Radiol Oncol 2018; 52(1): 105-111. doi: 10.2478/raon-2018-0004 105 research article The influence of genetic variability on the risk of developing malignant mesothelioma Alenka Franko1, Nika Kotnik2, Katja Goricar3, Viljem Kovac4, Metoda Dodic-Fikfak1, Vita Dolzan3 1 Clinical Institute of Occupational Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia 2 Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia 3 Pharmacogenetics Laboratory, Institute of Biochemistry, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia 4 Institute of Oncology Ljubljana, Ljubljana, Slovenia Radiol Oncol 2018; 52(1): 105-111. Received: 3 September 2017 Accepted: 12 September 2017 Correspondence to: Prof. Vita Dolzan, M.D., Ph.D., Pharmacogenetics Laboratory, Institute of Biochemistry, Faculty of Medicine, University of Ljubljana, Vrazov trg 2, SI-1000 Ljubljana, Slovenia. Phone: +386 1 543 7670; Fax: +386 1 543 7641; E-mail: vita.dolzan@mf.uni-lj.si Disclosure: No potential conflicts of interest were disclosed. Background. Malignant mesothelioma is a rare cancer with poor outcome, associated with asbestos exposure. Reactive oxygen species may play an important role in the mechanism of carcinogenesis; therefore, genetic vari- ability in antioxidative defence may modify an individual’s susceptibility to this cancer. This study investigated the influence of functional polymorphisms of NQO1, CAT, SOD2 and hOGG1 genes, gene-gene interactions and gene- environment interactions on malignant mesothelioma risk. Patients and methods. In total, 150 cases with malignant mesothelioma and 122 controls with no asbestos-related disease were genotyped for NQO1, CAT, SOD2 and hOGG1 polymorphisms. Results. The risk of malignant mesothelioma increased with smoking, odds ratio (OR) 9.30 [95% confidence interval (CI): 4.83–17.98] and slightly with age, OR 1.10 (95% CI: 1.08–1.14). Medium and high asbestos exposures represented 7-times higher risk of malignant mesothelioma compared to low exposure, OR 7.05 (95% CI 3.59–13.83). NQO1 rs1800566 was significantly associated with increased malignant mesothelioma risk, OR 1.73 (95% CI 1.02–2.96). Although there was no independent association between either CAT rs1001179 or hOGG1 rs1052133 polymorphism and malignant mesothelioma, interaction between both polymorphisms showed a protective effect, ORint 0.27 (95% CI 0.10–0.77). Conclusions. Our findings suggest a role of both genetic variability in antioxidative defence and repair as well as the impact of gene-gene interactions in the development of malignant mesothelioma. The results of this study could add to our understanding of pathogenesis of malignant mesothelioma and contribute to prevention and earlier diagnosis of this aggressive cancer. Key words: antioxidative enzymes; genetic polymorphism; malignant mesothelioma Introduction Malignant mesothelioma (MM) is a rare and ag- gressive disease with poor survival. It has been as- sociated 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%), perito- neum (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 oc- curred 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 carcinogen- esis is not yet completely understood. Asbestos fi- bre 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 Radiol Oncol 2018; 52(1): 105-111. Franko A et al. / Genetic variability and malignant mesothelioma106 the macrofages, which produces ROS, reactive ni- trogen species (RNS), cytokines, chemokines, pro- teases and growth factors.8,9 This may lead to DNA damage, genomic instability and a malignant trans- formation of mesothelial cells.9 A number of studies show that ROS and RNS and inflammation could have a central role in asbestos fibre toxicity.10-13 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 in- crease 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 influ- ence the expression level or activity have been re- ported in the genes coding for all these enzymes. CAT helps to maintain the oxidative balance by catalysing H2O2 to H2O and O2.14,15 Numerous poly- morphisms of CAT gene (CAT) have been described, rs1001179 being the most commonly studied one. It causes cytosine (C) to thymine (T) change at po- sition -262 in the promoter region (c.262C>T).14 Our previous study investigating the associa- tion of this polymorphism with asbestosis found a slight increase in the risk of the TT genotype.16 Superoxide dismutases (SOD) convert superoxide into H2O2 and O2. SOD2 is found in mitochondria, where the amount of ROS is very high. The most common polymorphism is rs4880, resulting in C to T substitution at position 201 (c.201C>T), which causes the change of alanine to valine at position 16 (p.Ala16Val). Several studies associate the 6q25 chromosome deletion