eISSN: 1897-4309
ISSN: 1428-2526
Contemporary Oncology/Współczesna Onkologia
Current issue Archive Manuscripts accepted About the journal Supplements Addendum Special Issues Editorial board Reviewers Abstracting and indexing Subscription Contact Instructions for authors Publication charge Ethical standards and procedures
Editorial System
Submit your Manuscript
SCImago Journal & Country Rank
1/2024
vol. 28
 
Share:
Share:
Original paper

Clinicopathological significance of protein disulphide isomerase A3 and phosphorylated signal transducer and activator of transcription 3 in cervical carcinoma

Asmaa Abdullatif
1
,
Aziza E. Abdelrahman
1
,
Adel Bakry
1
,
Shimaa A. Gharieb
1
,
Mohamed Sh. Ramadan
1
,
Mohamed A. Wasfy
1
,
Abdelfatah H. Abdelwanis
1
,
Enas M. Fouad
1

  1. Faculty of Medicine, Zagazig University, Zagazig, Egypt
Contemp Oncol (Pozn) 2024; 28 (1): 51–62
Online publish date: 2024/05/03
Article file
Get citation
 
PlumX metrics:
 

Introduction

Cervical carcinoma represents the fourth most common malignancy and the fourth leading cause of cancer deaths in the world [1]. In developing countries, cervical cancer is the second cause of cancer-associated death in females, particularly those under 20–39 years old [2, 3]. Deaths in these patients are usually due to invasion and metastasis due to the aggressive nature of the tumour [4]. Early diagnosis of cervical carcinoma can enhance the effectiveness of treatment and show better outcome, with a 5-year survival rate of 90% [5]. Therefore, it is critical to identify more potent therapeutic targets and new prognostic markers to detect high-risk patients early and treat them early.

Protein disulphide isomerase A3 (PDIA3) is a chaperone protein that is localised to the endoplasmic reticulum (ER). Under normal conditions, PDIA3 forms a complex with calreticulin and calnexin to correct folding of misfolded proteins in ER and new synthetic glycoproteins. This protein inhabits ER stress-induced apoptosis [6]. Furthermore, it is involved in stabilisation of MCH-I, modulating mechanistic target of rapamycin (mTOR) complex and regulation of signal transducer and activator of transcription 3 (STAT3) transcriptional potential [7]. Protein disulphide isomerase A3 is suggested to be upregulated in various cancers, such as hepatocellular carcinoma [8], gastric cancer [9], and glioma [10]. Its expression is correlated with the outcome of malignancy.

The signal transducer and activator of transcription 3 is the major pathway implicated in development and progression in HPV-positive cervical carcinoma. This pathway is triggered by inflammatory cytokines and growth factors [11, 12]. Tyrosine phosphorylation activates STAT3, resulting in the formation of a dimer (p-STAT3) that moves to the nucleus to bind DNA and promote the expression of genes that are essential in the proliferation, differentiation, and apoptosis of cells. It also controls cell response to hypoxia by angiogenesis in various cancers [1315].

Protein disulphide isomerase A3 binds with STAT3 in the nucleus. Protein disulphide isomerase A3-STAT3 complex is positively correlated with tumour progression in several tumours and is associated with radiotherapy resistance in laryngeal carcinoma by modification of STAT3 activity [16]. The aim of the work was to assess immunohistochemistry expression of PDIA3 and p-STAT3 in cervical carcinoma, and to investigate their correlation with the clinicopathological characteristics.

Material and methods

The present prospective cohort study conducted on 50 female patients of cervical cancer, where they operated at the General Surgery and Gynaecology & Obstetrics departments of Zagazig university hospitals by total hysterectomy with bilateral salpingo-oophorectomy, either with or without pelvic lymph-adenectomy, from January 2019 to January 2023. No cases received pre-operative anticancer therapy. The clinical data were gathered from pathology reports, including age, presentation, and imaging investigations as computed tomography of the pelvic abdomen and chest, and a bone scan. At the pathology department, tumour grade and stage were evaluated according to the International Federation of Gynaecology and Obstetrics (FIGO) grading and staging system and the eighth edition (2018) of the American Joint Committee on Cancer [17].

We evaluated the patient’s survival corresponding to follow-up data from the clinical records of medical and clinical oncology departments. Overall survival (OS) was assessed as time from surgical intervention to the death or the last follow-up. Disease-free survival (DFS) was assessed from end of treatment to the tumour relapse or most recent patient follow-up (censored). The ethical approval was attained from the local institutional board of Zagazig University hospitals (ethics code #11266).

