
==== Front
Medicine (Baltimore)
Medicine (Baltimore)
MD
Medicine
0025-7974
1536-5964
Lippincott Williams & Wilkins Hagerstown, MD

39312367
MD-D-24-03324
00068
10.1097/MD.0000000000039299
3
6800
Research Article
Observational Study
Association of MORC2 expression with progression-free survival in cervical cancer patients treated with concurrent chemoradiotherapy
He Jing MD 734045955@qq.com
ab*
https://orcid.org/0000-0002-9423-8698
Liao Xiao-Hong PhD 919524781@qq.com
b
Zhong Bing-Di MD 1422756294@qq.com
b
Liu An-Wen PhD a
a Department of Oncology, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi Province, China
b Department of Oncology, Ganzhou People’s Hospital (The Affiliated Ganzhou Hospital, Jiangxi Medical College, Nanchang University), Ganzhou, Jiangxi Province, China.
* Correspondence: Jing He, Department of Oncology, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, No. 1, Nanchang, 330006, Jiangxi Province, China (e-mail: 734045955@qq.com).
20 9 2024
20 9 2024
103 38 e3929928 3 2024
17 4 2024
23 7 2024
Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.
2024
https://creativecommons.org/licenses/by-nc/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is permissible to download, share, remix, transform, and buildup the work provided it is properly cited. The work cannot be used commercially without permission from the journal.

MORC family CW-type zinc finger 2 (MORC2) is a newly identified chromatin remodeling protein, and has been proposed as a prognostic biomarker associated with survival in some types of human cancer, but the role of MORC2 in cervical cancer remains unknown. Here, we investigated the role of MORC2 expression in predicting the survival outcomes of locally advanced cervical cancer patients treated with cisplatin-based concurrent chemoradiotherapy (CCRT). In this retrospectively study, we detected MORC2 immunohistochemical expression on 55 biopsies from patients who underwent CCRT. The association between the MORC2 expression and various clinicopathological characteristics were analyzed, as were association between MORC2 expression and locoregional failure and progression-free survival (PFS) of cervical cancer patients. MORC2 expression was positively associated with pelvic node metastasis and locoregional failure. Higher MORC2 expression was a significant indicator of worse PFS. Our results suggest that MORC2 expression may be a prognostic indicator in patients with locally advanced cervical cancer undergoing CCRT.

cervical cancer
chemoradiotherapy
MORC2
survival
the New Doctor Start-up Fund from Ganzhou Peopleâ€™s HospitalBsqd2018002 Xiao-Hong Liaothe Scientific Research Program of Ganzhou Municipal Health Commission2019-2022 Xiao-Hong LiaoBureau of Science and Technology of Ganzhou Municipality 10.13039/100017712 2023LNS17456 Xiao-Hong LiaoOPEN-ACCESSTRUE
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pmc1. Introduction

Cervical cancer is one of the most common gynecologic cancer world-wide, with high morbidity and mortality,[1,2] especially in China, where there are about 111,820 new cases and 61,579 cancer related deaths in 2020 available from Global Cancer Observatory (GLOBOCAN; https://gco.iarc.fr/). It poses a serious threat to the health and survival of women. In recent years, with the extensively application of cisplatin-based concurrent chemoradiotherapy (CCRT), there has been a significant improve in survival.[3] It is well established that lymph node metastasis, clinical stage, and blood squamous cell carcinoma antigen concentration are prognostic factors for cervical cancer patients who receive CCRT.[4–6] However, the usefulness of these factors in clinic remains controversial. It is a clinical challenge that needs to be addressed urgently to find specific prognostic biomarker in cervical carcinoma.