with certain forms of cancer, which is why some authors consider SOD2 to be a tumour suppressor gene.17,18 HOGG1 catalyses the repair of 8-oxoguanine that may result from ROS damage to the DNA. Functional polymor- phisms of the hOGG gene may impact DNA repair. In rs1052133 polymorphism, C replaces G in exon 7, causing the substitution of serine with cysteine in codon 326 (p.Ser326Cys). Although a changed structure of the polymorphic enzyme has not been proved, several studies have shown the association between hOGG1 Ser326Cys polymorphism and lung cancer risk.19,20 NQO1 catalyses the reduction of quinones to hydroquinones, preventing the for- mation of free radicals. The most frequently studied single nucleotide polymorphism (SNP), rs1800566, results in C to T change (c.609C>T), which causes proline to serine substitution (p.Pro187Ser).21 Some studies found this polymorphism to be associated with an increased risk of several malignant diseas- es: lung cancer, colorectal cancer, breast cancer and bladder cancer.22,23 Only few studies have investigated the inter- play between asbestos exposure and genetic vari- ability in antioxidant defence system in MM so far.24-26 Nevertheless, the interaction between as- bestos exposure and genetic susceptibility due to genetic polymorphism of antioxidant enzymes has been shown for asbestosis.27 We have previously described the association between SOD2 Ala/Ala genotype and asbestosis28 as well as association between CAT -262 TT genotype and asbestosis.16 Landi et al. reported on the association between SOD2 and the risk of MM25, but according to our knowledge and available literature, the impact of NQO1, CAT and hOGG1 polymorphisms on the risk of developing MM has not been studied so far. This study aimed to investigate whether func- tional polymorphisms in NQO1, CAT, SOD2 and hOGG1 genes influence the risk of MM, to investi- gate the interactions between genetic variability in antioxidative and DNA repair mechanisms and to investigate the interactions between asbestos expo- sure and the investigated polymorphisms in MM patients. Patients and methods Patients The study included 159 MM patients (cases), treat- ed at the Institute of Oncology Ljubljana between March 2007 and January 2013, along with 122 con- trols, who were occupationally exposed to asbes- tos 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 accord- ing to the Helsinki Declaration. The subjects were included in the study after providing a written in- formed consent. Methods The diagnosis of MM was made by means of thora- coscopy 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 Radiol Oncol 2018; 52(1): 105-111. Franko A et al. / Genetic variability and malignant mesothelioma 107 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 phy- sician, pulmonologist and radiologist, as previous- ly described.16 A personal interview with each of the subjects was conducted to get the data about smoking us- ing a standardized questionnaire.29 To determine asbestos exposure, a semiquantative method was used. For all the controls, data on cumulative as- bestos 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 sub- jects 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 cu- mulative asbestos exposure and were correspond- ingly 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 NQO1 rs1800566, CAT rs1001179, SOD2 rs4880 and hOGG1 rs1052133 polymorphisms as recom- mended by the manufacturer (Thermo Fisher Scientific, SNP genotyping assay C_2091255_30, C_11468118_10, C_8709053_10 and C_3095552_1_, respectively). Genotyping was performed blinded regarding the study endpoints and repeated in 20% of samples to check for genotyping accuracy and all the genotypes were concordant. Amplification was not successful in 11 subjects for NQO1, in 2 for CAT, in 6 for SOD2 and in 7 subjects for hOGG1 polymorphism. Statistical methods Standard descriptive statistics were first per- formed. Next, t-tests for differences of means of variables between the cases and controls were calculated, and Mann-Whitney (U) test was per- formed. The dominant genetic model was used for all the comparisons. To analyse the association between genotypes, cumulative asbestos exposure, and standard confounders (age, sex) and MM, uni- variate logistic regression was first used, followed by multivariate logistic regression modelling. A possible synergistic effect between genotypes and TABLE 1. Clinical characteristics of MM patients and controls Controls (n = 122) MM patients (n = 159) Test p Gender N (%) Male Female 88 (72.1) 34 (27.9) 123 (77.4) 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 smokers1 (%) 13 (10.7) 80 (52.6) χ2 = 53.185 < 0.001 Asbestos exposure2 N (%) No Yes 0 (0.0) 122 (100.0) 25 (16.6) 126 (83.4) Asbestos exposure3 N (%) Low Medium High 96 (78.7) 11 (9.0) 15 (12.3) 22 (34.4) 21 (32.8) 21 (32.8) χ2 = 35.941 < 0.001 Asbestos exposure3 N (%) Low Medium and high 96 (78.7) 26 (21.3) 22 (34.4) 42 (65.6) χ 2 = 35.541 < 0.001 MM = Malignant mesothelioma 1 data missing for 7 MM patients; 2 data missing for 8 MM patients; 3 data available for all controls and 64 MM patients Radiol Oncol 2018; 52(1): 105-111. Franko A et al. / Genetic variability and malignant mesothelioma108 cumulative asbestos exposure was investigated by using dummy variables. P-values less than 0.05 were considered as statistically significant. Results The clinical characteristics of MM patients and controls are presented in Table 1. There was no sta- tistical difference in gender between the cases and controls (p = 0.315), but MM patients were nota- bly 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 com- pared to asbestos exposed subjects without any as- bestos related disease (p < 0.001, Table 1). 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 pa- tients are presented in Table 2. Minor allele fre- quencies were 13.9% for NQO1 rs1800566, 22.4% for CAT rs1001179, 52.5% for SOD2 rs4880 and 18.8% for hOGG1 rs1052133. In controls, all SNPs were in Hardy-Weinberg equilibrium (all p > 0.05). The association between MM and the investigated polymorphisms was tested with univariate logistic regression using a dominant genetic model. The carriers of at least one polymorphic NQO1 allele TABLE 2. The distribution of antioxidative and repair gene polymorphisms in MM patients and controls and risk of MM Polymorphism Genotype MM patients Controls Unadjusted risk Adjusted by age Adjusted by smoking Adjusted by asbestos exposure N (%) N (%) OR (95% CI) p OR (95% CI) p OR (95% CI) p OR (95% CI) p NQO1 rs18005661 CC CT TT 98 (62.0) 57 (36.1) 3 (1.9) 82 (73.9) 27 (24.3) 2 (1.8) 1.73 (1.02–2.96) 0.043 1.63 (0.91–2.95) 0.103 1.88 (1.04–3.41) 0.037 1.72 (0.83–3.57) 0.124 CAT rs1001179 CC CT TT 79 (50.0) 64 (40.5) 15 (9.5) 70 (57.4) 47 (38.5) 5 (4.1) 1.35 (0.84–2.17) 0.220 1.21 (0.71–2.05) 0.484 1.47 (0.86–2.51) 0.159 1.45 (0.73–2.88) 0.288 SOD2 rs48802 CC CT TT 44 (27.7) 81 (50.9) 31 (19.5) 31 (25.8) 52 (43.3) 37 (30.8) 0.89 (0.52–1.52) 0.661 0.76 (0.41–1.39) 0.371 0.95 (0.52–1.73) 0.857 0.81 (0.38–1.73) 0.578 hOGG1 rs10521333 CC CG GG 99 (62.3) 52 (32.7) 6 (3.8) 82 (70.1) 32 (27.4) 3 (2.6) 1.37 (0.82–2.29) 0.225 1.42 (0.80–0.51) 0.232 1.36 (0.77–2.41) 0.286 1.77 (0.85–3.66) 0.125 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. 1missing data for 10 patients; 2missing data for 2 patients; 3mising data for 4 patients TABLE 3. 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) Gene 1 Gene 2 Interaction Genotypes OR (95% CI) p Genotypes OR (95% CI) p OR (95% CI) p NQO1 rs1800566 CT+TT vs.CC 1.73 (1.02–2.96) 0.043 hOGG1 rs1052133 CG+GG vs.CC 1.37 (0.82–2.29) 0.225 1.22 (0.36–4.13) 0.75 CAT rs1001179 CT+TT vs.CC 1.35 (0.84-2.17) 0.220 hOGG1 rs1052133 CG+GG vs.CC 1.37 (0.82–2.29) 0.225 0.27 (0.10–0.77) 0.014 SOD2 rs4880 CT+TT vs.CC 0.89 (0.52–1.52) 0.661 hOGG1 rs1052133 CG+GG vs.CC 1.37 (0.82–2.29) 0.225 0.78 (0.25–2.43) 0.669 OR = odds ratio Radiol Oncol 2018; 52(1): 105-111. Franko A et al. / Genetic variability and malignant mesothelioma 109 (CT and TT genotypes) had an increased risk of MM compared to those with CC genotype (OR = 1.73; 95% CI = 1.02–2.96; p = 0.043). No association was observed between MM and other genetic poly- morphisms (Table 2). Multivariate analysis was used to determine the combined effect of genetic determinants and clinical variables such as smoking, age and asbes- tos exposure. The association between NQO1 and MM risk remained significant after adjustment for smoking, but the risk was slightly lower when ad- justed by age or asbestos exposure. The association between other investigated polymorphisms and MM risk remained nonsignificant also after taking into account the effect of age, smoking and asbes- tos exposure (Table 2). Next, gene-gene interactions between the inves- tigated NQO, CAT, SOD2 and hOGG1 genotypes and the interactions between genotypes and as- bestos exposure were calculated. The interaction between CAT rs1001179 and hOGG1 rs1052133 had a protective effect on the risk of MM (ORint = 0.27; 95% CI = 0.10–0.77; p = 0.014). On the other hand, no gene-gene interactions were observed between other investigated polymorphisms (Table 3). Finally, we investigated the influence of inter- actions between polymorphisms and asbestos ex- posure on the risk of MM, but no interaction was found (Table 4). Discussion The association between asbestos exposure and MM has been clearly proved, but not much has been known about the influence of