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*** SPECIAL NOTE FROM DR. WICHMAN ***

The following excellent article was reproduced from OncoImmunology at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3812199/:

 

Oncoimmunology. 2013 Aug 1; 2(8): e25769.
Published online 2013 Jul 29. doi:  10.4161/onci.25769
PMCID: PMC3812199

GC protein-derived macrophage-activating factor decreases α-N-acetylgalactosaminidase levels in advanced cancer patients

 

Introduction

α-N-acetylgalactosaminidase (nagalase) is known to accumulate in the serum of cancer patients, where it mediates the deglycosylation of group-specific component (GC), best known as vitamin D-binding protein (VDBP), which is the precursor of GC protein-derived macrophage-activating factor (GcMAF). Deglycosylated VDBP cannot be converted into GcMAF1 and decreased GcMAF levels reportedly promote immunodeficiency in individuals bearing advanced neoplasms.2 The increase in nagalase activity observed in cancer patients is mostly due to the fact that malignant cells release enzymatically active nagalase.3 Thus, serum nagalase activity reflects not only tumor burden and aggressiveness, but also the clinical progression of the disease.4-7 Nowadays, the assessment of serum nagalase activity is proposed as a reliable means to determine the clinical severity of multiple neoplasms.3

In serum, nagalase acts as an endo- (but not as an exo-) enzyme, being unable to deglycosylate an N-acetylgalactosamine (GalNAc) residue of GcMAF.5 Thus, circulating nagalase cannot degrade exogenous GcMAF.5-7 This observation suggested that patients with elevated nagalase activity may benefit from the exogenous provision of GcMAF. Alongside, GcMAF was observed to exert multiple anticancer effects in vivo and in vitro, both in experimental and in spontaneous tumor models. Given the impact of GcMAF on macrophages and their central role anticancer immune responses, GcMAF is widely considered as an immunotherapeutic agent.7

However, in addition to stimulating tumor-infiltrating macrophages,8 GcMAF not only directly inhibits the proliferation of various human cancer cells in vitro,9,10 but also reverts the malignant phenotype of human breast cancer cells.10 Moreover, GcMAF reportedly inhibits angiogenesis, thus depriving neoplastic lesions of the oxygen and nutrient supplies that are needed for tumor progression and metastasis.10-13 Recently, it has been proposed that the antineoplastic effects of GcMAF are mediated by the vitamin D receptor (VDR), and it was demonstrated that GcMAF stimulates an intracellular signaling pathway impinging on cyclic AMP. This signal transduction cascade could actually be responsible for death of malignant cells exposed to GcMAF.12 Taken together, these in vitro and in vivo findings lend a rationale to the observation that GcMAF exert dramatic anticancer effects in (at least a fraction of) patients with advanced cancer.5-7 Of note, in the aforementioned studies, the anticancer effects of GcMAF were evaluated by measuring serum nagalase activity as a marker of tumor burden and progression.2,3,14

The biological effects of GcMAF have been documented in a variety of experimental systems and make the subject of more than 50 peer-reviewed papers published during the past 20 y.15 Because of the solid scientific rationale underlying the compassionate use of GcMAF in advanced cancer patients, hundreds of physicians in all parts of the world have adopted this approach for a variety of indications in which it could prove useful. Here, we present a series of clinical cases exemplifying the results that have been obtained with the administration of GcMAF to patients with diverse types of advanced cancers, with a particular focus on the effects of GcMAF on serum nagalase activity. We are well aware that these cases, because of their heterogeneity and reduced number, can be considered anecdotal. However, a very recent study on the evaluation of clinical practice strongly encourages the re-evaluation of individual cases such as those presented here.16 Thus, while some studies present large and impressive statistics obtained from large clinical cohorts, others may report a limited number of noteworthy cases, as we do here. According to this novel, authoritative, epistemological approach, “all of these stories become evidence of what works in medicine.”16Therefore, we believe that the clinical cases reported below point to beneficial effects for the administration of GcMAF to advanced cancer patients, prompting further studies to formally address this possibility.

Results

The mean pre-GcMAF treatment serum nagalase activity documented in our patient cohort was 2.84 ± 0.26 nM/min/mg, with a range of 1.00–5.60 nM/min/mg (Table 1). At the time of second testing (average interval = 112 d), the mean serum nagalase activity in the course of GcMAF treatment was 2.01 ± 0.22 nM/min/mg, with a range of 1.00–3.20 nM/min/mg. The difference between these values was statistically significant (p < 0.05). Of note, no patient of this cohort was initially observed to be within the laboratory reference range for serum nagalase activity (0.90–0.92 nM/min/mg). At the time of final testing (average interval = 263 d), the mean serum nagalase activity of the patient cohort was 1.59 ± 0.17 nM/min/mg, with a range of 0.60–2.80 nM/min/mg. The difference between this value and the serum nagalase activity recorded before the initiation of GcMAF treatment was also statistically significant (p < 0.01).

Table thumbnail
Table 1. Nagalase levels before and after GcMAF therapy*

Narrative description of some notable clinical cases from The Netherlands

The following reports were collected and communicated by Dr. Steven Hofman (CMC, Capelle aan den Ijssel; The Netherlands) and refer to the years 2011–2012. In addition to GcMAF, most patients were prescribed supplementation of vitamins D and A. Additional supplements are indicated when assumed. Most of the patients did not assume conventional anticancer chemotherapy along with GcMAF. However, several patients had been subjected to conventional anticancer therapies in the previous years, as indicated in individual reports. When patients assumed conventional therapeutics, such as hormones, in the course of GcMAF administration (e.g., patient #8), this is indicated in the individual report. When not indicated otherwise, patients received 100 ng GcMAF weekly, as a single intramuscular injection, in line the commonly accepted recommendations.5-7 Original reports are in italics. Each case is referred to with progressive numbers, as in Table 1.

In Figure 1, the decrease of serum nagalase activity in the patient cohort is plotted in function of the consecutive testing. Of note, since this is a retrospective analysis and not a clinical trial, nagalase determinations were not performed at the same time point in each individual patient. The overall shape of the graph, however, is very similar if not completely superimposable to that of other graphs of the same type that have previously been reported.5-7,17

figure onci-2-e25769-g1
Figure 1. Time course of GcMAF treatment in 7 cancer patients with serum nagalase activity as a prognostic index. Data correspond to the patients described in the section “Narrative description of some notable clinical cases from The Netherlands.” ...