The adjuvant treatment

The type of adjuvant treatment used depends on the tumour stage and surgical findings. For patients with tumour stage IA, IB, or IIA1 with free surgical margins, negative lymph nodes (LN), negative parametrial involvement, and in whom there were no cervical risk aspects after radical hysterectomy (the Sedlis criteria), observation was preferred. On the other hand, radiation therapy with (or without) concurrent platinum encompassing chemotherapy was delivered if there were positive nodes, positive margins, positive parametria, large primary tumour, deep stromal invasion, and/or lymph-vascular space invasion. Definitive chemo-radiotherapy was delivered for medically inoperable cases or those who refused surgery.

Stage IIB and stage III were treated with surgery plus adjuvant radiotherapy with (or without) concurrent chemo- radiotherapy or definitive concurrent chemoradiotherapy. Stage IVA was treated with definitive concurrent chemoradiotherapy. External beam radiotherapy was delivered by 3-dimensional conformal technique using a total dose 40–50 Gy to the pelvis with a daily fraction size of 2 Gy 5 times/week. External beam radiation therapy (EBRT) was administered through a 4-field technique utilising a linear accelerator with a multi-leaf collimator and a conventional fractionation delivery in 20–25 days. The treatment fields either included the pelvic lymphatics or pelvic and paraaortic lymphatics in patients with para-aortic nodal metastasis. The gross involved LN were boosted with 10–20 Gy of high conformal EBRT. In definitive radiation therapy, the primary cervical tumour was boosted using brachytherapy with an additional 30–40 Gy. Concurrent chemotherapy administrated weekly comprised cisplatin in the dose of 40 mg/m2 or weekly carboplatin AUC 2 for patients who were cisplatin intolerant.

Immunohistochemistry

The Dako EnVision™ kit of polymer envision detection system (Dako, Copenhagen, Denmark) was used. 3–5-µm tissue sections of formalin-fixed paraffin-embedded tissue blocks were deparaffinised, then rehydrated, and lastly incubated for 10 min in antigen retrieval solution (pH 6.0). Finally, the slides incubated with monoclonal PDIA3 antibody (OTI4D7 Invitrogen, Waltham, 1 : 150) and monoclonal p-STAT3 antibody (D3A7 Cell Signalling Technology, Danvers, MA, USA 1 : 100). The response was envisioned by incubating the tissue slides with DAB 15 min, and then after Mayer’s haematoxylin was used.

The cytoplasmic PDIA3 expression was scored according to the percentage of positive cells, into 0 for ≤ 5%, 1: 6–30%, 2: 31–80%, and 3: > 80%. The intensity scored 1–3 and the final score ranged from 0 to 9, considered as low (0–2) or high expression (3–9) [18].

Nuclear p-STAT3 immunoexpression was categorised according to the percentage of nuclear stained cells stained as follows: 0–50% positive tumour cells as negative, and > 50% positive tumour cells as positive [19].

The statistics

The studied continuous parameters were expressed as mean ±SD and median, but the studied categorical variables were expressed as percentages that compared by Fisher’s exact test or Pearson’s χ2 test. The stratification of DFS and OS was organised according to the studied immunohistochemical biomarkers. The time-to-event distributions were valued by Kaplan-Meier plot and compared via 2-sided exact log-rank test. All the used tests were 2 sided. All our statistics were finished using SPSS 22.0 for Windows and MedCalc for Windows.

Results

Patients’ characteristics

The mean age of patients was 52.24 ±61.14 years (range 40–65). Among the cases, 74% were squamous cell carcinoma while 26% were adenocarcinoma. FIGO grade III was predominant among the cases (36%). Parametrial invasion, nodal metastasis, and lymph-vascular invasion were noted in 72%, 64%, and 80 of cases, respectively. The majority of the patients (54%) presented at advanced stages (FIGO III–IV). The median duration of follow-up was 28 months (range 11–36 months), during which 15 cases (30%) died and 11 patients had a recurrence of tumour. A summary of clinicopathological features of involved cases is shown in Table 1.

Table 1

Clinicopathological features, immunohistochemical markers, and outcome of 50 patients with cervical carcinoma

ParametersAll studied patientsParametersAll studied patients
No.%No.%
Age group (years)FIGO stage
< 502040I816
> 503060II1530
Age (years)III1530
Mean ±SD52.24 ±61.14IV1224
Median (range)52 (40-65)
Size [cm]FIGO stage
< 4714IA112
> 44386IA224
HistopathologyIB136
SCC3774IB224
Adenocarcinoma1326IIA918
GradeIIB612
I1632IIIA1020
II1632IIIB510
III1836IVA1224
Stromal invasionTreatment
Superficial 1/3714Surgery alone510
Middle 1/32040Surgery + post-operative RT1224
Deep 1/32346Surgery + post-operative CCRT612
LVSIDefinitive CCRT2754
Absent1020
Present4080
Parametrial invasionResponse to CCRT(N = 27)
Absent1428Complete response1244.4
Present3672Partial response829.6
LNStable disease414.8
Negative1836Progressive disease311.1
Positive3264
p-STAT3 nuclearFollow-up duration (months)
Negative2856Mean ±SD27.68 ±6.56
Positive2244Median (range)28 (11 36)
PDIA3Relapse(N = 35)
Low2550Absent2468.6
High2550Present1131.4
p-STAT3 nuclear /PDIA3(N = 34)Mortality
Negative/low2058.8Alive3570
Positive/high1441.2Died1530

