|Year : 2022 | Volume
| Issue : 4 | Page : 249-254
Cortactin: A novel prognostic marker in chronic myeloid leukemia
Mostafa K El-Razzaz MD 1, Tamer M Ahmed1, Deena S Eissa2, NourElhoda H Abdalla1, Mohammed A Shaheen3, Haydi S Mohamed1
1 Department of Internal Medicine and Clinical Hematology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
2 Department of Clinical Pathology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
3 Department of Clinical Pathology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
|Date of Submission||07-May-2022|
|Date of Acceptance||10-May-2022|
|Date of Web Publication||09-Mar-2023|
Mostafa K El-Razzaz
Department of Internal Medicine and Clinical Hematology, Faculty of Medicine, Ain Shams University, Abbassyia 11566, Cairo
Source of Support: None, Conflict of Interest: None
Background Chronic myeloid leukemia (CML) is a clonal myeloproliferative disease characterized by leukocytosis and an accumulation of granulocytes and their precursors. Cortactin is an actin-binding protein substrate of Src kinase. High cortactin expression in many hematological malignancies has been correlated with adverse prognostic factors. Aim The aim of our study was to measure cortactin levels in patients with CML at diagnosis and correlate such levels with other prognostic factors. Patients and methods This is a case–control study that was executed at hematology unit, Ain-Shams University Hospital during the period between January 2021 and October 2021. The study included 25 newly diagnosed patients with chronic phase CML and 25 healthy controls. Accelerated phase and blast crisis were excluded from the study. Results Cortactin level at diagnosis was higher in the patients group compared with the control group (71.04 ± 20.04 vs. 36.8 ± 11.6%, P<0.001). Cortactin level was significantly higher in patients who did not achieve complete hematological remission (CHR) at 3 months in comparison with those who achieved CHR (88.49 ± 8.02 vs. 61.23 ± 17.98, P<0.001). Patients who failed to attain CHR at 3 months had a significantly worse prognostic score at diagnosis using Sokal, Hasford, and ELTS scores (P=0.016, 0.035, and 0.009, respectively), but this did not apply to EUTOS score (P=0.089). Conclusion Higher cortactin levels are associated with delayed CHR in newly diagnosed patients with chronic phase CML, and it can be used as a prognostic marker for patients with CML at diagnosis.
Keywords: chronic myeloid leukemia, cortactin, prognosis
|How to cite this article:|
El-Razzaz MK, Ahmed TM, Eissa DS, Abdalla NH, Shaheen MA, Mohamed HS. Cortactin: A novel prognostic marker in chronic myeloid leukemia. Egypt J Haematol 2022;47:249-54
|How to cite this URL:|
El-Razzaz MK, Ahmed TM, Eissa DS, Abdalla NH, Shaheen MA, Mohamed HS. Cortactin: A novel prognostic marker in chronic myeloid leukemia. Egypt J Haematol [serial online] 2022 [cited 2023 Jun 5];47:249-54. Available from: http://www.ehj.eg.net/text.asp?2022/47/4/249/371331
| Introduction|| |
Chronic myeloid leukemia (CML) is a clonal myeloproliferative disorder characterized by leukocytosis and accumulation of granulocytes and their precursors. The Philadelphia chromosome t(9;22) (q34;q11.2) is the main cytogenetic abnormality in CML cells .
Cortactin is an actin-binding protein that form a multidomain structure discovered as an 80/85-kDa substrate of Src kinase. Cortactin was known to co-localize with cortical F-actin at the cell periphery .
There is limited data available describing the cortactin functions in hematopoietic cells because cortactin was considered absent in hematopoietic cells as these cells express its homolog hematopoietic cell-specific lyn substrate-1. Recent studies illustrated functional expression of cortactin in various hematopoietic cells such as macrophages, dendritic cells, and lymphocytes .
Several studies on solid malignancies illustrated that overexpression of cortactin is associated with unfavorable pathologic parameters and metastasis, leading to poor prognosis in different cancers .
In hematological malignancies, some studies described an important role of cortactin in leukemic cell migration and organ infiltration, which led to poor prognosis and lower survival rates [5,6].