2. Male, born 1950. Carcinoma of the urine-bladder since 2009, previously treated with chemo-solutions locally. Nagalase level at presentation on July 4, 2011: 3.10. February 10, 2012: 2.30. May 25, 2012: 1.80. October 26, 2012: 1.40. Treatment with GcMAF and acupuncture, later GcMAF only (later intravenous route). Bladder considered clean by urologist in summer 2012. GcMAF-treatment continued. In this case, the consistent decrease in serum nagalase activity was associated with a significant clinical improvement. The drop in nagalase activity was evident at the first post-treatment testing, about 7 mo after the initiation of GcMAF treatment, and persisted until the last available determination, i.e., about 15 mo thereafter. The difference in serum nagalase activity as recorded before at last determination and before the initiation of GcMAF therapy was -1.70 nM/min/mg.

3. Female, born 1944. Bladder carcinoma treated since 2011 by urologist with curettage and BCG. Nagalase level at presentation on May 9, 2011: 4.10. October 24, 2011: 2.30. April 3, 2012: 1.40. September 10, 2012: 1.00. December 4, 2012: 0.75. During the nagalase testing period the Patient was advised to inject intramuscular GcMAF weekly, but the Patient was not consistent. The bladder was considered in good condition on several occasions this period by the treating urologist. Also in this case, a consistent decrease in serum nagalase activity was associated with a significant clinical improvement. Such a decrease in nagalase activity was evident at the first post-treatment testing, about 5 mo after the initiation of GcMAF treatment, and persisted until the last available determination, i.e., about 19 mo thereafter. The difference in serum nagalase activity as recorded before at last determination and before the initiation of GcMAF therapy was -3.35 nM/min/mg. The last available value of serum nagalase activity, 0.75 nM/min/mg, was within the normal range.

8. Male, born 1937. Prostate carcinoma found by PSA in 2009, no specific complaints. Treated by hormone-injections, which gave complaints. Before and in the same year colon carcinoma was found, and operated after irradiation and chemotherapy (no untreated tumor/metastases probable). Nagalase level at presentation on April 6, 2011: 2.00. August 29, 2011: 1.20. January 5, 2012: 0.81. July 5, 2012: 0.67. December 6, 2012: 0.75. Treatment with acupuncture and GcMAF; after some time, the hormone treatment was discontinued and complaints, also non-specific, improved a lot. Stays on low-frequency surveillance. Again, serum nagalase activity returned to normal values (0.75 nM/min/mg) after about 20 mo of GcMAF treatment. A decrease in nagalase activity, however, was evident already at the first test, i.e., 4 mo after the initiation of GcMAF treatment. According to the literature,7 the normalization of serum nagalase levels in prostate cancer patients may represent an index of tumor eradication.

9. Male, born 1948. Prostate carcinoma in 2008; prostate extirpated in 2009 with good prognosis. However aspecific reportts fatigue and pain stayed. GcMAF treatment was started, together with a few acupuncture treatments. Nagalase level at presentation on October 21, 2011: 1.90. February 2, 2012: 1.70. October 19, 2012: 1.20. Complaints decreased gradually and the injections were performed intravenously later on. The treatment continues.

10. Female, born 1947. Carcinoma of left breast (found on survey), operated with sentinel nodes in 2010, chemotherapy 4 of 6 series, no specific complaints left. Still some malaise, fatigue and sleep-disorder. Nagalase level at presentation on August 9, 2011: 1.70. January 16, 2012: 1.00. March 12, 2012: 0.72. December 11, 2012: 0.60. GcMAF-treatment (predominantly intravenous route) combined with acupuncture. GcMAF discontinued in April 2012. Aspecific complaints diminished. Patient still seen every few months. A significant decrease in serum nagalase activity could be observed after 5 mo of GcMAF treatment. Such a decrease persisted even after the interruption of GcMAF, and serum nagalase activity was normalized about 16 mo after the initiation of therapy. According to the literature,5 the normalization of serum nagalase activity in breast carcinoma patients may represent an index of tumor eradication.

11. Female, born 1950. Carcinoma of left breast, specific complaints, metastases probable. After local operation, irradiation of thorax, combined with chemotherapy, Herceptin-therapy. Partly complaints in association with treatments. Nagalase level at presentation on May 11, 2011: 5.60. October 6, 2011: 2.90. February 21, 2012: 1.80. October 18, 2012: 1.10. Treated with intramuscular, later intravenous GcMAF, and a few acupuncture-treatments. No further complaints (subsided in 3–6 weeks), still in intravenous GcMAF regimen. A significant decrease in serum nagalase activity could be observed approximately 5 mo after the initiation of therapy. Approximately after 17 mo of GcMAF treatment, serum nagalase levels approached normal values.

16. Male, born 1941. Larynx-carcinoma found and treated with curettage and irradiation in 2010. Hemorrhagic-recto-colitis in anamnesis, few complaints after 2005. Bladder carcinoma found in 2011, treated by local curettage and several cycles of BCG-instillations. Complaints related to tumor growth and treatments, no chemotherapy. Treatment consisted of acupuncture and GcMAF intramuscular, and later intravenous injections on a weekly basis. Nagalase level at presentation on May 16, 2011: 4.70. October 4, 2011: 2.00. February 10, 2012: 1.20. June 15, 2012: 1.00. October 23, 2012: 0.88. December 20, 2012: 0.90. During the immunotherapy with GcMAF there were interesting developments. Insisting on bladder extirpation by the urologists, coped with one change of urologist, two second opinions by a specialized cancer clinic and later by an urologist of the operation team scheduled. From the Patients side there were several favorable adjustments in lifestyle, like discontinuation of smoking and adopting a daily intake of cod-liver-oil and salvia-leaf (his own initiative). In the face of the urologists opinion I decided to give the GcMAF twice weekly over a period of six weeks. The last opinion of the treating urologist was to postpone a more final decision to February, due to a much better impression of the bladder mucosa beginning in January 2013. There is optimism in the three named actors in the current situation. In this case, a significant decrease of in serum nagalase activation following the administration of GcMAF was associated with significant clinical benefits, consistent with previous reports.7

Narrative description of some notable clinical cases from the United States of America

The following reports were communicated by RE and refer to the years 2012–2013. In most patients, the weekly administration of 100 ng GcMAF i.m. was initiated in August 2012, and the first assessment of serum nagalase activity was performed immediately before the initiation of treatment. None of the patients assumed conventional anticancer chemotherapy during along with GcMAF. Here, we report only those cases for which as least two nagalase determinations were available.