[i] CCRT – concurrent chemoradiotherapy, FIGO – International Federation of Gynaecology and Obstetrics, LN –lymph node, LVSI – lymph-vascular space invasion, p-STAT3 – phosphorylated signal transducer and activator of transcription 3, PDIA3 – protein disulphide isomerase A3 Categorical variables were expressed as number (%). Continuous variables were expressed as mean ±SD and median (range).

Association between protein disulphide isomerase A3 and phosphorylated signal transducer and activator of transcription 3 immunoexpression and clinicopathological features

Studying PDIA3 staining in the studied cases shows that there were 25 (50%) cases with PDIA3 high expression and 25 (50%) cases with PDIA3 low expression. The relationship between PDAI3 expression and different clinicopathological parameters revealed positive correlation between high PDAI3 expression and tumour grade (p < 0.001), and large tumours (≥ 4 cm) tended to show high expression more than small tumours < 4 cm (p = 0.010) (Fig. 1).

Fig. 1

Immunohistochemical expression of protein disulphide isomerase A3 in cervical carcinoma: low cytoplasmic expression in squamous cell carcinoma of the cervix (grade I) (400×) (A), high cytoplasmic expression in squamous cell carcinoma of the cervix (grade II, 400×) (B), high cytoplasmic expression in squamous cell carcinoma of the cervix (grade III, 400×) (C)

/f/fulltexts/WO/54088/WO-28-54088-g001_min.jpg

As regards histological types, 76.9% of adenocarcinoma cases and 59.5% of squamous cell carcinoma showed high PDIA3 expression with statistically significant association (p = 0.024). Furthermore, high PDIA3 expression was noticed to be related to depth of cervical stromal invasion (p = 0.017), lymph-vascular invasion (p = 0.005), parametrial invasion (p < 0.001), LN metastasis (p < 0.001), and higher FIGO stages (p < 0.001).

On the other hand, positive nuclear expression of p-STAT3 was detected in 22/50 (44%) of cases showing significant association with histological grade (p = 0.036), tumour stage (p = 0.021), LN metastasis (p = 0.020), and parametrial invasion (p = 0.045) (Fig. 2, Table 2, 3).

Fig. 2

Immunohistochemical expression of phosphorylated signal transducer and activator of transcription 3 in cervical carcinoma: nuclear expression in well differentiated squamous cell carcinoma of the cervix (400×) (A), nuclear expression in moderately differentiated squamous cell carcinoma of the cervix (400×) (B), nuclear expression in adenocarcinoma of the cervix (grade I, 400×) (C), nuclear expression in adenocarcinoma of the cervix (grade II, 400×) (D)

/f/fulltexts/WO/54088/WO-28-54088-g002_min.jpg
Table 2

Relation between clinicopathological features and immunohistochemical staining for phosphorylated signal transducer and activator of transcription 3 nuclear and protein disulphide isomerase A3 in cervical carcinoma patients

CharacteristicsAll patients
(N = 50)
p-STAT3 nuclearp-valuePDIA3p-value
Negative (n = 28)Positive (n = 22)Low (n = 25)High (n = 25)
No.%No.%No.%No.%No.%
Age group (years)
≤ 50204012608400.642a11559450.564a
> 5030601653.31446.71446.71653.3
Age (years)
Mean ±SD52.24 ±61.1451.39 ±4.8453.32 ±7.440.394b51.96 ±4.4952.52 ±7.520.734b
Median (range)52 (40–65)52 (40–58)52.50 (40–65)52 (42–62)53 (40–65)
Size [cm]
< 4714457.1342.91.000a7100000.010a
≥ 443862455.81944.21841.92558.1
Histopathology
SCC37742054.11745.90.640a2259.51540.50.024a
Adenocarcinoma1326861.5538.5323.11076.9
Grade
I163212754250.036c1593.816.2< 0.001c
II1632956.2743.8637.51062.5
III1836738.91161.1422.21477.8
Stromal invasion
Superficial 1/3714571.4228.60.701c7100000.017c
Middle 1/32040105010509451155
Deep 1/323461356.51043.5939.11460.9
LVSI
Absent10207703300.480a9901100.005a
Present40802152.51947.516402460
Parametrial invasion
Absent14281178.6321.40.045a1410000< 0.001a
Present36721747.21952.81130.62569.4
LN
Negative18361477.8422.20.020a1688.9211.1< 0.001a
Positive32641443.81856.2928.12371.9
FIGO stage
I8166752250.021c810000< 0.001c
II15301386.7213.31173.3426.7
III15303201280533.31066.7
IV122465065018.31191.7
FIGO stage
IA1121100000.014c110000< 0.001c
IA224210000210000
IB136133.3266.7310000
IB224210000210000
IIA918888.9111.1910000
IIB612583.3116.7233.3466.7
IIIA1020330770330770
IIIB510005100240360
IVA122465065018.31191.7
p-STAT3 nuclear
Negative28562071.4828.60.001a
Positive2244522.71777.3
PDIA3
Low255020805200.001a
High25508321768