Cortactin overexpression was noted in different hematological malignancies such as acute lymphoblastic leukemia (ALL), chronic lymphocytic leukemia (CLL), and non-Hodgkin’s lymphoma.
The aim of the current study was to measure cortactin levels in patients with CML at diagnosis and correlate such levels with other prognostic factors.
| Patients and methods|| |
The study included 25 newly diagnosed patients with chronic phase CML and 25 healthy controls of matched age and sex from the hematology unit of Ain-Shams University Hospital during the period between January 2021 and October 2021. Accelerated phase and blast crisis were excluded from the study.
All patients who participated in our study were subjected to full history taking; clinical examination; laboratory investigations, including complete blood count with differential, peripheral blood film, erythrocyte sedimentation rate, lactate dehydrogenase, uric acid, and kidney and liver function test; bone marrow aspiration for morphology; cytogenetics; and molecular genetics for diagnosis (FISH for t(9;22) and PCR for BCR–ABL). Cortactin was measured by flow cytometry on bone marrow and/or peripheral blood samples at diagnosis and in controls.
All procedures performed in our study were in agreement with the ethical standards of the institutional and national research committee and with the 1964 Helsinki declaration and its later amendments. Informed consent was obtained from all participants who participated in this study.
Complete hematological remission (CHR) was defined according to NCCN 2021 guidelines as a treatment response where all the following criteria were met: complete normalization of the peripheral blood count with white blood cell count less than 10 × 109/l; platelet count less than 450 × 109/l; no immature cells such as myelocytes, promyelocytes, or blasts in the peripheral blood; and no signs and symptoms of the disease, with resolution of palpable splenomegaly.
Cortactin was measured by flow cytometry on bone marrow and/or peripheral blood samples at diagnosis and in controls.
The amount of blood sample needed for cortactin assessment was 1-ml whole blood or marrow aspiration fluid on EDTA anticoagulant. The withdrawn samples were transported to the laboratory and processed immediately or stored at refrigerator for no more than 24 h.
Three reagents were used (all were purchased from Becton Dickinson: Franklin Lakes, New Jersey, USA):
- (1) Purified Mouse Anticortactin – BD Transduction Laboratories (primary antibody): Cat. No: 610049, Lot No: 8222661, 50 μg, 0.2 ml, 250 μg/ml, stored at −20°C.
- (2) FITC Goat Anti-Mouse Ig – BD Pharmingen (secondary antibody): Cat. No: 555988, Lot No: 0283899, 0.5 mg, 1 ml, 0.5 mg/ml, stored at 4°C.
- (3) Fixation and permeabilization solution – BD Cytofix/cytoperm – Cat. No: 51-2090KZ, Lot No: 4336859,125 ml, stored at 4°C.
Samples and kit reagents were brought to room temperature (15–30°C) and mixed well before using.
- (1) Red blood cells were lysed by lysis solution and then samples were washed two to three times by phosphate buffered saline (PBS) by centrifugation at 400 g for 5 min.
- (2) 100 μl of cytofix/cytoperm was added and incubated for 20 min in dark.
- (3) Anticortactin was diluted by PBS (100 μl of PBS with 50 μl of anticortactin).
- (4) 5 μl of diluted anticortactin was added and incubated for 30 min in dark.
- (5) Samples were washed as before, 5 μl of FITC anti-Ig was added, and then were incubated for 30 min in dark.
- (6) Samples were washed as before. Samples were resuspended in PBS.
- (7) Samples were analyzed on the Beckman Coulter flow cytometer. Results were printed using Navios software.
Data were analyzed with the Statistical Package for the Social Sciences (SPSS) version 15.0 (IBM, Armonk, New York, USA) and Microsoft Excel 2016 (Microsoft Corporation, Redmond, Washington, USA). Quantitative data were expressed as mean±SD. Qualitative data were expressed as frequency and percentage. Determining the extent that a single observed series of proportions differs from a theoretical or expected distribution was done using the χ2 test. Independent samples t test of significance was used when comparing between two means. Pearson’s correlation coefficient (r) test was used for correlating data. χ2 test was used for categorical variables to compare between different groups. P value less than 0.05 was considered significant.
| Results|| |
This study included 50 participants who were divided into 25 patients newly diagnosed with chronic phase CML and 25 healthy controls of matched age and sex. The mean±SD age in the patient group was 55.08 ± 9.4 years Navies versus 54.3 ± 10.04 years in the control group, with no statistically significant difference between the two groups.