1. Male, age 64. Bladder carcinoma. Nagalase level at first testing in October 2012: 2.90. In January 2013: 2.60. Improved. In this case, a decrease in serum nagalase activity could be documented in about 3 mo of GcMAF treatment and was associated with clinical improvement.

4. Female, age 60. Ovarian carcinoma. Nagalase level at first testing in June 2012: 3.30. November 2012: 2.80. CA-125 tumor marker in December 2012: 15.7. In February 2013: 19.1 Improved. The weekly administration of GcMAF resulted in a significant decrease of serum nagalase activity in about 3 mo. Such a decrease was associated with clinical benefits. These changes, however, were not (as yet) associated with a decrease in the circulating levels of cancer antigen 125 (CA-125), another tumor marker.

7. Male, age 67. Prostate carcinoma. Nagalase level at first testing in August 2012: 3.40. In December 2012: 2.80. Improved. In this case, clinical benefits were associated with a significant decrease in serum nagalase activity in about 4 mo from the initiation of GcMAF therapy. These results are consistent with the findings reported above as well as with previously described cases.7

12. Male, age 63. Squamous cell carcinoma of the tongue. Nagalase level at first testing in July 2012: 3.00. In September 2012: 1.50. In December 2012: 1.00. Improved. Again, clinical improvement was associated with a significant decrease in serum nagalase activity, which approached the normal range in approximately 5 mo. To the best of our knowledge, this is the first case of a patient affected by squamous cell carcinoma of the tongue receiving GcMAF. Also patient n. Thirteen (Table 1) was treated with GcMAF for a squamous cell carcinoma of the tongue and showed a decrease in serum nagalase activity in about 3 mo.

14. Male, age 54. Colorectal cancer. Nagalase level at first testing in July 2012: 3.90. In October 2012: 2.00. Discontinued. In this case, a significant decrease of serum nagalase activity could be documented approximately 3 mo after the initiation of GcMAF therapy. We are not aware of the reasons that led to treatment discontinuation.

15. Female, age 58. Squamous cell carcinoma of the head and neck. Nagalase level at first testing in June 2012: 2.90. In July 2012: 2.70. In February 2013: 2.00. Improved. In this case, a minimal decrease in serum nagalase activity as observed after 1 mo of GcMAF administration was associated with clinical benefits.

17. Female, age 35. Squamous cell carcinoma. Nagalase level at first testing in June 2012: 1.50. In September 2012: 1.10. Discontinued. In this case, a decrease of serum nagalase activity was observed after 3 mo of GcMAF therapy. We are not aware of the reasons that led to treatment discontinuation.

18. Female, age 69. Follicular lymphoma. Nagalase level at first testing in June 2012: 1.00. In August 2012: 1.30. In January 2013: 1.20. Improved. In this case, no association between serum nagalase activity, GcMAF treatment and clinical conditions could be revealed.

19. Female, age 66. Lymphoma. Nagalase level at first testing in August 2012: 2.20. In November 2012: 1.90. Improved. In this case, a clinical improvement was associated with a significant decrease in serum nagalase activity in about 3 mo after the initiation of GcMAF treatment.

Discussion

GcMAF has been shown to inhibit multiple aspects of neoplastic transformation in vitro, in a variety of tumor models.5-10 The clinical cases reported here are heterogeneous and refer to patients with different types of neoplasms and at different stages of malignant progression. These cases include cancer patients in whom the effects of GcMAF had not been described before, such as subjects bearing various types of head and neck carcinoma (including tumors of the larynx and tongue), lymphoma, oligodendrocytoma and ovarian carcinoma. In some instances, patients were simultaneously affected by multiple types of tumors, as reported in the narrative description. In many cases, patients received GcMAF along with other complementary treatments, such as acupuncture or administration of nutritional supplements. In all cases, GcMAF therapy was initiated at late stages of tumor progression, as conventional therapies were obviously preferred at less advanced stages. Thus, most of the cases described here fall under the category of compassionate treatment. In fact, most of these patients had undergone conventional anticancer therapy in the previous years and had referred to GcMAF treatment when conventional chemo- or radiotherapy had proven ineffective or intolerable, as described in the individual reports. Since this is an open-label, non-controlled, retrospective analysis, caution must be employed in drawing a cause-effect relationship between treatment and clinical outcome. However, the response to GcMAF was often relatively robust and certain trends stand out.

Trends from Dutch cases

1. All patients presented with serum nagalase activity well above the normal value, that is about 0.95 nM/min/mg.

2. All patients showed a significant decrease in serum nagalase activity following GcMAF injections.

3. In all cases, serum nagalase activity was reduced at the second assessment, and such a decrease persisted in the following determinations.

4. In 4/7 cases, serum nagalase activity returned to normal levels by the last assessment.

Trends from American cases

1. All patients, but one, presented with serum nagalase activity well above the normal value. Patient #18, indeed, presented with a serum nagalase activity that was very close to normal.

2. In most patients, a significant decrease in serum nagalase activity was observed upon the administration of GcMAF. In patient #18, such a decrease was not associated with clinical benefits, even though her serum nagalase activity was always on the low side. This lack of a strict inverse relationship between serum nagalase activity and clinical responses has been recently observed in a study describing the effects of GcMAF in autistic children. Most of these patients showed indeed a decrease in serum nagalase activity as well as a significant improvement of symptoms, but the two phenomena were not strictly correlated with each other.18

A significant point that emerges from the analysis of the cases described above is the apparent absence of GcMAF-related side effects. This point, which has previously been documented in autistic children,18 is of great importance when GcMAF is considered for the compassionate treatment of patients with advanced or incurable diseases. As a matter of fact, in many countries, the complete absence of side effects is a prerequisite for the compassionate administration of substances that have not yet been approved by local sanitary authorities.