[i] FIGO – International Federation of Gynaecology and Obstetrics, LN – lymph node, LVSI – lymph-vascular space invasion, p-STAT3 –phosphorylated signal transducer and activator of transcription 3, PDIA3 – protein disulphide isomerase A3 Continuous variables were expressed as the mean ±SD and median (range). Categorical variables were expressed as number (%).a χ2 test b Mann-Whitney U test c χ2 test for trend p-value < 0.05 is significant

Table 3

Relation between clinicopathological features and immunohistochemical staining for phosphorylated signal transducer and activator of transcription 3 nuclear/protein disulphide isomerase A3 co-expression in cervical carcinoma patients

CharacteristicsAll
patients (N = 34)
p-STAT3 Nuclear/PDIA3 Co-expressionp-value
Negative/low (n = 20)Positive/high (n = 14)
No.%No.%No.%
Age group (years)
< 501235.39753250.275a
> 502264.711501150
Age (years)
Mean ±SD53.15 ±5.8051.95 ±3.6754.857.760.127b
Median (range)52 (40-65)52 (46-59)55.50 (40-65)
Size [cm]
< 4411.84100000.126a
> 43088.21653.31446.7
Histopathology
SCC2676.51765.4934.60.228a
Adenocarcinoma823.5337.5562.5
Grade
I1235.31210000< 0.001c
II1235.3758.3541.7
III1029.4110990
Stromal invasion
Superficial 1/3514.75100000.106c
Middle 1/31544.1853.3746.7
Deep 1/31441.2750750
LVSI
Absent720.67100000.026a
Present2779.41348.11451.9
Parametrial invasion
Absent1132.411100000.001a
Present2367.6939.11460.9
LN
Negative1235.31210000< 0.001a
Positive2264.7836.41463.6
FIGO stage
I617.6610000< 0.001c
II926.5910000
III1338.2538.5861.5
IV617.6006100
FIGO stage
IA112.9110000< 0.001c
IA225.9210000
IB112.9110000
IB225.9210000
IIA823.5810000
IIB12.9110000
IIIA1029.4550550
IIIB38.8003100
IVA617.6006100

[i] FIGO – International Federation of Gynaecology and Obstetrics, LN – lymph node, LVSI – lymph-vascular space invasion, p-STAT3 – phosphorylated signal transducer and activator of transcription 3, PDIA3 – protein disulphide isomerase A3 Continuous variables were expressed as the mean ±SD and median (range). Categorical variables were expressed as number (%). a 2 test bMann-Whitney U test χ2 test for trend p-value < 0.05 is significant

Treatment outcome, survival, and progression analysis

High expression of PDIA3 was positively correlated with poor response to concurrent chemoradiotherapy with a progressive disease, while cases showing low PDIA3 expression achieved a complete response in 90.9% of cases (p = 0.001). Moreover, patients with negative p-STAT3 expression showed better treatment response than cases with positive p-STAT3 expression. Likewise, it was found that the higher PDIA3 expression was significantly associated with tumour relapse, poor DFS, and poor OS. Significant association was observed between p-STAT3 positivity and relapse (p = 0.002), mortality (p = 0.035), DFS (p < 0.001), and OS (p = 0.02).

Statistical analysis of the patient’s survival data revealed that shorter OS and DFS were associated with high PDIA3 expression and positive p-STAT3 immunoexpression (Table 4, 5). Kaplan-Meier survival curves that were utilised for PDIA3 expression and p-STAT3 immunoexpression are presented in Figures 3 and 4.

