Malignant mesothelioma (MM) is a rare and aggressive disease with poor survival. It has been associated with occupational and/or environmental exposure to asbestos in more than 86% of patients with this disease. 1,2 Malignant mesothelioma most commonly arises from pleura (65%–70%), peritoneum (30%) and very rarely other serous surfaces (1%). 3,4 Global incidence is expected to peak 30 to 40 years after the peak of asbestos usage that occurred in the 1960s and 1970s.3,5 However, recent studies still show a rise in incidence. 6
The implication of asbestos exposure in MM has been validated, but the mechanism of carcinogenesis is not yet completely understood. Asbestos fibre components, specifically iron, are hypothesized to contribute to reactive oxygen species (ROS) production. Iron catalyses both Fenton and Haber-Weiss reactions which produce hydroxyl radical (HO) from peroxide (H2O2). 7 Furthermore, all types of asbestos may cause frustrated phagocytosis in the macrofages, which produces ROS, reactive nitrogen species (RNS), cytokines, chemokines, proteases and growth factors. 8,9 This may lead to DNA damage, genomic instability and a malignant transformation of mesothelial cells.9 A number of studies show that ROS and RNS and inflammation could have a central role in asbestos fibre toxicity. 10,11,12,13
On the other hand, antioxidative enzymes such as catalase (CAT), superoxide dismutases (SOD-s), and NAD(P)H quinone dehydrogenase 1 (NQO1) participate in the enzymatic defence against ROS and RNS. 10 When the activity of these enzymes is decreased or changed, ROS concentrations increase and DNA damage may occur. One of the most important repair enzymes for oxidative DNA damage repair is human 8-oxoguanine glycosylase 1 (hOGG1). Functional polymorphisms that influence the expression level or activity have been reported in the genes coding for all these enzymes. CAT helps to maintain the oxidative balance by catalysing H2O2 to H2O and O214,15 Numerous polymorphisms of
Only few studies have investigated the interplay between asbestos exposure and genetic variability in antioxidant defence system in MM so far. 24,25,26 Nevertheless, the interaction between asbestos exposure and genetic susceptibility due to genetic polymorphism of antioxidant enzymes has been shown for asbestosis. 27 We have previously described the association between
This study aimed to investigate whether functional polymorphisms in
The study included 159 MM patients (cases), treated at the Institute of Oncology Ljubljana between March 2007 and January 2013, along with 122 controls, who were occupationally exposed to asbestos in the asbestos cement manufacturing plant of Salonit Anhovo, Slovenia, but did not develop any disease associated with asbestos exposure. All patients and controls were from Central European Caucasian (Slovenian) population. The study was approved by the Slovenian Ethics Committee for Research in Medicine and was carried out according to the Helsinki Declaration. The subjects were included in the study after providing a written informed consent.
The diagnosis of MM was made by means of thoracoscopy or video-assisted thoracoscopic surgery (VATS) in patients with pleural MM and by means of laparoscopy or laparotomy in peritoneal MM. The diagnosis was confirmed histopathologically by an experienced pathologist.2 The diagnosis of “no asbestos related disease” in the control group was confirmed by the experts of the Board for Recognition of Occupational Asbestos Diseases at the Clinical Institute of Occupational Medicine, which consisted of an occupational physician, pulmonologist and radiologist, as previously described. 16
A personal interview with each of the subjects was conducted to get the data about smoking using a standardized questionnaire. 29 To determine asbestos exposure, a semiquantative method was used. For all the controls, data on cumulative asbestos exposure in fibres/cm3-years were available from the previous study. 29 Data on cumulative asbestos exposure were also available for 27 MM patients. Based on these data, we divided the subjects into three groups: low (< 11 fibres/cm3-years), medium (11–20 fibres/cm3-years) and high (> 20 fibres/cm3-years) asbestos exposure. For the rest of the patients with MM, a thorough work history was obtained and where enough information was available, their exposures were compared with those from the group of patients with known cumulative asbestos exposure and were correspondingly divided into three groups with presumed low, medium and high asbestos exposures. 2 Thus, 37 MM patients were assigned to one of these three groups, but for 95 MM patients epidemiological data were not sufficient to allow the assignment of patients to one of the groups; consequently, they were only categorized as exposed or non-exposed. The influence of asbestos exposure on MM risk was determined in the subgroup of patients where the asbestos exposure was known or could be assessed.