Microrchidia (MORC) family CW-type zinc finger 2 (MORC2) is a member of the evolutionarily conserved MORC nuclear protein superfamily and ubiquitously expressed in human cells and tissues.[7–9] Recently, MORC2 has been defined as a global chromatin remodeler with emerging roles in the regulation of DNA damage response and gene transcription.[7,10,11] Studies from other laboratory indicate that MORC2 is frequently overexpressed in multiple types of human cancer and acts as a driver of oncogenesis.[9,12] In addition, recent work from Li et al shows that MORC2 promotes cancer metastasis and resistance to endocrine therapy and radiotherapy.[10,13,14] MORC2 has been documented as a promising prognostic biomarker in several cancer types including breast, liver, lung, ovary and colon.[7,12,15] However, the role of MORC2 in cervical cancer still remains unknown and the correlation between MORC2 and prognosis of cervical cancer patient receiving CCRT has not been studied.

In this study, we investigated the association between the prognosis of locally advanced cervical cancer treated with CCRT and the expression of MORC2 in biopsy samples collected before treatment. We aimed to reveal whether MORC2 could be a prognostic biomarker in patients with locally advanced cervical carcinoma.

2. Materials and methods

2.1. Study and design

Samples were collected with written informed consent from all patients under Institutional Review Board-approved protocols. All procedures were conducted in accordance with the Declaration of Helsinki and International Ethical Guidelines for Biomedical Research Involving Human Subjects. The current study cohort comprised 55 patients diagnosed with cervical squamous cell cancer at the department of Oncology, Ganzhou People’s Hospital who underwent CCRT as initial treatment from January 2017 to December 2019. Each patient was evaluated by the multidisciplinary team before the beginning of CCRT. The radiation dose of external beam radiotherapy was 45Gy in 25 fractions and intracavitary radiotherapy 36Gy in 6 fractions. Anonymized clinical information, including age and International Federation of Gynecology and Obstetrics (FIGO) clinical stages at diagnosis, was extracted from institutional database. Lymph node metastasis and parametrial invasion were evaluated by 3 radiologists. Lymph node metastasis was defined as present if the short axis of a lymph node was ≥10 mm. Progression-free survival (PFS) was defined as the time from the first day of CCRT to the date of progression or death, or otherwise the date of the last follow-up on which the patient was reported alive and progression-free.

2.2. Immunohistochemistry staining and evaluation of MORC2 expression

Hematoxylin-eosin stained sections were obtained from paraffin blocks of the biopsy specimens and preliminarily evaluated for the quantity of neoplastic cells. After pathological assessment of hematoxylin-eosin stained slides, the additional sections representative of all the paraffin-embedded biopsy samples were used for evaluation of MORC2 expression on neoplastic cells. Immunohistochemistry (IHC) staining was carried out using EnVision Detection System Peroxidase/DAB (DAKO, Santa Clara) following the manufacturer’s recommendations. The primary antibody against human MORC2 (Novus, #NBP1-89295) was diluted at dilution of 1:100 and then incubated at 4°C overnight in a humidified container. Positive and negative controls were used for each run of staining. Interpretation of the IHC results was performed by 2 independent pathologists who were blinded to the clinicopathological information. MORC2 positivity was calculated as percentage of cells with nucleus staining, either strong or weak, with or without cytoplasmic staining. All neoplastic cells present in each biopsy sample were evaluated. Slides were evaluated using light microscopy and a standard semiquantitative immunoreactivity score. By recording the percentage of positive staining (0 = negative, 1 ≤ 0%, 2 = 10–50%, 3 ≥ 50%) and staining intensity (0 = no, 1 = weak, 2 = moderate, 3 = strong) for each sample, immunoreactivity score (IRS; 0–9) was calculated by multiplying positive staining percentage with staining intensity. Low and high expression were defined as IRS of < 6 and ≥ 6, respectively.