Obviously, these preliminary observations require a prolonged follow-up period to determine the best indications for the compassionate administration of GcMAF. As of today, GcMAF has been used (always as a compassionate therapy) with encouraging results in patients affected by virtually all types of cancers and at all stages of disease progression. However, it is tempting to hypothesize that patients bearing specific types and/or stages of malignancy might obtain consistent clinical benefits from the administration of GcMAF. Also the genetic background of patients, in particular in terms of VDR polymorphisms, might influence the individual response to GcMAF. In fact, we have recently demonstrated that the degree of response of human monocytes to GcMAF is associated with individual VDR genotypes.13 It can therefore be hypothesized that the antineoplastic effects of GcMAF may also be influenced by such polymorphisms. Moreover, it should be kept in mind that the prognosis of patients affected by all types of cancers is dependent upon their nutritional and inflammatory status, which can be monitored by the Prognostic Inflammatory and Nutritional Index (PINI).19 The PINI score might therefore become part of the laboratory assessments performed in the course of GcMAF therapy, and - together with the assessment of serum nagalase activity testing and VDR polymorphisms - it may assist physicians in monitoring the response of individual patient to GcMAF and adjusting doses and schedules in the course of treatment, if required. Studies investigating the impact of GC polymorphisms on the response of cancer patients to GcMAF therapy as well as the contribution of distinct GC variants to the relative amounts of “non-inducible,” inactive GcMAF species20 will also be instrumental in determining the most correct approach to GcMAF administration.

The results reported here are consistent with previous results5-7 as well as with a recent publication by Inui et al.,21 who described three clinical cases successfully treated with combinatorial therapeutic regimens including subcutaneous or intramuscular injections of GcMAF-containing human serum. At variance with this latter study, the results presented here were obtained with highly purified GcMAF, ruling out the effects of other serum proteins that might have acted as confounding factors.

In conclusion, the clinical cases presented here reinforce the hypothesis that GcMAF could become part of anticancer immunotherapeutic regimens.

Materials and Methods

GcMAF production

Physicians obtained GcMAF from Immuno Biotech Ltd (Guernsey, UK). GcMAF was highly purified according to previously described procedures.7 Briefly, VDBP was isolated from purified human serum obtained from the American Red Cross, using either 25-hydroxyvitamin D3-sepharose high affinity chromatography or actin-agarose affinity chromatography. Bound material was eluted and further processed by incubation with three immobilized enzymes. The resulting GcMAF was filter sterilized. Protein content and concentration of the GcMAF solution were assayed using standard Bradford protein assay methods.22At the end of the production process, GcMAF was checked for sterility in-house as well as externally, by independent laboratories. The safety and biological activity of GcMAF were tested on human monocytes,13human breast cancer cells,10 and chick embryo chorionallantoic membranes.12

Data collection

A retrospective chart review for the analysis of nagalase testing was accomplished on the initial cohort of patients seen by the clinicians (RE and Dr. Steven Hofman, CMC, Capelle aan den Ijssel; The Netherlands). All records were reviewed by physicians for confirmation of serum nagalase activity values, diagnoses, time intervals between testing, GcMAF dosing and clinical responses. The diagnosis of cancer was confirmed by other treating physicians.

GcMAF administration

The administration of GcMAF to individual patients was performed exclusively by their physicians (RE and Dr. Steven Hofman, CMC, Capelle aan den Ijssel; The Netherlands), according to the national rules and regulations. Original clinical records are conserved by the physicians, in their respective locations, as indicated. In the Results section, clinical cases are reported as close as possible to the originals notes of physicians, with minimal grammar and spelling corrections. Since each physicians used described the condition of individual patients in a different fashion, some heterogeneity in these notes has to be expected. The notes are purposely presented as they had been written so that each reader can draw her/his conclusions.

Serum nagalase activity determinations

Serum nagalase testing was performed at ELN Laboratories (Bunnik, The Netherlands) following the procedure published by Yamamoto et al.14 In particular, serum nagalase activity was determined by using an endpoint enzymatic assay based on a chromogenic substrate. ELN Laboratories established a reference range of 0.32–0.95 nM/min/mg of substrate based on serum samples collected from healthy volunteers, a range slightly higher than that previously reported, which was of 0.35–0.65 nM/min/mg.14 Further studies on elevated numbers of subjects will establish the most appropriate reference range. Irrespective of this issue, since all determinations were performed in the same laboratory, a relative decrease of in serum nagalase activity following GcMAF administration was used as an index of therapeutic efficacy.

Statistical methods

Statistical comparisons between the serum nagalase activity observed before and after (at two distinct time points) the administration of GcMAF were performed by Student’s t-tests.


Articles from Oncoimmunology are provided here courtesy of Taylor & Francis

 

STEP ONE

Be informed.  Read information below.

STEP TWO

Schedule test & interpretation with R. Douglas Wichman, MD.

STEP THREE

Submit "New Patient Form", current labwork, & imaging results prior to interpretation.

STEP FOUR

Establish if you are a candidate for therapy

in accordance with the Georgia

"Access to Medical Treatment Act".

 

----------------------------------------------------------------------------------------------------------------------------------------------------------

*** SPECIAL NOTE FROM DR. WICHMAN ***

The following excellent article was reproduced from Clinical Proteomics at https://clinicalproteomicsjournal.biomedcentral.com/articles/10.1186/s12014-016-9103-3:

 

ENOX2-based early detection (ONCOblot) of asbestos-induced malignant mesothelioma 4–10 years in advance of clinical symptoms

  • D. James MorréThis email address is being protected from spambots. You need JavaScript enabled to view it.,
  • Brandon Hostetler,
  • David J. Taggart,
  • Dorothy M. Morré,
  • A. W. Musk,
  • Bruce W. S. Robinson and
  • Jenette Creaney
Clinical Proteomics201613:2

DOI: 10.1186/s12014-016-9103-3

Received: 14 July 2015

Accepted: 13 January 2016

Published: 22 January 2016

The Erratum to this article has been published in Clinical Proteomics 2016 13:3

Abstract

Background

Malignant mesothelioma is an aggressive, almost uniformly fatal tumor, caused primarily by exposure to asbestos. In this study, serum presence of mesothelioma-specific protein transcript variants of ecto-nicotinamide adenine dinucleotide oxidase disulfide-thiol exchanger 2 (ENOX2), a recently identified marker of malignancy, were investigated using the ONCOblot tissue of origin cancer detection test.

