kuno I, Takayanagi D, Asami Y, et al. Genomic alterations in STK11 can predict clinical outcomes in cervical cancer patients. Gynecol Oncol. 2020;156:203–210. doi: 10.1016/j.ygyno.2019.10.022. [DOI] [PubMed] [Google Scholar]
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Supplementary Materials
Association between FRα expression and disease-free survival