Table 4

Relation between immunohistochemical staining for phosphorylated signal transducer and activator of transcription 3 nuclear and protein disulphide isomerase A3 and outcome in cervical carcinoma patients

OutcomeAll patientsp-STAT3 nuclearp-valuePDIA3p-value
NegativePositiveLowHigh
No.%No.%No.%No.%No.%
Response to CCRT(N= 27)(n= 17)(n= 10)(n= 11)(n= 16)
Complete response1244.41058.82200.062a1090.9212.50.001a
Partial response829.6211.866019.1743.8
Stable disease414.8317.611000425
Progressive disease311.1211.811000318.8
Relapse(N= 35)(n= 21)(n= 14)(n= 24)(n= 11)
Absent2468.61990. 5535.70.002a2187.5327.30.001a
Present1131.429.5964.3312.5872.7
DFS
Mean (months)31.97 months35.11 months27.36 months< 0.001d34.64 months24.64 months< 0.001d
(95% CI)(29.96–33.98)(33.93–36.28)(23.89–30.82)(33.17–36.11)(22.45–26.82)
1-year100100100100100
2-year801005095.845.5
3-year67.689.535.786.7
Mortality(N= 50)(n= 28(n= 22)(n= 25)(n= 25)
Alive35702382.11254.50.035a239212480.001a
Died1530517.91045.5581352
OS
Mean (months)31.36 months32.65 months29.06 months0.020d35.28 months24.64 months< 0.001b
(95% CI)(29.31–33.41)(29.83–35.48)(26.16–31.97)(34.30–36.26)(22.39–26.89)
1-year9692.910010092
2-year79.385.670.810056.7
3-year65.880.840.590.9

[i] CCRT – concurrent chemoradiotherapy, DFS – disease-free survival, OS – overall survival, p-STAT3 – phosphorylated signal transducer and activator of transcription 3, PDIA3 – protein disulphide isomerase A3 Continuous variables were expressed as mean (95% CI). Categorical variables were expressed as number (%).a χ2 test b Log rank test p < 0.05 is significant

Table 5

Relation between immunohistochemical staining for phosphorylated signal transducer and activator of transcription 3 nuclear/protein disulfide isomerase A3 and outcome in cervical carcinoma patients

OutcomeAll patientsp-STAT3 nuclear/PDIA3 co-expressionp-value
Negative/lowPositive/high
No.%No.%No.%
Response to CCRT(N= 19)(n= 8)(n= 11)
Complete response1052.6787.5327.30.076a
Partial response736.8112.56 54.5
Stable disease15.30019.1
Progressive disease15.30019.1
Relapse(N= 25)(n= 19)(n= 6)
Absent17681684.2116.70.006a
Present832315.8583.3
DFS
Mean (months)31.78 months33.74 months24.50 months0.003d
(95% CI)(29.31–34.24)(31.37–36.11)(22.29–26.70)
1-year100100100
2-year8484.266.7
3-year67.484.2
Mortality(N = 34)(n = 20)(n = 14)
Alive2573.520100535.7< 0.001a
Died926.500964.3
OS
Mean (months)32.37 months36 months25.11 months< 0.001d
(95% CI)(30.34–34.40)(23.44–26.78)
1-year100100100
2-year81.610054.5
3-year70.1100

[i] CCRT – concurrent chemoradiotherapy, DFS – disease free survival, OS – overall survival, p-STAT3 – phosphorylated signal transducer and activator of transcription 3, PDIA3 – protein disulfide isomerase A3 Continuous variables were expressed as mean (95% CI). Categorical variables were expressed as number (%). a χ2 test b Log rank test p < 0.05 is significant

Fig. 3

Kaplan-Meier curves of disease-free survival stratified according to protein disulphide isomerase A3 (PDIA3) immunohistochemistry (IHC) expression (A), phosphorylated signal transducer and activator of transcription 3 (p-STAT3) IHC expression (B), and combined expression of PDIA3 and p-STAT3 (C)

p-STAT3 – phosphorylated signal transducer and activator of transcription 3, PDIA3 – protein disulphide isomerase A3

/f/fulltexts/WO/54088/WO-28-54088-g003_min.jpg
Fig. 4

Kaplan-Meier curves of overall survival stratified according to protein disulphide isomerase A3 (PDIA3) immunohistochemistry (IHC) expression (A), phosphorylated signal transducer and activator of transcription 3 (p-STAT3) IHC expression (B), and combined expression of PDIA3 and p-STAT3 (C)

p-STAT3 – phosphorylated signal transducer and activator of transcription 3, PDIA3 – protein disulphide isomerase A3

/f/fulltexts/WO/54088/WO-28-54088-g004_min.jpg

A significant association between p-STAT3 and higher PDIA3 expression was noted (p = 0.001). Combined expression of PDIA3 and p-STAT3 was significantly associated with worse malignant criteria as high tumour grade (p < 0.001), LN metastasis (p < 0.001), vascular invasion (p = 0.026), and advanced stage (p < 0.001) in cervical carcinomas with worse OS (p < 0.001).