Methods

Sequential serum samples collected from asbestos-exposed individuals prior to the development of frank mesothelioma were assayed for ENOX2 presence by 2-D gel immunoblot analysis to determine how long in advance of clinical symptoms mesothelioma-specific ENOX2 transcript variants could be detected.

Results

Two mesothelioma-specific ENOX2 protein transcript variants were detected in the serum of asbestos-exposed individuals 4–10 years prior to clinical diagnosis of malignant mesothelioma (average 6.2 years). Either one or both ENOX2 protein transcript variants indicative of malignant mesothelioma were absent in 14 of 15 subjects diagnosed with benign pleural plaques either with or without accompanying asbestosis.

Conclusions

In a population of asbestos-exposed subjects who eventually developed malignant mesothelioma, ENOX2 protein transcript variants characteristic of malignant mesothelioma were present in serum 4–10 years in advance of clinical symptoms. As with all biomarker studies, these observations require validation in a larger, independent cohort of patients and should include prospective as well as retrospective sampling.

Background

Malignant mesothelioma is an aggressive, almost uniformly fatal, asbestos-induced cancer [12]. It is a tumor of the serosal cavities, predominantly of the pleura and is generally widespread throughout the cavity at the time of presentation. Patients who are treated with supportive care have a median survival of only 9 months [3]. Those treated with the best available chemotherapy (pemetrexed and cisplatinum) have an average increased survival of only 10 weeks [4], with a median survival between 9 and 14 months [5]. However, in select patients with early-stage epithelial disease who undergo extra pleural pneumonectomy, followed by adjunct chemotherapy and radiotherapy, 5-year survival rates of 46 % have been reported [6]. Therefore, like most cancers, early detection of malignant mesothelioma has the potential to improve patient outcomes [7].

Recently, the ONCOblot tissue of origin cancer detection test, a serum-based method for cancer detection, has been described [8]. The test is based on the discovery that there are cancer-specific transcript variants of ecto-nicotinamide adenine dinucleotide oxidase disulfide-thiol exchanger 2 (ENOX2) [89] and consists of 2-D gel electrophoretic separation of serum proteins followed by immunoblot analysis with an ENOX2-specific recombinant antibody. ENOX2 belongs to a family of cell surface proteins that oxidize reduced pyridine nucleotides [NAD(P)H] and are essential for cell enlargement and growth [10]. At least 20 tissue of origin specific patterns of ENOX2 transcript variants have been described (and/or combinations of isoforms) indicative of the cancer tissue of origin [8]. These ENOX2 proteins are shed into the circulation and can be detected in some early stage cancers, including: breast, lung, colon, prostate and ovarian cancer (Table 1).
Table 1

Table of ranges

Cancer

N

Acceptable ranges

Protein 1

Protein 2

Protein 3

MW

(kDa)

pI

(pH)

MW

(kDa)

pI

(pH)

MW

(kDa)

pI

(pH)

Bladder

25

63–66

4.2–5.6

42–48

4.1–4.8

   

Blood cell (total)

88

34–47

3.5–4.5

       

Breast

538

64–69

4.2–4.9

       

Cervical

37

90–100

4.2–5.4

       

Colorectal

90

80–96

4.4–5.4

50–65

4.2–5.3

33–46

3.8–5.2

Endometrial (uterine)

60

67–71

4.2–5.1

41–48

3.7–5.4

   

Esophageal

9

42–47

4.6–5.2

       

Gastric

10

120–188

4.7–5.5

50–62

4.5–5.6

45–53

2.4–3.6

Hepatocellular

19

58–70

4.5–5.0

34–40

4.1–5.2

   

Kidney (renal cell)

21

69–73

4.7–5.4

54–61

4.1–5.2

38–43

3.7–4.3

 Leukemiaa

32

34–45

3.5–4.5

       

Lung (total)

103

52–56

4.1–5.3

       

 Lung, non-small cella

71

54–56

4.7–5.3

       

 Lung, small-cella

32

52–53

4.1–4.6

       

 Lymphomaa

33

43–45

3.5–4.5

       

Melanoma

39

37–41

4.6–5.3

       

Mesothelioma

25

60–68

3.8–4.1

38–44

3.8–4.6

   

 Myelomaa

23

38–47

3.6–4.5

       

Ovarian

102

72–90

3.7–5.0

37–47

3.7–5.0

   

Pancreatic

62

48–51

3.9–5.4

       

Prostate

182

71–88

5.1–6.5

       

Sarcoma

22

50–55

5.2–5.6

37–45

4.3–4.9

   

Squamous cell

46

57–68

5.0–5.4

       

Testicular germ cell

5

61–62

5.0–5.4

42–45

4.4–4.7

   

Thyroid follicular

14

48–56

4.7–5.1

37–42

4.5–5.2

   

Thyroid papillary

22

56–67

4.5–5.0

37–44

3.2–3.6

   

Totals

1519

           

aBracketed entries are aggregate cancers or subsets already represented in the totals as aggregates (lung) or subsets (blood cell cancers)

ENOX2 transcript variants of specific molecular weights and isoelectric points (pIs) are produced uniquely by patients with cancer [10]. Identification of cancer presence by detecting ENOX2 transcript variants produces a low incidence of both false positives and false negatives (>1 % for subjects with clinically confirmed cancers), as they are molecular signature molecules produced specifically by cancer cells and are absent from non-cancer cells [10]. The predictive correlation between ONCOblot findings and the onset of cancer is based on findings that support ENOX2 as a marker of cancer presence [11].