2.3. Statistical analysis

In the descriptive analysis, quantitative variables were described as mean and range, while qualitative variables were described as number or percentage. Correlation was estimated using Spearman’s rho and comparison was evaluated using the nonparametric Mann–Whitney U test. The interobserver agreement for evaluation of MORC2 expression was analyzed by the Cohen’s K statistical analysis. To determine factors associated with progression-free survival (PFS), univariable and multivariate logistic regression models were used. Results of univariate and multivariate analysis were expressed as hazard ratios (HR) and 95% confidence intervals (CI). All analysis were performed using IBM SPSS Statistics for Windows Version 27.0 (Armonk) or GraphPad Prism (GraphPad, Inc., San Diego).

3. Results

3.1. Clinicopathological characteristics of patients

The clinicopathological characteristics of the 55 patients in this study are presented in Table 1. Median age at diagnosis was 56 (range from 21–81). In 58% of cases, the diameter of the tumor was >4 cm. The pelvic lymph nodes (PLN) and para-aortic lymph nodes (PAN) metastasis, assessed by magnetic resonance, were presented in 30 patients (55%) and 9 patients (16%) respectively. The FIGO clinical stages were as follows: stage II (n = 22), stage III (n = 33). The histologic subtype of all the cases was squamous cell carcinoma and all the patients in this survey received CCRT.

Table 1 Correlation between MORC2 expression and clinicopathological characteristics.

Characteristic	MORC2 expression	P value	
Low (N = 26)	High (N = 29)	
Age (yr)			.505	
 <50	12	16		
 ≥50	14	13		
Tumor size			.119	
 <4 cm	8	15		
 ≥4 cm	18	14		
PLN metastasis			.026 *	
 Negative	16	9		
 Positive	10	20		
PAN metastasis			.117	
 Negative	24	22		
 Positive	2	7		
Parametrial invasion			.394	
 Negative	8	6		
 Positive	18	23		
Vaginal invasion			.377	
 Negative	6	4		
 Positive	20	25		
FIGO stage			.155	
 II	13	9		
 III	13	20		
FIGO = International Federation of Gynecology and Obstetrics, MORC2 = MORC family CW-type zinc finger 2, PAN = para-aortic lymph nodes, PLN = pelvic lymph nodes.

* P < .05.

3.2. Correlation of MORC2 with clinicopathological characteristics

We next analyzed MORC2 expression by IHC staining in the 55 biopsies (Fig. 1). Of the 55 patients, 29 biopsies (52.7%) had “high MORC2” expression, whereas 26 (47.3%) showed “low MORC2” expression (Table 1). To further characterize the role of MORC2 expression in cervical cancer, we examined the correlation between expression of MORC2 on neoplastic cells and clinicopathological characteristics (age, tumor size, PLN metastasis, para-aortic lymph node metastasis, parametrial invasion, vaginal invasion and clinical stage; Table 1). We found that high expression of MORC2 on neoplastic cells was positively associated with PLN (P = .026) metastasis. However, there was no significant relationship between MORC2 expression and other clinicopathological characteristics.

Figure 1. Staining intensity of MORC2 on neoplastic cells in cervical cancer biopsies. MORC2 immunohistochemical stain on neoplastic cells, scored as low MORC2 (A) and high MORC2 (B).

3.3. The relationship between MORC2 and locoregional failure

Locoregional failure included uncontrolled cervical mass and cervical local recurrence during follow-up. Locoregional failure is an important factor affecting the prognosis of cervical cancer.[16] Thus, the factors that affect locoregional failure often have significant impact on prognosis. Therefore, we further analyzed the correlation between MORC2 expression and locoregional control rate (LCR) of cervical cancer. A total of 9 patients experienced locoregional failure, of which 8 cases were in high MORC2 group and the other 1 case was in low MORC2 group (Table 2). The difference of locoregional control rate (LCR) between high MORC2 group and low MORC2 group is significant (P = .041). This result indicates MORC2 expression is not favorable for locoregional control of cervical cancer.

Table 2 Relationship between MORC2 and locoregional failure of cervical cancer.

Characteristic	MORC2 expression	P value	
Low (N = 26)	High (N = 29)	
Locoregional failure			.041 *	
 No	25	21		
 Yes	1	8		
MORC2 = MORC family CW-type zinc finger 2.

