Adipocytokines in Endometrial Cancer

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Brief Title

Adipocytokines in Endometrial Cancer

Official Title

Adipocytokines and Their Relationship to Obesity and Endometrial Cancer

Brief Summary

      The number of women diagnosed with uterine cancer continues to rise each year. Since the
      early 1990s, there has been almost 55% rise in the United Kingdom (UK). 34% of endometrial
      cancer can be attributed to obesity. In the obese state, the function of adipose tissue
      deteriorates resulting in a state of chronic inflammation. Adipocytokine-related signalling
      pathways promote cancer development by causing inflammation, cell proliferation, DNA damage
      and by inhibiting apoptosis. The investigators postulate that adipocytokines levels are
      significantly different in uterine cancer patients of different weight categories and
      different grade/stage/ type of tumour.

      Any woman attending the hospital with endometrial cancer and receiving treatment here will be
      invited to participate in the study. Consent will be sought to obtain 30mls (2 1/2
      tablespoons) of venous blood at the time of surgery, on day 1 post-surgery and 3/6 months
      post-surgery during routine follow-up to check biomarker (adiponectin, leptin, tumour
      necrosis factor alpha, interleukin-6, Insulin-like growth factors 1 and 2) levels to see if
      the markers can be used to assess response to treatment. The investigators will also get
      consent to collect tissue - adipose tissue (after surgery) and uterine cancer tissue and
      lymph nodes (after histo-pathological evaluation) to assess for biomarkers. The investigators
      will also obtain blood samples from patients undergoing chemotherapy for advanced stage
      endometrial. All tissues procured will be anonymised and analysed at the oncology laboratory,
      Leggett building, University of Surrey and later correlated with patients' medical data as
      well as with tumour grade, stage and type. The investigators will also use archival tissue
      blocks stored at the same laboratory for analysis (previously consented for use in research).
      These are anonymised tissue and there is no link to patients' data.

      The aim would be to ultimately find immuno-stimulatory/ suppressive biomarkers in order to
      develop novel diagnostic/ prognostic tools.
    

Detailed Description

      1. BACKGROUND

           Endometrial cancer is the most common malignancy of the female genital tract. It is the
           fourth most common cancer in the UK with around 9,500 new cases in 2017, current
           lifetime risk being 1 in 36 women. The number of women diagnosed with endometrial cancer
           continues to rise each year. Since the early 1990s, uterine cancer incidence rates have
           increased by almost three-fifths (55%) in the UK (2015-2017). The association between
           endometrial cancer and obesity is well documented. 7.5% of all cancers in women in UK
           are attributable to being overweight / obese (BMI ≥25 kg/m2). For endometrial cancer,
           this risk rises to 34%. A review of meta-analyses showed endometrial cancer risk is 16%
           higher per 5 kg- gained during adulthood, 29% higher per 10cm increase in hip
           circumference and 27% higher per 10cm increase in waist circumference. This higher
           endometrial cancer risk with raised BMI is present in both pre- and post-menopausal
           women. Moreover, patients who are obese tend to have a poorer outcome with more
           co-morbidities than their non-obese counterparts.

           In the overweight and obese state, the function of the adipose tissue deteriorates
           resulting in a state of chronic inflammation. In this inflammatory state, adipocytes and
           macrophages secrete several molecules, adipokines and inflammatory cytokines, which may
           promote tumour development and angiogenesis and stimulate adhesions and migration of
           cells.

           Most implicated adipocytokines in the tumorigenesis pathway are adiponectin, leptin,
           tumour necrosis factor-α (TNF-α), Interleukin-6 (IL-6) and Insulin-like growth factor 1
           and 2 (IGF 1 and 2).

           Adipocytokine related signalling pathways are important in the development of an
           inflammatory microenvironment for tumours. This process is thought to increase the risk
           of endometrial cancer by inducing cell proliferation and preventing cell apoptosis.
           Adiponectin, the most abundant adipokine, has been suggested to have anti-angiogenic,
           anti-inflammatory, and anti-apoptotic properties. Raised leptin levels in obese state
           promotes inflammation by stimulating the production of IL-6, TNFα as well as IL-1 and
           IL-126. Leptin and adiponectin secretion are counter-regulated in vivo. A study by Luhn
           et. al. has shown adiponectin to have inverse relationship with the risk of endometrial
           cancer and leptin to have a direct correlation.

           Also, in an inflammatory environment, macrophages secrete potent proinflammatory
           cytokines such as TNF-α and IL-6, which are known to activate numerous transcription
           factors that regulate the expression of genes involved in immune responses,
           anti-apoptosis, angiogenesis, and metastasis. The mechanisms of tumorigenesis are
           thought to be involved are free-radical production that cause DNA damage and impaired
           DNA repair.

           Research have further suggested that systemic levels of insulin-like growth factor (IGF)
           is dysregulated in obesity either due to increased IGF production or by down-regulation
           of IGF binding protein (IGFBP) production. IGF 1 is a growth and proliferation promotor
           and has inhibitory effects on cell death and is a major contributor in many neoplastic
           transformations.