genetic poly- morphisms that may modify the risk of develop- ing this aggressive cancer. Our present study in- vestigated 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 ge- netic polymorphisms and asbestos exposure on the risk of developing this cancer. In the study, we have found that smoking in- creased 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 inves- tigated the association between ROS and carcino- genesis, caused by tobacco smoke.31 According to the free radical hypothesis of aging, ROS and RNS can drive the accumulation of cell and DNA dam- age32 leading to carcinogenesis and cancer.33-36 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 ex- posed 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 predomi- nantly 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 la- tency period, including dose response, age, gender and location of MM.39 An important finding of our study is that me- dium and high asbestos exposures increase the risk of MM by 7-fold compared to low asbestos expo- sure. 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.40-43 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 pre- vious 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 NQO1 rs1800566 T allele. According to the available literature, the association between NQO1 polymorphisms and MM has not been in- vestigated yet. However, some studies have found an increased risk of lung cancer21, colorectal can- TABLE 4. The influence of interactions between the investigated polymorphisms and asbestos exposure on risk of malignant mesothelioma Polymorphism OR CI (95%) p NQO1 rs1800566 1.56 0.35–6.86 0.560 CAT rs1001179 1.57 0.39–6.29 0.522 SOD2 rs4880 1.13 0.24–5.18 0.880 hOGG1 rs1052133 0.50 0.12–2.14 0.352 CAT = catalase; hOGG1 = human 8-oxoguanine glycosylase 1; NQO1 = NAD(P)H quinone dehydrogenase 1; OR = odds ratio; SOD2 = superoxide dismutase 2 Radiol Oncol 2018; 52(1): 105-111. Franko A et al. / Genetic variability and malignant mesothelioma110 cer44 and bladder cancer22 among the carriers of the polymorphic allele. On the other hand, a risk of MM was not statistically significantly increased for other investigated polymorphisms. Contrary to the findings of this study, the only other study investi- gating the SOD2 polymorphism in relation to MM risk25 showed an increased risk of pleural MM in SOD2 Ala/Ala genotype. Regarding other asbestos related diseases, we have previously reported an association between SOD2 Ala/Ala genotype and higher risk of asbestosis.28 Furthermore, a signifi- cantly higher risk of lung cancer was reported in carriers of both Ala/Val and Val/Val genotypes.45,46 Even though there was no association between CAT rs1001179 or hOGG1 rs1052133 alone and MM, one of the key findings of this study was that the interactions between CAT rs1001179 and hOGG1 rs1052133 have a protective effect on the risk of MM. This can be explained by the fact that CAT as an antioxidative enzyme constitutes a part of the primary defence system against ROS, while hOGG1 as a repair enzyme removes oxidized bas- es such as 8-oxoguanine. According to the above- mentioned mechanisms of defence against ROS, we can consider our observations as biologically plausible. We have also previously reported slight- ly increased risk of asbestosis among the carriers of the CAT rs1001179 TT genotype.16 Furthermore, Erculj et al. have observed an association between hOGG1 Ser326Cys polymorphism and higher DNA damage levels in healthy young population.47 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 asbes- tos exposure could not be determined for all MM patients, as proper assessment is very difficult, especially for environmental or occasional expo- sure. 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 in- vestigated gene-gene as well as gene-environment interactions in MM patients.48 Neri et al. analysed a different set of genes, including several glutathione S-transferases that also contribute to antioxidative defence mechanisms and also showed the pres- ence of gene-gene interactions as well as gene- environment interactions in the development of MM.48 Therefore, further studies including a larger number of subjects with well-defined asbestos ex- posure are needed to elucidate the role of gene-en- vironment interactions in the development of MM. Considering that pathogenesis of MM is still not completely understood, polymorphisms of other enzymes that could affect the removal of ROS and RNS and other DNA repair mechanisms, also need to be investigated. In conclusion, our study showed for the first time that NQO1 polymorphism influences the risk of MM both independently and after adjustment by smoking. 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