Considerable interest exists in the development of early screening tests for malignant mesothelioma in asbestos-exposed populations. Therefore, the present study was undertaken to determine if cancer-specific ENOX2 transcript variants might serve as biomarkers to detect the presence of malignant mesothelioma in advance of clinical symptoms. To this end, serum samples, collected prior to diagnosis as part of a prospective cohort study [1213], were examined by using the ONCOblot test. This examination of serum samples from asbestos-exposed subjects revealed that patients with a clinically confirmed diagnosis of malignant mesothelioma produced a consistent pattern of two ENOX2 transcript variants. These two transcript variants were detected well in advance of clinical symptoms. These findings indicate that the ONCOblot Tissue of Origin Cancer Detection Test might, if validated in other studies, provide a useful addition to the diagnostic repertoire of tests for the early detection of malignant mesothelioma [1415].

Results

Study population characteristics

Sera from 17 individuals with confirmed malignant mesothelioma were studied (Table 2). The majority of the malignant mesothelioma cases were of epithelial histology and all occurred in the pleural cavity. The majority of cases were male and the mean age of diagnosis was 67. The median survival for this group of patients was 24 months (95 % CI 20–30) after clinical diagnosis. For seven individuals, annual pre-diagnosis samples were available for analysis (Figs. 1a,b; 2). Sera from 15 asbestos-exposed subjects but free of malignancy were analyzed in parallel (Table 3). These subjects had a variety of benign lung and pleural disease and were of a similar age to the malignant mesothelioma patients at the time of serum collection (mean age 72 years). The asbestos-exposed control group included two females. For three individuals, annual serum samples were available for analysis (Table 3).
Table 2

Molecular weights and isoelectric points of mesothelioma-specific ENOX2 transcript variants from analyses of 17 confirmed male malignant mesothelioma patients

Patient

Age at sample

Protein 1

Protein 2

kDa

pH

kDa

pH

7457

70

60

3.8

38

4.4

7716

63

61

3.9

38

4.4

6500

53

60

3.8

38

4.4

2101

67

61

4.0

40

4.5

2215

75

61

3.9

42

3.8

94

66

63

3.8

42

3.8

103

54

68

3.9

41

4.1

129

64

66

3.8

39

4.3

2341

65

68

3.9

39

4.3

2744

68

63

4.0

41

3.9

7744

63

67

4.0

43

4.3

9484

73

65

3.8

42

4.6

9394

72

65

4.0

42

4.4

9111

72

67

3.8

42

4.2

9113

67

63

4.0

43

4.3

9446

63

62

3.9

44

4.5

9926

76

64

3.9

42

4.3

Mean

63.6

3.9

40.9

4.3

Standard deviation

±2.7

±0.1

±1.9

±0.2

https://static-content.springer.com/image/art%3A10.1186%2Fs12014-016-9103-3/MediaObjects/12014_2016_9103_Fig1_HTML.gif
Fig. 1

ONCOblot images. Images are from patient ID 2101 (a) and patient ID 2215 (b), beginning 106 months (−106) before diagnosis of asbestos-induced malignant mesothelioma. Isoelectric focusing was in the first dimension, pH range 3–5 shown, with sodium dodecyl sulfate gel electrophoresis in the second dimension with comparisons to a standard reference protein, α-fetuin. The α-fetuin reference protein is common to all non-cancer and cancer patient sera. The long arrows indicate the higher molecular weight transcript variant (Protein 1) and the short arrows indicate the lower molecular weight ENOX2 transcript variant (Protein 2)

https://static-content.springer.com/image/art%3A10.1186%2Fs12014-016-9103-3/MediaObjects/12014_2016_9103_Fig2_HTML.gif
Fig. 2

Summary diagram. Serial assays of the seven male subjects, median age of diagnosis 67 years, beginning 168–96 months before diagnosis of asbestos-induced malignant mesothelioma are represented. Solid symbols—both Protein 1 and Protein 2 evident. Open symbols—neither Protein 1 nor Protein 2 evident. Shaded symbols—only Protein 1 evident

Table 3

ENOX2 transcript variants and quantitation by spot size from analyses of 15 subjects (mean age 72) diagnosed with benign, asbestos-related lesions

Pt. ID

Gender

Diagnosis

Disease-free

(years)

Protein 1

diama

(mm)

Protein 2

diama

(mm)

1268

M

Plaques + Asbestosis

1

2.0

1.3

2

2.0

1.3

4

1.5

0.8

5

1.5

1.0

7

1.0

1.3

8

1.0

1.0

10

0.8

1.3

1542

M

Plaques

1

NS

NS

2

NS

1.6

4

NS

1.8

6

NS

1.6

9

NS

1.3

10

NS

1.3

11

NS

1.6

1842

M

Plaques + Asbestosis

1

NS

NS

2374

M

Plaques + Asbestosis

 

NS

NS

2397

M

Plaques

 

NS

NS

2426

M

Plaques + Asbestosis

 

NS

NS

3720

M

Plaques

 

NS

NS

3768

M

Plaques

 

NS

NS

3846

M

Plaques

 

NS

NS

4288

F

Plaques + Asbestosis

8

2.2

NS

9

2.0

NS

10

1.8

NS

4334

M

Plaques + Asbestosis

 

NS

1.5

4476

M

Plaques

 

NS

1.4

9629

M

Plaques

 

NS

NS

9676

M

Plaques + Asbestosis

 

NS

NS

10011

F

Plaques

 

1.6

NS

aSpot diameter in mm

NS = no spot

ENOX2 transcript variants indicative of malignant mesothelioma

The signature pattern of ENOX2 isoforms produced by malignant mesothelioma consisted of two ENOX2 transcript variants (Table 1; Fig. 1a, b). Consistently, two isoforms of ENOX2 were detected in sera samples collected from subjects an average 7.5 months (SD = 8) after confirmed diagnosis of malignant mesothelioma (Table 2). The larger ENOX2 transcript variant (Protein 1) had a molecular weight of 64 ± 2.7 kDa and a pI of pH 3.9 ± 0.1. The smaller variant (Protein 2) had a molecular weight of 41 ± 1.9 kDa and a pI of pH 4.3 ± 0.2. Both were detected in all 17 patients. The range in size and pI was 60–68 kDa, pH 3.8–4.1 for Protein 1 and 38–44 kDa, pH 3.8–4.6 for Protein 2 (Table 1).