           The above biomarkers are physiologically interrelated and are likely to reflect a more
           restricted number of underlying biological pathways. Possibly, they work in a
           synergistic capacity to modulate the risk of developing endometrial cancer. If specific
           patterns of cytokine expression were found to be predictive of adverse outcome, then the
           specific receptors may be targeted as a therapeutic option for endometrial cancer11. No
           study so far has looked at all these markers together in the serum and tissue samples of
           the same endometrial cancer patients to give a more wholesome idea about their effect on
           tumour genesis, progression and outcome. Therefore, this study is designed to assess the
           prognostic significance of these six biomarkers in the blood and tissue of endometrial
           cancer patients and co-relating the levels with their BMI and tumour type, after
           adjusting for age, parity, smoking status, menopausal status, use of hormone replacement
           therapy (HRT)/ hormonal contraception, and prevalence of diabetes and hypertension.

        2. RATIONALE

           Development of novel biomarkers for a variety of uses including diagnosis, treatment
           monitoring and prognostication is on the Cancer Reform Strategy agenda and actively
           encouraged by the National Cancer Research Institute and Medical Research Council.

           Understanding how adipocytokines influence endometrial cancer risk may help to elucidate
           biological mechanisms important for the observed obesity-endometrial cancer association.

        3. THEORITICAL FRAMEWORK

           As the incidence of endometrial cancer continues to rise there is a health need for a
           better diagnostic and prognostic approach.

           Studying the different biomarker levels in blood and cancer tissue will enable us to
           look for new targets that may be useful in the treatment and prognostication of this
           cancer.

           Also, if the levels of these markers change significantly post-treatment, the
           investigators can investigate if it will be possible to use these markers to assess
           response to treatment as follow-up for risk of recurrence forms an important part of the
           treatment protocol.

        4. RESEARCH QUESTIONS / OBJECTIVES:

           To assess the relationship between the endometrial cancer and blood and tissue
           biomarkers in patients referred for endometrial cancer management to Royal Surrey NHS
           Foundation trust and to correlate with obesity and tumour characteristics.

        5. STUDY DESIGN and METHODS of DATA COLLECTION AND DATA ANALYSIS

           5.1. Study design

           All patients being referred to the Royal Surrey NHS Foundation trust with diagnosed
           uterine cancer will be given the research information leaflet.

           Initially, an invitation letter will be sent alongside the patients' clinic appointment
           letter to inform them of the study and give them time for preliminary consideration of
           the study.

           Patients will then be approached in the outpatients' clinics after the initial
           consultation by the clinician. They will be given a participant information leaflet
           detailing the study rationale, methodology and analysis. Patients who agree to
           participate in the study will be asked to sign a consent form after explanation.

           Demographic data will be collected at the same time to correlate various risk factors
           associated with the development of uterine cancer. This data will be collected by:

             -  A short patient interview (10 minutes)

             -  Patients' medical notes Data from the interview will be directly entered into an
                existing departmental database for Gynaecological oncology which is password
                protected and stored on NHS computers. A copy of the data proformas from the
                interview will be filed in a secure room within the University department to allow
                for source data verification.

           Participants will then have 30mls (2 ½ tablespoons) of venous blood taken on the day of
           the surgery.

           Tissue samples from the participants undergoing hysterectomy will be collected as
           follows: the PI will collect any fresh tissue (adipose tissue) directly from theatre
           before fixing as it is not needed for establishing diagnosis and the uterine cancer
           tissue and lymph node will be collected by the PI after histo-pathological examination
           from the histo-pathology department after the diagnosis is established. All tissue
           processing will adhere to Human Tissue Authority (HTA) guidelines and will be performed
           at the Oncology laboratory at Leggett building at University of Surrey.

           The participants will have a repeat blood test (30mls) on day 1 post-surgery and at
           their 3 or 6 months routine post-surgery follow up appointment.

           For those participants who are recommended chemotherapy, the investigators will also ask
           consent to collect demographic data at the time of consultation and baseline blood
           sample (30mls venous blood) before commencing chemotherapy and after 3rd and 6th
           chemotherapy cycles to assess any changes in the biomarkers that may correlate with
           progression or regression of disease.

           The investigators will also obtain archival tissue blocks (of uterine cancer patients
           consented from a previous study for use during an appropriate ethics committee approved
           research) to help increase the number of recruitments for this study. Their demographic
           data with identification log will be made available to the PI only to assess for
           correlation between their data and the tissue diagnosis during analysis.

           5.2. Sample analysis

           ELISA will be used to assay bio-marker levels in blood samples.