The patient group included 16 (64%) males and nine (36%) females, whereas the control group included 13 (52%) males and 12 (48%) females.
Cortactin level at diagnosis was higher in the patient group as compared with the control group (71.04 ± 20.04 vs. 36.8 ± 11.6%, P<0.001).
A total of 16 (64%) patients achieved CHR after 3 months treatment by imatinib 400 mg daily as a first-line drug according to our hospital protocols.
We classified the patients into two groups according to their CHR status after 3 months of follow-up.
Although the initial total leukocytic count (TLC) was higher in patients who did not achieve CHR in comparison with those who did, but this difference did not translate into statistical significance (283.89 ± 131.08 × 103 vs. 245.31 ± 116.11 × 103, P=0.454).
No statistical significance was detected between the two groups regarding platelet count, basophils, eosinophils, blasts, and Philadelphia chromosome (P=0.413, 0.902, 0.918, 0.281, and 0.223, respectively).
Initial hemoglobin (HB) level was significantly higher in patients who achieved CHR at 3 months (11.21 ± 1.07 vs. 9.82 ± 1.01 g/dl, P=0.004).
Initial spleen size was significantly larger in patients who did not achieve CHR at 3 months compared with those who did (9.17 ± 2.65 vs. 6.38 ± 2.99 cm below costal margin, P=0.029).
Cortactin level was significantly higher in the group of patients who did not achieve CHR in comparison with those who achieved CHR (88.49 ± 8.02 vs. 61.23 ± 17.98, P<0.001) ([Table 1]).
|Table 1: Relation between laboratory investigation findings at diagnosis and hematological remission after 3 months of treatment|
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A statistically significant positive correlation was found between cortactin expression percentage and both TLC and blast percentage at diagnosis (0.618, P<0.001, and 0.688, P<0.001, respectively). Moreover, a statistically significant negative correlation was found between cortactin percentage and HB level at diagnosis (−0.512, P<0.001).
No statistically significant correlation was observed between cortactin percentage and platelet count (0.212, P=0.140) ([Table 2]).
|Table 2: Correlation between laboratory investigations at diagnosis and cortactin percentage|
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After 3 months of follow-up
A statistically significant positive correlation was observed between cortactin expression and TLC (0.810, P<0.001). Moreover, a statistically significant negative correlation was observed between cortactin percentage and HB level (−0.433, P<0.001).
No statistically correlation was found between cortactin percentage and platelet count (0.236, P=0.256) ([Table 3]).
|Table 3: Correlation between laboratory investigations 3 months after treatment and cortactin percentage|
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A statistically significant positive correlation between spleen size after 3 months of treatment and cortactin expression percentage was observed ([Figure 1]).
|Figure 1: Scatter plot diagram for correlation between spleen size after 3.|
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Months and cortactin %
The area under the receiver operating characteristic curve of cortactin percentage for prediction of hematological remission was 0.917, with an estimated cutoff point of equal or less than 73.8000 for predicting CHR ([Figure 2]).
|Figure 2: ROC curve of cortactin % for prediction hematological remission. ROC, receiver operating characteristic.|
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By using the prognostic scores of CML 3 months after treatment according to European Treatment and Outcome Study, it was observed that patients who did not achieve CHR had higher scores than those who achieved CHR, with a statistically significant difference between the two groups except for EUTOS (P=0.016, 0.035, 0.009, and 0.089 for Sokal, Hasford, ELTS, and EUTOS scores, respectively) ([Table 4]).
|Table 4: Relation of prognostic scores with hematological remission after 3 months of treatment|
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| Discussion|| |
Many studies have shown that cortactin overexpression was related to disease progression and poor prognosis in breast cancer, head and neck cancer, gastric carcinoma, and colorectal cancer ,,,,.
Regarding hematological malignancies, different studies illustrated an important role of cortactin overexpression in leukemic cells with effect on disease progression [5,6].