Discussion

Cervical cancer is a complex disease closely related to high-risk HPV infection; despite the great advances in therapeutic strategies its prognosis has not improved, and the mortality rate is still high [20, 21]. The survival rate of localised cervical carcinomas (stage IB1) is 91.6% [22]. Thus, it is important to find prognostic markers and new targets for therapy to improve the long-term prognosis of cervical carcinoma.

Protein disulphide isomerase A3, also known as ERp57/GRP58, is oxidoreductase enzyme that promotes oxidative folding of glycoprotein. Protein disulphide isomerase A3 is critical in major histocompatibility complex (MHC) class I, calcium homeostasis, apoptotic signalling, mTOR complexes, and promoting monocyte/macrophage differentiation [23]. The current study revealed that high PDIA3 expression was noted in 50% of the cases with higher expression comparable to normal tissue, suggesting that higher PDIA3 expression may play an essential role in the development of cervical carcinoma.

Additionally, we found that PDIA3 overexpression was significantly correlated with poor clinicopathological characteristics including tumour size, high tumour grade, deep stromal invasion, lymph-vascular invasion, parametrial invasion, LN metastasis, and advanced FIGO stage. Furthermore, patients with high PDIA3 expression showed significantly lower DFS and OS rates than patients with low expression. Our results are in line with Zhang et al. [18], who found that PDIA3 was highly expressed in 60.4% and was significantly higher than that in normal tissue (p < 0.05) and showing strong correlation with pathological type, progression of tumour stage, lower OS, and DFS, suggesting that high expression of PDIA3 can be used as an indicator of poor prognosis of cervical carcinoma.

Similarly, Liao et al. [24] found that expression of PDIA3 increased in 73% of cervical carcinomas. It was intense in adenocarcinoma compared with squamous cell carcinoma (p < 0.05), depth of cervical stroma invasion, and lower OS (p = 0.007 and RFS (p = 0.013), as confirmed by Rong et al. [25]. These findings are consistent with previous reports suggesting that higher PDIA3 expression had poor survival prognosis in diffuse glioma [10], renal clear cell carcinoma [26], and non-small cell lung cancer [27]. Takata et al. [28] suggested that PDIA3 might be a key molecule in new targeted therapies for hepatocellular carcinoma.

On the other hand, this finding disagrees with previous reports on early-stage gastric cancer [9], endometrial carcinoma [29], and papillary thyroid carcinoma [30] revealing that high PDIA3 expression was correlated with favourable prognosis. This might be due to dysfunction of the MHC class I complex. Protein disulphide isomerase A3 forms a complex with MHC class I to activate an immune response against the tumour. In contrast, when MHC class I expression is down-regulated, tumour cells avoid the cytotoxic effects of immune cells [9, 31].

Constitutive activation of STAT3 (p-STAT3) promotes cancer by directly regulating oncogene expression, such as cyclin B1, CDC2, p53, MCL-1, Survivin, VEGF, BCL2, and BAX. In addition, activated STAT3 down-regulates the expression of mediators critical for activation of the immune system against cancer. The key roles of tumour promotion and immunosuppression in the STAT3 pathway make STAT3 an important target for effective immunotherapy [32].

In this study, positive p-STAT3 was expressed in 44% of cases of cervical carcinoma and was significantly associated with high grade, LN metastases, and advanced FIGO stage. Shukla et al. [33] found that 56% of cervical carcinoma were positive for p-STAT3. Some studies reported different expressions of p-STAT3 in cervical carcinoma: Takemoto et al. [34] showed that 56% were positive for p-STAT3, while Choi et al. and Wu et al. [19, 35] reported that positive nuclear p-STAT3 was 67% and 78.3%, respectively. Chen et al. [36] reported 24%, which may be explained by their use of preserved tissue blocks or tissue arrays or different methods for assessing pSTAT3.

Our findings are in line with those of reported studies that have shown that positive expression of nuclear p-STAT3 was correlated with bad prognosis and decreased survival, as it was closely linked to high grade, presence of LN metastases, invasion, advanced stage, reduced OS, low disease-specific survival, and low relapse-free survival by functioning as a tumour promoter. Based on these findings, p- STAT3 might be a potential marker for poor prognosis and metastasis, and a therapeutic target for cervical cancer [19, 33, 35, 37].

We found a positive correlation between PDIA3 and p-STAT3 expression, which was significantly associated with worse malignant criteria such as high tumour grade, LN metastasis, vascular invasion and advanced stage in cervical carcinoma, and worse OS. Protein disulphide isomerase A3, unlike other PDI family members that are only localised in ER, was also found in other subcellular locations where PDIA3 forms a complex with p-STAT3 and facilitates transportation STAT3 to the nucleus. In addition, PDIA3 binds to DNA and enhances DNA-binding of STAT3 complex to promote transcription oncogenic genes [38]. Knockdown of those markers might improve the management of cervical carcinoma and inhibit tumour invasion, metastases, and recurrence.