           For tissue analysis the investigators will set up a tissue microarray (TMA). This will
           allow more uniform staining of the sample for immunohistochemistry with no
           inter-specimen variation of the staining method. Each case will be reviewed, and the
           area of interest (tumour) will be marked on the slide and cores from the areas of
           interest will be used to create the microarray block. Sections can then be cut from the
           microarray block and slides prepared for immune staining. The advantage of using this
           method is that the samples are subjected to the same conditions while being stained and
           the same part of a tumour can be reliably stained for several markers. Tissue sections
           from the TMA will be used for immune-staining and the expression of the markers of
           interest will be scored. Clinical data which is available on the cases will then be
           correlated with the histological and immunohistochemical scores and statistical analysis
           will be carried out.

           5.3. Data analysis

           Standard statistical analytical tools will be used to analyse the data. Relation between
           different variables will be sought with odds ratio, confidence interval and significance
           with P value (<0.05 significant). The Mann-Whitney U test will be used to assess
           differential expression of immune markers between tissue types -blood and tumour tissue.
           Correlation with clinical characteristics will be determined using univariate log-rank
           and multivariable Cox proportional hazards adjusting for age, stage, grade and
           histology.

        6. SAMPLE AND RECRUITMENT

      Potential participants will be identified in the Royal Surrey NHS Foundation trust - either
      seen here or referred here and receiving her treatment here for diagnosed endometrial cancer.

      6.1. Sample size

      The investigators will aim to recruit 30-60 patients with diagnosed endometrial cancer in the
      study. This sample size will also include archived tissue sample (formerly consented and
      stored in Leggett building, University of Surrey, for use in future ethical research).

      6.2. Recruitment

      All patients seen or referred with endometrial cancer at the Royal Surrey Oncology Department
      will be invited to participate in the study.

      Patients will not receive any payments for participation in the study. The investigators aim
      to obtain all information and samples at the time of routine visits.

      6.2.1. Sample identification

      Patients diagnosed with endometrial cancer will be identified through the Gynaecological
      Oncology Multi-Disciplinary Team meeting or by the Gynaecological Oncology or Medical
      Oncology teams.

      6.2.2. Consent

      Written consent will be obtained after the patient has received the participant information
      leaflet and had the opportunity to discuss and ask questions about the study. Enough time
      will be given for the purpose. Patients must all have capacity to consent. Consent will be
      undertaken by clinicians on the Gynaecological Oncology team. If necessary, a translator or
      language line can be used.

      Consent will also be taken for use of samples (anonymised and stored in Leggett building,
      University of Surrey following all regulations by HTA) for use in future research.
    


Study Type

Interventional


Primary Outcome

Levels of adipokines (adiponectin and leptin) - by ELISA (blood) and Immunohistochemistry (tissues) for patients having surgery for endometrial cancer

Secondary Outcome

 Correlation between levels of adipocytokines (biomarkers) and tumour grade, stage and type by using statistical tools like univariate log-rank and multivariable Cox proportional hazards analysis

Condition

Endometrial Cancer

Intervention

Blood and tissue sample collection from patients with endometrial cancer

Study Arms / Comparison Groups

 Patients with endometrial cancer
Description:  Potential participants will be identified in the Royal Surrey NHS Foundation trust - either seen here or referred here and receiving her treatment here for diagnosed endometrial cancer.
Patients diagnosed with endometrial cancer will be identified through the Gynaecological Oncology Multi-Disciplinary Team meeting or by the Gynaecological Oncology or Medical Oncology teams.
Blood sample will be collected on the day of the surgery when they are in the theatres and then repeated on day 1 post-operative in gynaecology ward and at 3/6 months post-surgery follow-up in clinic.
For the women undergoing chemotherapy, blood sample will be procured prior to commencing chemotherapy and after 3rd (with the blood test before the fourth cycle of chemotherapy) and 6th cycles of chemotherapy.

Publications

* Includes publications given by the data provider as well as publications identified by National Clinical Trials Identifier (NCT ID) in Medline.

Recruitment Information


Recruitment Status

Diagnostic Test

Estimated Enrollment

60

Start Date

April 12, 2021

Completion Date

December 2022

Primary Completion Date

December 2022

Eligibility Criteria

        Inclusion Criteria:

          1. Women diagnosed with endometrial cancer

          2. Age 18 or above

          3. Of sound mind so they can give informed consent

          4. Historical tissue sample/ blocks from previous cases in the laboratory in the
             University of Surrey, also be used if appropriate consent is in place.

        Exclusion Criteria:

          1. Under 18yrs age

          2. Unable to give consent /denies consent
      

Gender

Female

Ages

N/A - N/A

Accepts Healthy Volunteers

No

Contacts

, 07490749704, [email protected]

Location Countries

United Kingdom

Location Countries

United Kingdom

Administrative Informations


NCT ID

NCT04697264

Organization ID

SPON/2020/012/FHMS


Responsible Party

Sponsor

Study Sponsor

University of Surrey

Collaborators

 Royal Surrey County Hospital NHS Foundation Trust

Study Sponsor

, , 


Verification Date

April 2021