Previous studies were done on pediatric patients with B-cell acute lymphoblastic leukemia (B-ALL) and cell lines, and it reported that cortactin is overexpressed in this group of patients and shown to be a poor prognosis marker .
Aref et al.  reported that cortactin overexpression at diagnosis was a poor prognostic marker of T-cell ALL patient outcomes.
Similar results were shown by Velazquez-Avila et al.  in B-ALL and by Martini et al.  in CLL.
Moreover, cortactin overexpression was accompanied with increased expression of poor prognostic factors, such as ZAP-70, CD38, and somatic hypermutations, in the Ig heavy-chain variable region in patients with CLL .
Our study was the first study to assess the prognostic effect of cortactin in patients with CML. It showed that cortactin levels were significantly higher in the patient group compared with the control group. We could not find previous studies of cortactin in patients with CML. However, there are some related studies in other hematological malignancies, such as Aref et al. , who showed significantly higher cortactin expression in patients with B-ALL in comparison with the control group.
Aref et al.  also showed that cortactin levels were significantly higher in patients with T-ALL as compared with controls.
Martinez et al.  showed that cortactin was upregulated in T-ALL and in normal activated T cells.
Gattazzo et al.  studied cortactin in CLL and reported that cortactin overexpression was associated with increased CLL spreading.
Our study revealed significantly higher cortactin levels in patients who did not achieve CHR at 3 months compared with patients who achieved CHR; thus, cortactin levels may predict hematological remission in patients with CML.
Aref and colleagues reported similar results in T-ALL. They showed that induction of remission response was higher in patients with T-ALL with lower cortactin expression levels as compared with patients with higher levels. The high expressions of cortactin and hematopoietic cell-specific lyn substrate-1 were significant predictors of bone marrow relapse and CNS infiltrations. Furthermore, cortactin overexpression was associated with shorter overall survival in patients with B-ALL as compared with those with lower levels .
Moreover, Martinez et al.  showed that higher cortactin expression in B-ALL was correlated with infiltration, failure of steroid treatment, and relapse.
Similar results were published by Velazquez-Avila et al.  in B-ALL who reported that high cortactin levels were correlated with B-ALL organ infiltration and bone marrow relapse. They concluded that cortactin is a good diagnostic test to identify poor-risk patients and optimize their treatments.
Our study also revealed that cortactin levels were positively correlated with TLC and blast count at diagnosis and after 3 months of treatment and negatively correlated with HB levels at diagnosis and after 3 months of treatment. So, cortactin may be related to tumor volume; patients with higher cortactin levels had larger tumor volume. Moreover, such correlation may point to the importance of cortactin as an independent prognostic marker in patients with CML.
Similar results in B-ALL were published by Aref et al. , who reported that higher cortactin expression was significantly associated with lower HB level, lower red blood cell count, lower platelet count, and higher bone marrow blasts. Such results illustrate the role of cortactin in blast cells emersion from bone marrow into peripheral tissues, which increases tumor burden. Moreover, Aref et al.  reported that cortactin overexpression was significantly associated with higher TLCs and peripheral blast cells in T-ALL.
Our study also revealed that cortactin levels positively correlated with prognostic scores (Sokal, Hasford, and ELTS scores), with high cortactin percent in patients with high-risk scores. Our results were concordant with that of Gattazzo et al. , who reported that cortactin correlated with poor prognostic factors for CLL, such as expression of ZAP-70, CD38, absence of somatic hypermutation in the immunoglobulin heavy-chain variable region, abnormal karyotype, the requirement of therapy, and death for CLL.
Similarly, in B-ALL, Aref et al.  reported that higher expression of cortactin was associated with higher risk cytogenetics.
| Conclusion and recommendations|| |
Cortactin percentage was higher in patients with CML compared with the control group, especially in high-risk patients. Cortactin could be useful as a prognostic marker for patients with CML. Patients with higher levels may need different treatment protocols to achieve remission. So, we recommend that further studies should follow up a larger number of patients with CML for longer periods to correlate cortactin level at diagnosis and after treatment with disease progression and overall survival. Moreover, cortactin should be assessed in patients who initially present with advanced disease (accelerated and blastic phases).
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Conflicts of interest
The authors declare no conflict of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]