Liu et al. [26] demonstrated that PDAI3 activates p-STAT3 in clear cell renal carcinoma. Up-regulation of PDIA3 improved clear cell renal cell carcinoma (ccRCC) cell survival by promoting a STAT3/ILF3 feedback loop. These findings provide a therapeutic target to treat ccRCC. Furthermore, Kondoa et al. [8]. illustrated that PDIA3 is closely linked with unfavourable phenotype of hepatocellular carcinoma through its association with STAT3 signalling. Knockdown of PDIA3 decreases p-STAT3 and downstream proteins of the STAT3 pathway.

Conclusions

We concluded that high expression of PDIA3 and p-STAT3 is related to highly aggressive cervical carcinoma with poor prognosis and high risk of recurrence after the standardised protocol of treatment. So, both PDIA3 and p-STAT3 could be novel biomarkers for tumour progression and a promising target in the management of cervical carcinoma patients.

Disclosures

Institutional review board statement

Not applicable.

Assistance with the article

None.

Financial support and sponsorship

None.

Conflicts of interest

None.

References

1 

Sung H, Ferlay J, Siegel R, et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2021; 71: 209-249.

2 

Bruni L, Albero G, Serrano B, et al. Human papillomavirus and related diseases in the world. ICO/IARC Information Centre on HPV and cancer (HPV Information Centre). Summary report 17 June 2019.

3 

Ferlay J, Steliarova-Foucher E, Rosso S, et al. Cancer incidence and mortality patterns in Europe: estimates for 40 countries in 2012. Eur J Cancer 2013; 49: 1374-1403.

4 

Lee M, Shen M. Epithelial-mesenchymal transition in cervical carcinoma. Am J Transl Res 2012; 4: 1-13.

5 

Cibula D, Pötter R, Planchamp F, et al. The European Society of Gynaecological Oncology/European Society for Radiotherapy and Oncology/European Society of Pathology Guidelines for the Management of Patients with Cervical Cancer. Virchows Arch 2018; 472: 919-936.

6 

Mahmood R, Xu M, Awan MUN, et al. PDIA3: structure, functions and its potential role in viral infections. Biomed Pharmacother 2021; 143: 112110.

7 

Tu Z, Ouyang Q, Long X, et al. Protein disulfide-isomeraseA3 is a robust prognostic biomarker for cancers and predicts the immunotherapy response effectively. Front Immunol 2022; 13: 837512.

8 

Kondo R, Ishino K, Wada R, et al. Downregulation of protein disulfide-isomerase A3 expression inhibits cell proliferation and induces apoptosis through STAT3 signaling in hepatocellular carcinoma. Int J Oncol 2019; 54: 1409-1421.

9 

Shimoda T, Wada R, Kure S, et al. Expression of protein disulfide isomerase A3 and its clinicopathological association in gastric cancer. Oncol Rep 2010; 41: 2265-2272.

10 

Chiavari M, Ciotti G, Canonico F, et al. PDIA3 expression in glioblastoma modulates macrophage/microglia pro-tumor activation. Int J Mol Sci 2020; 21: 1-22.

11 

Yu H, Pardoll D, Jove R. STATs in cancer inflammation and immu-nity: a leading role for STAT3. Nat Rev Cancer 2009; 9: 798-809.

12 

Nikolaou K, Sarris M, Talianidis I. Molecular pathways: the complex roles of inflammation pathways in the development and treatment of liver cancer. Clin Cancer Res 2013; 19: 2810-2816.

13 

Bromberg J. Stat proteins and oncogenesis. J Clin Invest 2002; 109: 1139-1142.

14 

Subramaniam A, Shanmugam M, Perumal E, et al. Potential role of signal transducer and activator of transcription (STAT3) signaling pathway in inflammation, survival, proliferation, and invasion of hepatocellular carcinoma. Biochim Biophys Acta 2013; 1835: 46-60.

15 

Kim J, Patel M, Ruzevick J, et al. STAT3 activation in glioblastoma: biochemical and therapeutic implications. Cancers (Basel) 2014; 6: 376-395.

16 

Choe M, Min J, Jeon H, et al. ERp57 modulates STAT3 activity in radioresistant laryngeal cancer cells and serves as a prognostic marker for laryngeal cancer. Oncotarget 2015; 6: 2654-2666.

17 

Bhatla N, Aoki D, Sharma D, et al. Cancer of the cervix uteri: 2021 update. Int J Gynaecol Obstet 2021; 155: 28-44.