* P < .05.

3.4. Correlation of factors and PFS

Using the identified cutoff values, correlations between clinicopathological factors (age, tumor size, PLN metastasis, para-aorta lymph node metastasis, parametrial invasion, clinical stage, vaginal invasion and MORC2) and prognosis were summarized in Table 3. PFS was significantly better in patients with no PLN metastasis in univariate analysis (P = .045), but not in multivariate analysis (P = .305). On the other hand, PFS was better in patients with low levels of MORC2 expression on neoplastic cells both in univariate (P = .01) and multivariate (P = .013) analysis (Table 3).

Table 3 Univariate and multivariate analysis of factors associated with PFS.

Factors	Univariate analysis	Multivariate analysis	
P value	HR (95% CI)	P value	HR (95% CI)	
Age (yr)	.487	0.648 (0.191–2.202)	.479	0.472 (0.059–2.074)	
 <50					
 ≥50					
Tumor size	.593	0.71 (0.202–2.491)	.367	4.52 (0.371–10.22)	
 <4 cm					
 ≥4 cm					
PLN metastasis	.045 *	0.236 (0.057–0.971)	.305	3.743 (0.301–6.53)	
 Negative					
 Positive					
PAN metastasis	.164	0.347 (0.078–1.54)	.053	0.138 (0.019–1.027)	
 Negative					
 Positive					
Parametrium	.689	0.744 (0.174–3.176)	.297	3.545 (0.329–8.102)	
 Negative					
 Positive					
Vaginal invasion	.24	0.274 (0.031–2.382)	.168	0.163 (0.012–2.144)	
 Negative					
 Positive					
FIGO stage	.317	0.511 (0.137–1.901)	.238	0.145 (0.026–1.513)	
 II					
 III					
MORC2	.01 *	0.118 (0.023–0.597)	.013 *	0.031 (0.002–0.476)	
 Low					
 High					
CI = confidence intervals, FIGO = International Federation of Gynecology and Obstetrics, HR = hazard ratios, MORC2 = MORC family CW-type zinc finger 2, PAN = para-aortic lymph nodes, PFS = progression-free survival, PLN = pelvic lymph nodes.

* P < .05.

4. Discussion

Development and progression of malignant tumors are characterized by complex factors, such as the characteristic changes of tumor cells.[8,12,14,17,18] The tumor cells themselves have been reported to play an important role in the progress of cancer development and affect response to therapy and clinical outcome.[8,12,15] There has been strong interest in studying the tumor cells themselves. In most human cancers, including breast, liver, lung, ovary and colon, MORC2 has been found to be upregulated in tumor cells and associated with tumorigenesis, metastasis and therapy resistance.[9,10,13,15] The usefulness of MORC2 expression on tumor cells as prognostic biomarkers has been reported for some types of cancers.[7,15,19] In this study, we collected biopsy specimen from 55 patients with stage II and III cervical cancer who had subsequently received CCRT, and performed immunohistochemical (IHC) staining of MORC2. Based on previous reports that the expression of MORC2 on tumor cells, instead of stromal cells, is a prognostic factor in several kinds of cancers such as non-small cell lung cancer and breast cancer.[7,12,15,19] We evaluated MORC2 expression only on tumor cells, not on surrounding stromal cells. Correlations between MORC2 expression and clinicopathologic characteristics were examined, as were relationships between MORC2 expression and locoregional failure and the prognosis of patients with stage II and III cervical cancer who underwent CCRT. We first demonstrate that absent or low expression of MORC2 on neoplastic cells in pre-CCRT biopsies is significant associated with less pelvic node metastasis, but not para-aortic lymph nodes metastasis. We then find that higher MORC2 expression is associated with higher locoregional failure of cervical cancer. We finally show the correlation of higher MORC2 expression with worse PFS in cervical cancer patients undergoing CCRT.

