Arsenic Trioxide Effectively Controls Malignant Pleural Effusion In Non-small Cell Lung Cancer Patients By Blocking TP53-VEGF Pathway

BackgroundMalignant pleural effusion(MPE)is the most serious and common complication of non-small cell lung cancer(NSCLC).About 15% of NSCLC patients are initially diagnosed with malignant pleural effusion,and 50% of NSCLC patients are eventually Will develop into MPE.MPE patients often have a large volume of effusion,are prone to relapse,and cause breathing difficulties due to compression of lung tissue.This is a life-threatening complication.The clinical appearance of MPE indicates a poor prognosis.From diagnosis to death,the median survival is only 3-12.For this reason,the international TNM staging standard specifically classifies patients with lung cancer with malignant pleural effusion as M1 a,IV.The recurrence rate of MPE treatment is high,and the best treatment method for MPE at home and abroad has been controversial.International clinical guidelines recommend the use of pleural fluid drainage combined with chemical pleural fixation to treat MPE,that is,talc,bleomycin,tetracycline and other hardening agents are injected into the pleural cavity after draining the pleural fluid from the intercostal tube to promote pleural adhesion and pleural space In order to inhibit the formation of pleural effusion,talc is the most effective sclerosing agent,and its success rate can reach 71-100%.However,the talc powders on the market in China have not reached the level of medical hardeners,so bleomycin is often used in China.However,bleomycin has many side effects such as side fever and chest pain,which makes many patients suffering.Other methods of MPE include water restriction,diuresis,and thoracoscopy.However,the clinical effect of these methods is usually poor.Therefore,it is important to understand the pathogenesis of MPE in order to find new safe and effective treatments.MPE is the result of the integration and interaction between host cells and tumor cells.Generally,tumor pleura metastasis produces many vasoactive substances to promote new angiogenesis and increase vascular permeability,which leads to increased pleural exudation.Among these vasoactive substances,VEGF plays a central role.More and more evidence shows that VEGF levels in pleural effusions of MPE patients are significantly increased,and VEGF levels in pleural effusions are important indicators affecting the prognosis of MPE patients.Previous research by our group found that Arsenic trioxide(ATO)can inhibit the growth of pleural metastases in a mouse lung cancer model by inhibiting angiogenesis,and the expression of VEGF in pleural metastases is reduced after administration.Further clinical application of ATO thoracotomy MPE patients found that the pleural effusion changed from the original bloody pleural effusion to pale yellow,the pleural effusion volume was significantly reduced,and the red blood cell count in the pleural effusion decreased several times.This suggests that ATO may have great potential value for the treatment of MPE,but there is no evidence-based medical evidence at this stage to confirm the effectiveness and safety of ATO thoracic infusion for MPE,and the specific mechanism of ATO’s effect on VEGF is unknown.Hypoxia-induced factor-1(HIF-1)is the most important activator of VEGF transcription in the hypoxic environment of tumor tissues,and wild-type tumor suppressor gene TP53 can promote the hypoxia-induced factor-1α subunit(hypoxiainduced factor-1α,HIF-1α)degradation,but TP53 is also the gene with the highest mutation rate in all cancers.Mutated TP53 not only loses its role as a tumor suppressor gene,but also further transcribes and translates into TP53 oncoprotein,which promotes cancer development,development of.Related clinical studies have shown that elevated levels of VEGF are detected in peripheral serum of patients with TP53 mutations,and patients with TP53 mutations are also more sensitive to VEGF inhibitors than patients with wild-type TP53.Therefore,mutant TP53 may have important enhancement effects on the oxygen sensing pathway.ATO has been shown to block mutant TP53 by altering the conformation of mutant TP53 protein and promoting the ubiquitination of mutant TP53 protein,so we speculate that ATO may down-regulate HIF-1α by inhibiting mutant TP53– VEGF signal reduces VEGF expression level,reduces pleural vascular permeability,and inhibits the formation of malignant pleural effusion in non-small cell lung cancer.ObjectiveThe efficacy and adverse effects of arsenic trioxide(ATO)and positive control drug bleomycin in the treatment of MPE were compared,and the effectiveness and safety of ATO pleural infusion for MPE were clarified.Further analysis of pleural effusion before and after treatment in the ATO group,to explore the possible mechanism of ATO inhibiting the formation of pleural effusion.MethodsThe first part of this study was a real-world study of ATO intrathoracic infusion for non-small cell lung cancer MPE.A total of 110 patients with malignant pleural effusion who met the criteria from January 2015 to January 2018 in our hospital were divided into ATO groups(80 cases)according to different intrathoracic injections after sufficient puncture and drainage.In the bleomycin group(30 cases),the bleomycin group was used as a positive drug control.The efficacy and safety of ATO in the treatment of MPE were evaluated 6 weeks after the administration.The main outcome indicators were: Objective Response Rate(ORR)at 6 weeks.Secondary outcome measures were: overall survival(OS),duration of response(Do R),adverse reactions,and average length of hospital stay.The second part is the mechanism of ATO inhibiting the formation of MPE.The pleural effusions of some patients in the ATO group before treatment and 24 hours after treatment were retained,and the erythrocyte counts and VEGF levels of pleural effusions before and after treatment were compared.The genome sequencing data of large non-small cell lung cancer cohorts were collected using the Cancer Genome Atlas(TCGA)and analyzed.Effects of TP53 mutation status on the expression levels of VEGF