DNA of the MM patients and some controls without asbestos related diseases was available from our previous studies2,30, DNA of the rest of the controls was isolated from peripheral venous blood samples using FlexiGene DNA kit (Qiagen, Hilden, Germany).
Real-time polymerase chain reaction (PCR) based TaqMan assays were used for the analysis of
Standard descriptive statistics were first performed. Next,
The clinical characteristics of MM patients and controls are presented in Table 1. There was no statistical difference in gender between the cases and controls (p = 0.315), but MM patients were notably older (p < 0.001) and a much higher number of the patients were smokers (p < 0.001). All the controls (122) and 126 (83.4%) MM patients had been exposed to asbestos. For all the controls and 64 (50.8%) MM patients, asbestos exposure could be categorized into the groups. Among the subjects with known asbestos exposure, the MM patients had a significantly higher asbestos exposure compared to asbestos exposed subjects without any asbestos related disease (p < 0.001, Table 1).
Clinical characteristics of MM patients and controls data missing for 7 MM patients data missing for 8 MM patients data available for all controls and 64 MM patients data available for all controls and 64 MM patients MM = Malignant mesotheliomaControls (n = 122) MM patients (n = 159) Test p Gender N (%) Male 88 (72.1) 123 (77.4) Female 34 (27.9) 36 (22.6) χ2 = 1.008 0.315 Age (years), median (range) 54 (48–60.3) 65 (57–72) U = 4392.000 < 0.001 No. of smokers 13 (10.7) 80 (52.6) χ2 = 53.185 < 0.001 Asbestos exposure No 0 (0.0) 25 (16.6) Yes 122 (100.0) 126 (83.4) Asbestos exposure Low 96 (78.7) 22 (34.4) χ2 = 35.941 < 0.001 Medium 11 (9.0) 21 (32.8) High 15 (12.3) 21 (32.8) Asbestos exposure Low 96 (78.7) 22 (34.4) χ2 = 35.451 < 0.001 Medium and high 26 (21.3) 42 (65.6)
Univariate regression logistic analysis has shown that the risk of MM was influenced by smoking, age and asbestos exposure, but not by gender. The risk of MM was increased in smokers (OR = 9.30; 95% CI = 4.83–17.98; p < 0.001) and older patients (OR = 1.10; 95% CI = 1.08–1.14; p < 0.001). Compared to a low exposure to asbestos, medium and high asbestos exposures increased the risk of MM 7-fold (OR = 7.05; 95% CI = 3.59–13.83; p < 0.001). Gender did not influence MM risk (OR = 0.76; 95% CI = 0.44–1.30; p = 0.316).
Genotype frequencies for controls and MM patients are presented in Table 2. Minor allele frequencies were 13.9% for
The distribution of antioxidative and repair gene polymorphisms in MM patients and controls and risk of MM missing data for 10 patients missing data for 2 patients missing data for 4 patients CAT = catalase; hOGG1 = human 8-oxoguanine glycosylase 1; MM = Malignant mesothelioma; NQO1 = NAD(P)H quinone dehydrogenase 1; OR = odds ratio; SOD2 = superoxide dismutase For determining MM risk, carriers of at least one polymorphic allele were compared to non-carriers.Polymorphism Genotype MM patients Controls Unadjusted risk Adjusted by age Adjusted by smoking Adjusted by abestos exposure N (%) N (%) OR (95% CI) p OR (95% CI) p OR (95% CI) p OR (95% CI) p CC 98 (62.0) 82 (73.9) CT 57 (36.1) 27 (24.3) 1.63 0.103 1.72 0.124 TT 3 (1.9) 2 (1.8) (0.91–2.95) (0.83–3.57) CC 79 (50.0) 70 (57.4) CT 64 (40.5) 47 (38.5) 1.35 0.220 1.21 0.484 1.47 0.159 1.45 0.288 TT 15 (9.5) 5 (4.1) (0.84–2.17) (0.71–2.05) (0.86–2.51) (0.73–2.88) CC 44 (27.7) 31 (25.8) CT 81 (50.9) 52 (43.3) 0.89 0.661 0.76 0.371 0.95 0.857 0.81 0.578 TT 31 (19.5) 37 (30.8) (0.52–1.52) (0.41–1.39) (0.52–1.73) (0.38–1.73) CC 99 (62.3) 82 (70.1) CG 52 (32.7) 32 (27.4) 1.37 0.225 1.42 0.232 1.36 0.286 1.77 0.125 GG 6 (3.8) 3 (2.6) (0.82–2.29) (0.80–0.51) (0.77–2.41) (0.85–3.66)
Multivariate analysis was used to determine the combined effect of genetic determinants and clinical variables such as smoking, age and asbestos exposure. The association between
Next, gene-gene interactions between the investigated
Gene-gene interactions between rs1800566 NAD(P)H quinone dehydrogenase 1 (NQO1), rs1001179 catalase (CAT), rs4880 superoxide dismutase 2 (SOD2), and rs1052133 human 8-oxoguanine glycosylase 1 (hOGG1) OR = odds ratioGene 1 Gene 2 Interaction 1.37 0.225 1.22 0.75 VS.CC CG+GG VS.CC (0.82–2.29) (0.36–4.13) 1.35 0.220 1.37 0.225 CT+TT VS.CC (0.84-2.17) CG+GG VS.CC (0.82–2.29) 0.89 0.661 1.37 0.225 0.78 0.669 CT+TT VS.CC (0.52–1.52) CG + GG VS.CC (0.82–2.29) (0.25–2.43)
Finally, we investigated the influence of interactions between polymorphisms and asbestos exposure on the risk of MM, but no interaction was found (Table 4).