ENOX2 transcript variants detected in pre-diagnosis serum samples

For seven mesothelioma patients, annual serum samples were available before clinical diagnosis. For all seven, both ENOX2 protein isoforms were detected in pre-diagnostic serum samples (Figs. 1a, b; 2) available at least 4 years before diagnosis. For one subject, ENOX2 was detected 10 years prior to diagnosis (Fig. 2). While in five subjects both the Protein 1 and Protein 2 were detected at the same time point, expression of only Protein 1 was encountered in advance of Protein 2 in serial sample sets from Patients ID 94 and 2774 (Fig. 2). Also, for one subject (ID 129), Protein 2 was detected intermittently between 96 and 72 months prior to diagnosis. Overall, both of the mesothelioma-specific ENOX2 transcript variants were detected 4–10 years in advance of clinical symptoms and with an average of 6.2 ± 2.6 years in advance of clinical symptoms (Fig. 2).

Subjects diagnosed with benign pleural plaques alone or with accompanying asbestosis

Of the fifteen asbestos-exposed subjects with benign pleural plaques either alone, or with accompanying asbestosis (Table 3), ENOX2 proteins were not detected in the sera of nine subjects (i.e., 60 %). Only one subject (ID 1268), was positive for both mesothelioma specific ENOX2 protein transcripts. Of the remainder, three subjects (ID 1542, 4334, and 4476) expressed only Protein 2 and two subjects (ID 4288 and 10011) expressed only Protein 1 (Table 3). Of the benign subjects exhibiting only Protein 1, both were female. For three subjects, longitudinal annual serum samples were available. For patient ID 1268, both ENOX2 protein isoforms were detected over a 10 year period (Table 3). This individual remains clinically malignancy-free 1.5 years after the last sample was analyzed. He has extensive pleural plaques, has never smoked and has a normal serum mesothelin level (data not shown). Only one of the ENOX2 isoforms was expressed in the other two benign patients examined longitudinally, though the protein was present over several years. Patient ID 4288 died approximately 1.5 years after the last sample was analyzed from non-malignant causes. Patient ID 1542 remains alive approximately a year after the last sample was examined.

Correlation between clinical diagnosis and ENOX2 spot diameter

For subjects who developed mesothelioma, the spot diameter at the earliest date of detection for both Protein 1 and Protein 2 was 1.95 ± 0.3 mm (not shown). The diameter remained more or less constant, increasing slightly to 2.3 ± 0.3 mm at the last date prior to mesothelioma diagnosis and a diameter of 3.2 ± 0.9 mm within the year following diagnosis. This represented approximately a twofold increase in serum ENOX2 concentration between the initial date of early detection and the clinical diagnosis of frank mesothelioma (Fig. 3).
https://static-content.springer.com/image/art%3A10.1186%2Fs12014-016-9103-3/MediaObjects/12014_2016_9103_Fig3_HTML.gif
Fig. 3

Log-log linear relationship between spot diameter and amount of ENOX2 protein. Varying amounts of purified, recombinant ENOX2 were analyzed by immunoblot. The log of the diameter of the detected ENOX2 spot was then plotted as a function of the log of the amount of ENOX2 loaded

In contrast, the amount of ENOX2 detected in the sera of time series subjects who have not developed mesothelioma (Table 3) either remained constant or declined. For subject ID 1268, spot diameter declined progressively from 2.0 to 0.8 mm between disease-free year 1 and 10. This decrease in spot diameter for Protein 1 for subject 1268 represents a reduction in the circulating ENOX2 concentration of approximately 90 % during the observation period, based on the relationship shown in Fig. 3. For subject ID 4288, expressing only Protein 1, the spot diameter declined from 2.2 to 1.8 mm between disease-free year 8 and 10. For patient ID 1542 expressing only Protein 2, spot diameters remained at 1.3 ± 0.3 mm over the 10 year observation period and for subject ID 1268 exhibiting both Protein 1 and Protein 2, the spot diameter remained constant at 1.3 ± 0.2 mm for a similar duration.

Discussion

The identification of specific ENOX2 isoforms in sera can be indicative of the presence of cancer and also indicative of the cancer site. Malignant mesothelioma is characterized by the presence of two ENOX2 protein species of molecular weight 64 and 41 kDa, and pI 3.9 and 4.3, respectively.

All 17 patients who were diagnosed with malignant mesothelioma displayed both mesothelioma-specific protein ENOX2 isoforms. Importantly, both ENOX2 isoforms were required for a correct identification of malignant mesothelioma by using the ONCOblot test (Table 1).

Of the cancer types examined to date, the ONCOblot pattern for malignant mesothelioma most closely resembles that of bladder cancer (Table 1). However, the pI of the larger molecular weight transcript variant is sufficiently different to avoid mischaracterization (Table 1). In any case, differentiating these two cancers rarely presents a diagnostic dilemma clinically. For malignant mesothelioma two ENOX2 protein transcript variants are evident; indeed multiple ENOX2 isoforms are seen in approximately half of the different types of cancer (Table 1).

The two ENOX2 transcripts were apparent in the seven mesothelioma patients examined, 4–11 years before the clinical onset of disease (Fig. 2). This is an exciting finding and implies that production of ENOX2 proteins are an early event in carcinogenesis. To our knowledge, this is the earliest prediagnostic indicator of cancer thus far reported. The use of serum biomarkers for the early detection of cancer has been the goal of many individual researchers and research consortia, such as the Early Detection Research Network [1617]. While some serum biomarkers have been described, few are used in routine clinical practice [18], and most give a lead time of less than a year [19]. Biomarker utility is hampered by low levels of specificity combined with a propensity to yield false positives [20]. The only useful biomarker for mesothelioma is mesothelin which is elevated in between 15 and 40 % of individuals exposed to asbestos before diagnosis of mesothelioma [7]. Asbestos-exposed individuals represent an ideal cohort to evaluate prospective serum biomarkers for cancer detection, due to both their quantifiable exposure to a carcinogen and the well-established link to a specific cancer type, malignant mesothelioma.

The distribution of histological asbestos-related lung cancer is similar to that of lung cancers of other etiologies [2122]. The test has been evaluated previously for both non-small cell and small cell lung cancers (Table 1). Those cancers exhibit a single ENOX2 protein unique to lung cancer but can be distinguished by their pIs [8].

