| Abstract|| |
Background: Matrix metalloproteinase 7 (MMP7) has largely been studied in pancreatic cancer which is the most common component of periampullary cancer in the western population. In India, the ampullary carcinoma is seen as the most common periampullary cancer in resected pancreaticoduodenectomies. We aimed to study the expression of MMP7 and its correlation with clinicopathological features in ampullary cancer. Materials and Methods: Consecutive cases of all ampullary cancer in a 3-year period were reviewed for histological differentiation (intestinal and pancreatobiliary) by morphology and immunohistochemistry (CDX2, MUC2, cytokeratin 20 [CK20], MUC1, cytokeratin 7 [CK7], and cytokeratin 17 [CK17]). All cases were stained for MMP7 and expression was correlated with histological variables, differentiation, and overall survival. Results: There were a total of 91 ampullary carcinomas (36 intestinal, 44 pancreatobiliary and 6 other types). Ampullary carcinoma showed MMP7 expression in 63.7% cases. Two-third of intestinal type and half of the pancreatobiliary type cancers showed MMP7 expression. MMP7 expression was significantly higher in low pathological T-stage of total ampullary carcinomas; however, it was seen more commonly in higher overall stage of the pancreatobiliary type compared to intestinal type of ampullary carcinoma. Overall survival in patients with MMP7 expression was lower compared to MMP7 negative patients. Conclusions: This is the first study on MMP7 expression in ampullary cancer. MMP7 expression was seen in nearly 64 % of ampullary cancer and showed a significant correlation with low pathological (T-) stage and high overall stage with a shorter survival. MMP7 can be explored as a target for MMP inhibitor therapy in the future.
Keywords: Ampullary, intestinal, matrix metalloproteinase 7, pancreatobiliary
|How to cite this article:|
Kumari N, Singh RK, Krishnani N, Shukla P. Matrix metalloproteinase 7 expression in ampullary carcinoma. Indian J Pathol Microbiol 2015;58:274-8
| Introduction|| |
Matrix metalloproteinases (MMP) are enzymes that degrade extracellular matrix proteins and facilitate cancer invasion and metastasis. Different MMPs have been studied in a variety of cancers. MMP-7 (Matrilysin 1) is a 28 kDa protein that cleaves collagen types IV and X, elastin, fibronectin, gelatin, laminin, and proteoglycans. It is regulated mainly by tissue inhibitor of metalloproteinases-1 (TIMP-1) and TIMP-2.  MMPs have been studied in serum as well as in tissues. It has been shown that increased expression of certain MMPs correlate with poor prognostic parameters. Allgayer et al. found that high levels of MMP2 were associated with poor prognosis in gastric cancer.  Murray et al. have shown an association of overexpression of MMP1 with poor prognosis of colorectal cancers.  In renal cell carcinoma, MMP2 and 9 and TIMP 1 and 2 were associated with poor prognosis.  MMP7 is expressed immunohistochemically (IHC) in 98% of pancreatic ductal adenocarcinomas and its high levels have been associated with poor prognosis in tumors of the pancreas, colon, stomach, prostate, and brain. MMP7 is expressed in tumor epithelial cells rather than stromal cells in contrast to other MMPs and has a role in many stages of tumor progression, including tumor formation, growth, invasion, metastasis and inflammation.  Marimastat, a general matrix metalloproteinase inhibitor has been studied under phase III trial and showed an improved response on survival of the patient with pancreatic adenocarcinomas.  Periampullary carcinoma is a heterogeneous group of entity comprising of four anatomically distinct cancers, however, this term is used by some workers for those tumors which cannot be categorized into these four distinct categories that include cancers of ampulla, distal bile duct, pancreatic head, and duodenal. MMP7 has been studied largely in pancreatic head cancer within the periampullary group. There is not enough information on the expression of MMP-7 in other tumors of periampullary group. In Indian population, the ampullary carcinoma forms the bulk (approximately 85%) of all resected pancreaticoduodenectomies.  We studied MMP7 expression and its correlation with clinicopathological variables in ampullary cancer and its histological subtypes (intestinal and pancreatobiliary).
