eNOSpolymorphisms and clinical outcome in advanced HCC patients receiving sorafenib: final results of the ePHAS study

// Andrea Casadei Gardini 1, * , Giorgia Marisi 2, * , Luca Faloppi 3 , Emanuela Scarpi 4 , Francesco Giuseppe Foschi 5 , Massimo Iavarone 6 , Gianfranco Lauletta 7 , Jody Corbelli 8 , Martina Valgiusti 1 , Floriana Facchetti 6 , Cristina della Corte 6 , Luca Maria Neri 9 , Stefano Tamberi 8 , Stefano Cascinu 3 , Mario Scartozzi 10 , Dino Amadori 1 , Oriana Nanni 4 , Elena Tenti 1 , Paola Ulivi 2, ** , Giovanni Luca Frassineti 1, ** 1 Department of Medical Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy 2 Biosciences Laboratory, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy 3 Department of Medical Oncology, Azienda Ospedaliero Universitaria Ospedali Riuniti, Università Politecnica delle Marche, Ancona, Italy 4 Unit of Biostatistics and Clinical Trials, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy 5 DPT Internal Medicine, Faenza Hospital, AUSL Romagna, Faenza, Italy 6 A.M.&A. Migliavacca Center for Liver Disease, 1st Division of Gastroenterology, Fondazione IRCCS Ca' Granda Maggiore Hospital, University of Milan, Milan, Italy 7 Department of Biomedical Sciences and Human Oncology, Internal Medicine “G. Baccelli”, University of Bari “A. Moro”, Bari, Italy 8 Department of Medical Oncology, Faenza Hospital, AUSL Romagna, Faenza, Italy 9 Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy 10 Department of Medical Oncology, University Hospital Cagliari, Cagliari, Italy * These first authors contributed equally to this work ** These authors have contributed equally to this work Correspondence to: Giorgia Marisi, e-mail: giorgia.marisi@irst.emr.it Keywords: hepatocellular carcinoma, endothelial nitric oxide synthase, single nucleotide polymorphisms, biomarkers, angiogenesis Received: February 08, 2016     Accepted: March 28, 2016     Published: April 4, 2016 ABSTRACT Sorafenib may reduce endothelial nitric oxide synthase (eNOS) activity by inhibiting vascular endothelial growth factor receptors (VEGF-R), leading to a decrease in nitric oxide production. In the Italian multicenter ePHAS ( eNOS polymorphisms in HCC and sorafenib) study, we analyzed the role of eNOS polymorphisms in relation to clinical outcome in patients with hepatocellular carcinoma (HCC) receiving sorafenib. Our retrospective study included a training cohort of 41 HCC patients and a validation cohort of 87 HCC patients, all undergoing sorafenib treatment. Three eNOS polymorphisms ( eNOS -786T>C, eNOS VNTR 27bp 4a/b and eNOS +894G>T) were analyzed by direct sequencing or Real Time PCR in relation to progression-free survival (PFS) and overall survival (OS) (log-rank test). In univariate analysis, training cohort patients homozygous for eNOS haplotype (HT1:T-4b at eNOS -786/ eNOS VNTR) had a lower median PFS (2.6 vs. 5.8 months, P < 0.0001) and OS (3.2 vs. 14.6 months, P = 0.024) than those with other haplotypes. In the validation set, patients homozygous for HT1 had a lower median PFS (2.0 vs. 6.7 months, P < 0.0001) and OS (6.4 vs. 18.0 months, P < 0.0001) than those with other haplotypes. Multivariate analysis confirmed this haplotype as the only independent prognostic factor. Our results suggest that haplotype HT1 in the eNOS gene may be capable of identifying a subset of HCC patients who are resistant to sorafenib.