Of the subjects with benign disease, 60 % lacked ENOX2 proteins in their serum (Table 3). Both protein transcript variants were found in the serum of only one subject currently diagnosed with benign disease (subject ID 1268). For the remaining five subjects diagnosed with benign disease, only one protein transcript variant was detected. It is possible that the presence of one of the two mesothelioma-specific isoforms is an indicator of early pathological changes that predate the development of mesothelioma, as the transition from benign disease to malignant mesothelioma may be required for both transcript variants to be present. This issue would require longer follow-up to elucidate. Within the ONCOblot test, the presence of only the high molecular weight mesothelioma-specific ENOX2 transcript variant would be identified as ‘not in the database’ as no malignancy characterized to date produces a single ENOX2 transcript variant with a similar molecular weight and pI as this ENOX2 transcript variant. In contrast, the presence of only the low molecular weight transcript variant would be misidentified as a cancer of blood cell origin (Table 1).

Of note, for the three patients who were diagnosed with benign disease and examined in a time series, the detected ENOX2 spot size either remained constant or declined during the observational period. Two of these subjects (subject ID 1542 and 4288) produced only one ENOX2 transcript variant (Table 3). Although the remaining patient (subject ID 1268) produced both mesothelioma-specific transcript variants (Table 3), a steady decline of Protein 1–40 % of the initial amount detected was observed over a 9 year period. The largest spot diameter encountered in patients clinically diagnosed with mesothelioma was 6.6 mm representing a nearly tenfold increase in ENOX2 proteins in the serum compared to levels giving rise to a 2 mm diameter spot at early detection. It is possible, though not proven, that as the controls in this study have all been exposed to asbestos that these false positives may represent a pre-malignant stage of mesothelioma that has yet to become clinically meaningful. Furthermore, mesothelioma is recognized for the long latency period between asbestos exposure and malignancy, so it is possible that during this phase equilibrium is maintained between the host and the cancer. The presence of one of the mesothelioma-associated ENOX2 transcript variants may reflect this interaction. The immune system is capable of influencing the outcome of mesothelioma patients, as evidenced by the occasional finding of spontaneous mesothelioma regression accompanied by strong lymphocyte infiltration [23] and by spontaneous humoral responses [24]. This notion will be investigated further.

A test that can detect mesothelioma at an early stage might offer the prospect of early intervention as an approach to improve patient outcomes. The data from this study demonstrate that serum ENOX2 proteins characteristic of malignant mesothelioma can be detected in subjects 4–11 years before diagnosis based on clinical symptoms, and raises the possibility that the benefits of early intervention could be studied in such individuals.

Conclusions

In a population of asbestos-exposed subjects who eventually developed malignant mesothelioma, ENOX2 transcript variants characteristic of malignant mesothelioma were present in serum 4–10 years in advance of clinical symptoms. As with all biomarker studies, these observations require validation in a larger, independent cohort of patients and should include prospective as well as retrospective sampling.

Methods

Case control identification

Serum samples were randomly selected from individuals who participated in an ongoing cancer prevention program [1213]. Samples were chosen from individuals with (1) a diagnosis of malignant mesothelioma confirmed by the Western Australian Mesothelioma Registry [25] and (2) from asbestos-exposed control subjects with benign pleural plaques either alone or with accompanying asbestosis [26]. For a sub-set of subjects, annually collected longitudinal serum samples were available. This study was approved by the Sir Charles Gairdner Hospital Human Research Ethics Committee.

ONCOblot tissue of origin cancer detection test

Serum samples were analyzed for the presence of ENOX2 protein transcript variants by using the ONCOblot Tissue of Origin Cancer Detection Test as described [8910]. Briefly, 25 µl of serum were separated using two-dimensional gel electrophoresis with isoelectric focusing in the first dimension to determine pI and SDS–polyacrylamide gel electrophoresis in the second dimension to determine molecular weight. Proteins were transferred to nitrocellulose and ENOX2 proteins were identified by immunoblot analysis with an ENOX2-specific recombinant antibody linked to alkaline phosphatase using a colorimetric substrate for detection. Blots were scanned and the pI and molecular weight of each ENOX2 transcript variant present was calculated by comparison to molecular weight standards and to two internal reference proteins (serotransferrin, ca. 82 kDa, pI 6.8, and α-fetuin, ca. 53 kDa, pI 4.1). The two reference serum proteins, serotransferrin and α-fetuin are detected on western blots because they both share a similar five amino acid sequence within the antibody combining site shared by all ENOX2 protein transcript variants [10]. Transferrin or α-fetuin antibodies were not added nor is the reaction unspecific. Each transcript variant of ENOX2 migrates to a specific location defined by the two reference proteins and has a specific location (molecular weight and pI) on the blot that correlates to the known tissue of origin determined from banked sera samples collected from individuals with a clinically confirmed diagnosis of cancer (Table 1).

The protein chemistry differences that underlie the molecular weight and pI differences that distinguish tissue-specific ENOX2 transcript variants result from alternative splicing of the ENOX2 mRNA [27]. Each of the protein transcript variants share a common exon 5 which contains the ENOX2-specific antibody-combining site including the amino acid sequence EEMTE. The overall sensitivity of the test is estimated to be >95 %.

The different tissues of origin provide for non-overlapping patterns of ENOX2 protein transcript variants each with a characteristic number of protein transcript variants, molecular weights and pIs. The majority of the tissues of origin, including small cell and non-small cell lung cancer, are represented by a single transcript variant. Several tissues of origin, including mesothelioma, ovarian, hepatocellular, uterine and six others are represented by two transcript variants. Three cancer tissues of origin, stomach, colon and kidney, have three [8].

Quantitation of ENOX2 based on spot diameter

To estimate relative amounts of ENOX2 in sera, data from patients were compared to a standard curve of known amounts of a functional, 46 kDa form of recombinant human ENOX2 generated in E coli. The log of the spot diameter and the log of the mass of ENOX2 detected by immunoblot after 2-D separation correlated linearly, r2 = 0.95 (Fig. 3). The complete amino acid sequence of a 72 kDa form of ENOX2 is available from GenBank under accession no. AF207881. The limit of detection of the ONCOblot assay is approximately 100 femtomoles of an ENOX2 protein [11].

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Copyright

© Morré et al. 2016

 

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