| Materials and Methods|| |
All ampullary carcinomas received within a period of 3 years were included in the study. The cases were reviewed histologically using morphological criteria given by Albores-Saavedra et al.  as well as a panel of immunohistochemical markers to sub-classify into intestinal and pancreatobiliary differentiation. All cases were stained with MMP7 primary antibody (Ab-1, 1:50, Thermo Scientific). Briefly heat induced antigen retrieval was done using citrate buffer at pH 6.0. Primary antibody was incubated for 1 h at room temperature followed by secondary antibody (Envision, DAKO). Positivity staining was considered when >30% tumor cells were positive according to Masaki et al.  For histological sub-classification, CDX2, cytokeratin 20 (CK20), and MUC2 were used for intestinal differentiation and MUC1, CK7, and CK17 were used for pancreatobiliary differentiation. The source and dilution of antibodies are as follows: MUC1 (polyclonal, dilution 1:50) and CK17 (clone E3, dilution 1:40) from Thermo scientific (San Jose, CA, USA), MUC2 (clone Ccp58, dilution 1:100) from Novocastra, Newcastle, UK, CDX2 (MU392A.UC, dilution 1:50) from Biogenex (Fremond, CA, USA), CK7 (clone OV-TL 12/30, dilution 1:80), and CK20 (clone Ks 20.8, dilution 1:80) from Dako (Glostrup, Denmark). Each type of differentiation was considered if two of the three markers were positive in the corresponding panel. Expression of MMP7 was correlated with histological prognostic variables in ampullary carcinoma, intestinal type ampullary carcinoma, and the pancreatobiliary type ampullary carcinoma using Chi-square test. Overall survival in MMP7 positive and negative tumors was correlated using Kaplan-Meier log-rank test.
| Results|| |
Ninety-one cases of ampullary carcinoma were resected during the 3 years period comprising of 64 males and 27 females (age range 27-81 years with mean 56 and median 55.9 years). There were 36 cases of intestinal and 44 cases of pancreatobiliary differentiation. Others included 6 mixed, 1 adenosquamous, 2 signet ring cell, and 2 cases of undifferentiated carcinoma.
Matrix metalloproteinase 7 expression
In the 91 cases of ampullary carcinoma, 58 cases (63.7%) showed MMP expression [Figure 1]a and b. The MMP7 expression was significantly higher in low pathological T-stage tumors of ampullary carcinoma (P = 0.03) [Table 1]. However, when overall stage was correlated with histological differentiation, pancreatobiliary type ampullary carcinoma had significantly higher MMP7 expression in stage II tumors compared to stage I tumors (P = 0.04). The intestinal type of ampullary carcinoma did not show significant correlation of MMP7 with either pathological T-stage or overall stage (P = 0.07) [Table 2]. The overall survival in patients with MMP7 positive tumors was lower than in MMP7 negative tumors although it was not statistically significant. The histological type is an independent predictor of survival in periampullary carcinomas with intestinal type having higher overall survival than the pancreatobiliary type, and this has been shown by us as well as other authors previously.  The intestinal type MMP7 negative or positive cancers had a higher overall survival than MMP7 negative or a positive pancreatobiliary type cancers, respectively. MMP7 negative cancers in both intestinal or pancreatobiliary types showed longer survival than MMP7 positive cancers although none of the group had statistically significant survival difference [Figure 2]a-d. The MMP7 negative pancreatobiliary type ampullary cancer had a mean survival of 57.9 months compared to MMP7 positive tumors with a mean survival of 29.5 months, which was nearly significant (P = 0.05). Intestinal type ampullary cancers had marginally lower survival in MMP7 positive tumors compared to MMP7 negative tumors (46.1 and 51.7 months, respectively). The mean survival in total MMP7 positive ampullary cancers was also lower than MMP7 negative tumors although it was not statistically significant (45.0 months vs. 58.8 months). Thus, MMP7 positive tumors showed lower survival than MMP7 negative ampullary carcinoma irrespective of their histological differentiation.