and HIF-1α;TP53 immunohistochemical staining was performed on lung cancer tissue pathological specimens of some patients in the ATO group to determine the TP53 mutation status(wild-type TP53 protein expression is extremely low under normal conditions and high after mutation)Expression)to compare the effect of TP53 mutation status on the efficacy of MPE treatment.Provide theoretical basis for the application of ATO in clinical treatment of MPE.ResultsPart 1 Real-world study of arsenic trioxide intrathoracic infusion for non-small cell lung cancer with malignant pleural effusion1.6 week objective remission rate: 80 cases in the experimental group,10 cases(13.16%)of complete response(CR),40 cases(52.63%)of partial remission(PR),stable(stable disease,SD))22 cases(28.95%),4 cases(5.26%)of progression disease(PD),4 cases that could not be evaluated,objective response rate ORR(CR + PR)was 65.79%,30 cases in the control group,1 case in CR(3.33)%),PR in 12 cases(40%),SD in 15 cases(50%),PD in 2 cases(6.67%),and ORR was 43.33%.There is a statistically significant difference between the two(P = 0.0339).The response rate was better than the bleomycin group.2.Overall survival(OS)and duration of response(Do R): The median OS in the ATO group was 7.5 months(95% CI,6.966-8.034),and the median OS in the bleomycin group was 7.25 months(95%).(CI,5.931-8.569),there was no significant difference between the two groups(P = 0.96).The median Do R of the ATO group was 5 months(95% CI,4.621-5.379),and the median Do R of the bleomycin group was 4 months(95% CI,2.679-5.321).The difference between the two groups was statistically significant.(P = 0.008),the duration of remission was longer in the ATO group.3.Main treatment adverse reactions: 21 cases of fever(26.25%)in the ATO group,of which 18 cases wereⅠdegree,3 cases wereⅡdegree;27 cases of chest pain(33.75%),including 19 cases ofⅠdegree,3 cases ofⅡdegree,and III degree 5 cases(6.25%);9 cases(11.25%)of nausea / vomiting,of which 8 cases wereⅠdegree,1 case wasⅡdegree;6 cases(7.5%)were bone marrow suppression,all wereⅠdegree.In the bleomycin group,there were 14 cases of fever(46.67%),of which 10 cases were Grade I and 4 cases were Grade II;12 cases of chest pain(40%),including 9 cases of Grade I and 3 cases of Grade III(10%);There were 7 cases of vomiting(23.33%),5 cases of degree I,1 case of degree II,1 case of degree III(3.33%),and 3 cases of bone marrow suppression,all of which were degree I.The adverse reactions of the two groups were compared.The incidence of fever in the ATO group was less than that in the bleomycin group,and the difference was statistically significant(P = 0.041).There were no significant differences in the incidence of adverse reactions such as bone marrow suppression,nausea / vomiting,and chest pain(all P> 0.05).4.Length of hospitalization: The number of days of hospitalization in the ATO group was(median,8 days [IQR,6-10]),and the number of days of hospitalization in the bleomycin group was(median,10 days [IQR,9-11.75]).The difference was statistically significant(P <0.001).Part 2 Arsenic trioxide down-regulates HIF-1α-VEGF signaling by inhibiting mutant TP53 to treat malignant pleural effusion1.Changes in erythrocyte counts of pleural effusion in 16 patients in the ATO group before and 24 h after treatment: The median(interquartile range)of pleural erythrocyte counts in 16 patients in the ATO group was 4400(2050-42077.5)The median red blood cell count(interquartile range)of pleural effusion at 24 h after administration was 1925(1125-12225),and the difference between the two was statistically significant(P <0.001).2.Changes of VEGF protein levels in 16 patients with pleural effusion before and24 hours after treatment in ATO group: The median(interquartile range)of VEGF in pleural fluid before ATO administration in 16 patients was 210.06(162.2-270.93),The median(interquartile range)of VEGF in pleural fluid at 24 h after administration was 86.17(72.43-149.09),and the difference between the two was statistically significant(P <0.001).3.Effect of TP53 mutation status on VEGF and HIF-1α m RNA expression levels:VEGFA m RNA expression level in mutant TP53 patients was 12.28±1.01,and VEGFA m RNA expression level in wild-type patients was 12.06 ±1.01.(P <0.05);The expression level of HIF-1α m RNA in mutant patients was 12.13±0.75,and the expression level of HIF-1α m RNA in wild-type patients was 11.97±0.77.There was a statistically significant difference between the two(P < 0.05).4.The effect of TP53 mutation on the efficacy of ATO in the treatment of MPE: 13 patients with TP53 mutation,including CR 2(15.38%),PR 7(53.85%),6-week evaluation of pleural effusion ORR = 69.23%;TP53 wild-type patients 8 cases,including CR 0 and PR 3(37.5%),6-week assessment of pleural effusion ORR = 37.5%,although the ORR of TP53 mutant patients for ATO treatment was higher than that of wild-type patients in this sample,but due to the sample size Less,the difference in ORR between the two was not statistically significant(P> 0.05).Conclusion1.ATO intrathoracic perfusion treatment of non-small cell lung cancer MPE objective response rate is better than bleomycin,patients with effective treatment have a longer duration of remission,pleural effusion recurrence,later progression,lower incidence of side effects,and hospitalization time It is shorter and saves medical resources.The treatment method can be considered for clinical promotion.2.After pleural ATO infusion,the color of pleural fluid of patients with non-small cell lung cancer MPE becomes lighter,red blood cell count decreases,and VEGF level decreases,suggesting that the mechanism of ATO treatment of MPE may be related to reducing pleural vascular permeability.3.Compared with TP53 wild type patients,patients with TP53 mutations are moresensitive to ATO treatment.The expression of VEGF and HIF-1α in patients with TP53 mutations is significantly increased,and the level of VEGF in pleural fluid is significantly reduced after treatment,suggesting that ATO may down-regulate HIF-1α-VEGF signal by inhibiting TP53 mutations to reduces VEGF levels,thereby inhibiting the formation of pleural effusion.