The influence of interactions between the investigated polymorphisms and asbestos exposure on risk of malignant mesothelioma CAT = catalase; hOGG1 = human 8-oxoguanine glycosylase 1; NQO1 = NAD(P)H quinone dehydrogenase 1; OR = odds ratio; SOD2 = superoxide dismutase 2Polymorphism OR CI (95%) p 1.56 0.35–6.86 0.560 1.57 0.39–6.29 0.522 1.13 0.24–5.18 0.880 0.50 0.12–2.14 0.352
The association between asbestos exposure and MM has been clearly proved, but not much has been known about the influence of genetic polymorphisms that may modify the risk of developing this aggressive cancer. Our present study investigated the effect of genetic polymorphisms of some of the most important enzymes involved in removal of ROS and RNS (NQO1, CAT, SOD2) and DNA damage repair (hOGG1) on the risk of MM, as well as the impact of interactions between the observed genetic polymorphisms and between genetic polymorphisms and asbestos exposure on the risk of developing this cancer.
In the study, we have found that smoking increased the risk of MM. It has been well proved that exposure to asbestos fibres results in an increased generation of ROS.8,9 Many studies have also investigated the association between ROS and carcinogenesis, caused by tobacco smoke.31 According to the free radical hypothesis of aging, ROS and RNS can drive the accumulation of cell and DNA damage32 leading to carcinogenesis and cancer.33,34,35,36 The combined effect of both asbestos and smoking may thus greatly increase the amount of ROS in the cells and may cause more DNA damage than smoking or asbestos exposure alone. That could explain the observed higher risk of MM among smokers exposed to asbestos compared to non-smokers.
Our study also showed a slight increase in MM susceptibility in older patients, which is in line with other studies in which MM is found predominantly as disease of the elderly.37 Mortality due to pleural MM increased between 75 and 89 years of age and in peritoneal MM between 65 and 84 years of age.37 This may be due to the long latency time, which is the period from the first exposure to the diagnosis of MM, and can range from 20 to over 50 years.38 There are many factors affecting the latency period, including dose response, age, gender and location of MM.39
An important finding of our study is that medium and high asbestos exposures increase the risk of MM by 7-fold compared to low asbestos exposure. This is in line with the results of some studies that have also reported that the MM risk is related to the amount of exposure.40,41,42,43 An Australian study reported an increased risk of MM with higher and longer occupational or environmental exposure to asbestos.40, 41 A Norwegian study also observed a correlation between the duration of occupational exposure and risk of MM42,43 However, in our previous study, low levels of asbestos exposure were reported in almost 36% of patients with MM.2
Another important finding of the current study indicates a higher risk of MM among subjects with the
Even though there was no association between
A limitation of this study was that MM patients were significantly older than controls, however we accounted for that with adjustment for age in the statistical analysis. Furthermore, cumulative asbestos exposure could not be determined for all MM patients, as proper assessment is very difficult, especially for environmental or occasional exposure. Therefore, some of the analyses were only performed on the subgroup of MM patients. On the other hand, our study is one of the few that investigated gene-gene as well as gene-environment interactions in MM patients.48 Neri
In conclusion, our study showed for the first time that