18 

Zhang J, Li H, Lin D, et al. Expression and prognostic significance of PDIA3 in cervical cancer. Int J Genomics 2022; 2022: 25.

19 

Choi C, Song S, Kang H, et al. Prognostic significance of p-STAT3 in patients with bulky cervical carcinoma undergoing neoadjuvant chemotherapy. J Obstet Gynaecol Res 2010; 36: 304-310.

20 

Park S, Eom K, Kim J, et al. MiR-9, miR-21, and miR-155 as potential biomarkers for HPV positive and negative cervical cancer. BMC Cancer 2017; 17: 1-8.

21 

Zhou C, Ma J, Huang L, et al. Cervical squamous cell carcinoma-secreted exosomal miR-221-3p promotes lymphangiogenesis and lymphatic metastasis by targeting VASH1. Oncogene 2019; 38: 1256-1268.

22 

Wright J, Matsuo K, Huang Y, et al. Prognostic performance of the 2018 International Federation of Gynecology and Obstetrics cervical cancer staging guidelines. Obstet Gynecol 2019; 134: 49-57.

23 

Chichiarelli S, Altieri F, Paglia G, et al. ERp57/PDIA3: new insight. Cell Mol Biol Lett 2022; 27: 12.

24 

Liao C, Wu T, Huang Y, et al. Glucose-regulated protein 58 modulates cell invasiveness and serves as a prognostic marker for cervical cancer. Cancer Sci 2011; 102: 2255-2263.

25 

Rong X, Guo Q, Abudulimu H. The expression and possible diagnostic significance of MHC class I antigen presentation associated proteins (GRP78, CRT, ERP57) in human cervical cancer. Chin J Clin and Exp Path 2011; 27: 463-467.

26 

Liu Y, Wang J, Nie Z, et al. Upregulation of ERp57 promotes clear cell renal cell carcinoma progression by initiating a STAT3/ILF3 feedback loop. J Exp Clin Cancer Res 2019; 38: 439.

27 

Wang K, Li H, Chen R, et al. Combination of CALR and PDIA3 is a potential prognostic biomarker for non-small cell lung cancer. Oncotarget 2017; 8: 96945-96957.

28 

Takata H, Kudo M, Yamamoto T, et al. Increased expression of Pdia3 and its association with cancer cell proliferation and poor prognosis in hepatocellular carcinoma. Oncol Lett 2016; 12: 4896-4904.

29 

Yu F, Liu X, Li M, Liu X, et al. Protein disulfide isomerase A3 as novel biomarker for endometrial cancer. Front Oncol 2023; 13: 1247446.

30 

Kure S, Chiba T, Ebina A, et al. Correlation between low expression of protein disulfide isomerase A3 and lymph node metastasis in papillary thyroid carcinoma and poor prognosis: a clinicopathological study of 1,139 cases with long-term follow-up. Endocr J 2022; 69: 273-281.

31 

Chen C, Chang C, Su T, et al. Identification of calreticulin as a prognosis marker and angiogenic regulator in human gastric cancer. Ann Surg Oncol 2009; 16: 524-533.

32 

Yang L, Lin S, Xu L, et al. Novel activators and small-molecule inhibitors of STAT3 in cancer. Cytokine Growth Factor Rev 2019; 49: 10-22.

33 

Shukla S, Mahata S, Shishodia G, et al. Functional regulatory role of STAT3 in HPV16-mediated cervical carcinogenesis. PLoS ONE 2013; 8: e67849.

34 

Takemoto S, Ushijima K, Kawano K, et al. Expression of activated signal transducer and activator of tran-scription-3 predicts poor prognosis in cervical squamous-cell carcinoma. Br J Cancer 2009; 101: 967-972.

35 

Wu L, Shen B, Li J, et al. STAT3 exerts pro-tumor and anti-autophagy roles in cervical cancer. Diagn Pathol 2022; 17: 1-10.

36 

Chen C, Hsieh F, Lieblein J, et al. Stat3 activation in human endometrial and cervical cancers. Br J Cancer 2007; 96: 591-599.

37 

Wang H, Deng J, Ren H, et al. STAT3 influences the characteristics of stem cells in cervical carcinoma. Oncol Lett 2017; 14: 2131-2136.

38 

Aureli C, Gaucci E, Arcangeli V, et al. ERp57/PDIA3 binds specific DNA fragments in a melanoma cell line. Gene 2013; 524: 390-395.

Copyright: © 2024 Termedia Sp. z o. o. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International (CC BY-NC-SA 4.0) License (http://creativecommons.org/licenses/by-nc-sa/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material, provided the original work is properly cited and states its license.
 
Quick links
© 2024 Termedia Sp. z o.o.
Developed by Bentus.