|Figure 1: (a) Intestinal type carcinoma showing matrix metalloproteinase 7 (MMP7) expression (IHC, ×40). (b) Pancreatobiliary type carcinoma showing MMP7 expression (IHC, ×40)|
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|Figure 2: (a) Overall median survival in periampullary cancer with matrix metalloproteinase 7 (MMP7) expression. (b) Overall median survival in ampullary cancer with MMP7 expression. (c) Overall median survival in pancreatobiliary type periampullary cancer with MMP7 expression. (d) Overall median survival in the pancreatobiliary type ampullary cancer with MMP7 expression|
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|Table 1: Correlation of MMP7 expression with clinicopathological characteristics in ampullary cancers (n = 91)|
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|Table 2: Correlation of MMP7 expression with clinicopathological characteristics in intestinal and the pancreatobiliary type of ampullary cancers (n = 80)|
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| Discussion|| |
Matrix metalloproteinase expression in tumors is associated with increased tumor progression and their expression is significant as they can be used for designing novel therapeutic markers. Maristamat, a general MMP inhibitor is being explored to target the expression of MMPs in different cancers. Periampullary carcinoma is a heterogeneous group comprising of ampullary, pancreatic head, distal bile duct, and duodenal cancers. In the western population, incidence of pancreatic cancer is far more than ampullary cancers whereas in Indian population the incidence of ampullary carcinoma outweighs the other components in all resected pancreatico-duodenectomies.  Gress et al. showed that elevation of mRNA levels of MMP2, MMP9, TIMP1, and TIMP2 in pancreatic carcinomas and were associated with a degree of desmoplastic reaction but not with tumor differentiation or tumor stage.  Koshiba et al. has shown that increased levels of MMP2 in pancreatic cancers are correlated with regional lymph node and distant metastasis and post resection recurrence but not with survival in pancreatic cancers.  High levels of MMP7 have been associated with poor prognosis of tumors of the pancreas, colon, stomach, prostate, and brain. MMP7 has been shown to be an independent prognostic factor in pancreatic adenocarcinomas and both MMP7 and MMP11 predicted survival of the disease in one study. 
In the present study, MMP7 expression was analyzed in ampullary carcinoma and also with its intestinal and pancreatobiliary subtypes and it was found to be expressed in 63.7% of ampullary cancers. Oka et al. found MMP7 immunoreactivity in 69% of biliary tract cancers considering positive staining as 10% of carcinoma cells positive for MMP7. They found MMP7 positivity in 80% extrahepatic bile duct cancer, 50% of gallbladder cancer and 69% of carcinoma of the ampulla of Vater, however, did not find any correlation of histopathological characteristics with MMP7 expression.  Akishima-Fukasawa et al. studied 111 cases of colorectal cancer with and without metastasis and found 35% of tumors to be positive for MMP7 expression. They considered positive expression when >30% of cancer cells were positive because a cut-off value of 30% or 20% was the most powerful discriminatory factor with histological parameters in their study and found that MMP7 expression was independent predictor of lymph node metastasis.  In the present study also, the same cut-off of 30% positivity was used and of all the histological prognostic parameters, the pathological (T-) stage showed a significant correlation with MMP7 positive ampullary tumors and its pancreatobiliary subtype showed a significant correlation with overall stage. The median survival was also longer in patients with MMP7 negative expression than with MMP7 expression and was nearly double in the pancreatobiliary type of cancers (P = 0.05). The relation of MMP7 expression with tumor grade and stage has been analyzed in very few studies. Polistena et al. studied 28 cases of colorectal cancer and showed that MMP7 was expressed more in well-differentiated tumors compared to poorly differentiated tumors, but did not find any significant difference between stage I and II tumors with stage III and IV tumors.  Similarly, Pesta et al. also showed slightly higher expression in stage I and II tumors compared to stage III and IV tumors although it was statistically insignificant.  Thus, there is scarce information in the literature demonstrating relation of MMP7 expression with tumor stage and grade and is also quite variable. Li et al. found that 63.8% pancreatic adenocarcinoma tissues and 7/12 PanIN lesions showed MMP7 expression. This expression was significantly associated with metastasis and survival time of pancreatic cancer, but not with tumor size, cell proliferation activity, and degree of differentiation suggesting that MMP-7 plays a key role not only in the earlier stages of pancreatic tumorigenesis, but also in the progression of pancreatic carcinoma, and thereby contributes to a poor prognosis. 
| Conclusion|| |
This is the first study to show MMP7 expression in ampullary cancer as it is the predominant type in all resected pancreato-duodenectomies in Indian population. MMP7 expression was seen in two-third of intestinal type and about half of the pancreatobiliary type cancers. The MMP7 expression showed a significant positive correlation with low pathological (T-) stage cancers in ampullary carcinoma and with overall stage in pancreatobiliary subtypes of ampullary carcinoma. MMP7 expression was associated with shorter overall survival than MMP negative tumors. Ampullary cancers being the most common periampullary cancer in our population can be evaluated as target for MMP inhibitor therapy in unresectable and metastatic cases.
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Dr. Niraj Kumari
Department of Pathology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]
[Table 1], [Table 2]