Generally, higher chance of pelvic lymph node metastasis is associated with higher stage.[20] In our study, higher MORC2 shows higher chance of pelvic lymph node metastasis, but not higher FIGO stage. Actually, some studies have shown that MORC2 is positively associated with lymph node metastasis, but not with stage in other cancer types,[9,15,21,22] which is consistent with our findings of this study. that may be because of tumor stage is determined by various factors, including tumor size, depth of tumor infiltration, lymph node metastasis and distant metastasis.[20] Additional, higher stage usually indicates worse PFS,[20] but in our study stage II and stage III did not show any difference in PFS. The reasons why there was no difference in PFS between stage II and stage III in our study are due to the small number of cases and the changes in staging criteria, which may lead to a shift in staging. In further study, the enroll the patients should be under a unified staging criteria at diagnosis to avoid bias.

To the best of our knowledge, this study is the first to explore the association between the prognosis of patients receiving CCRT for locally advanced cervical cancer and MORC2 expression. The limitations of this study include a relatively small sample size and short follow-ups after CCRT. Previous studies have reported a positive correlation between PLN metastasis and overall survival (OS) in locally advanced cervical cancer patients received CCRT. In our study, we did not analyze the association between PLN metastasis and OS because of the short follow-ups, as well as the correlation between MORC2 expression and OS. More samples and longer follow-ups should be included in future studies.

In summary, we retrospectively analyzed 55 cervical cancer patients by comparing many clinicopathological factors, including age, tumor size, lymph node status, parametrial invasion, vaginal invasion, clinical stage and MORC2 protein expression. We introduced the expression of MORC2 on neoplastic cells to reflect the tumor capacity. High MORC2 expression showed significant correlation with positive PLN metastasis, and strongly associated with worse PFS.

5. Conclusions

Our results indicate that the expression of MORC2 on neoplastic cells may be a prognostic indicator in patients with locally advanced cervical squamous cell cancer undergoing CCRT.

Acknowledgments

We sincerely acknowledge the staff members of the Department of Pathology (Ganzhou People’s Hospital) for their excellent technical assistance. The work is supported, in whole or in part, by the New Doctor Start-up Fund from Ganzhou People’s Hospital (No. Bsqd2018002) and sponsored by the Scientific Research Program of Ganzhou Municipal Health Commission (2019–2022) and Bureau of Science and Technology of Ganzhou Municipality-Science and Technology Plan Project (No. 2023LNS17456).

Author contributions

Conceptualization: Xiao-Hong Liao.

Data curation: Jing He, Xiao-Hong Liao.

Formal analysis: Bing-Di Zhong.

Funding acquisition: Xiao-Hong Liao.

Methodology: Jing He.

Project administration: Xiao-Hong Liao, An-Wen Liu.

Resources: Jing He.

Software: Jing He.

Supervision: Xiao-Hong Liao.

Validation: Xiao-Hong Liao.

Writing – original draft: Jing He, Xiao-Hong Liao, Bing-Di Zhong.

Writing – review & editing: Xiao-Hong Liao.

Abbreviations:

CCRT cisplatin-based concurrent chemoradiotherapy

CI confidence intervals

FIGO International Federation of Gynecology and Obstetrics

HR hazard ratios

IHC immunohistochemistry

MORC2 MORC family CW-type zinc finger 2

OS overall survival

PAN para-aortic lymph nodes

PFS progression-free survival

PLN pelvic lymph nodes

This study is approved by the institutional review board of Ganzhou Peoples’ Hospital (No. TY-ZKY2022-68-01).

The authors have no conflicts of interest to disclose.

All data generated or analyzed during this study are included in this published article [and its supplementary information files].

How to cite this article: He J, Liao X-H, Zhong B-D, Liu A-W. Association of MORC2 expression with progression-free survival in cervical cancer patients treated with concurrent chemoradiotherapy. Medicine 2024;103:38(e39299).
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