Functional genetic variant of WW domain-containing oxidoreductase (WWOX) gene is associated with hepatocellular carcinoma risk
Functional genetic variant of WW domain- containing oxidoreductase (WWOX) gene is associated with hepatocellular carcinoma risk
Hsiang-Lin Lee 0
Hsin-Lin Cheng 0
Ming-Chih Chou 0
Shun- Fa Yang 0
Sheng-Nan Lu, Chang Gung Memorial
Hospital Kaohsiung Branch, TAIWAN
0 Institute of Medicine, Chung Shan Medical University , Taichung, Taiwan , 2 School of Medicine, Chung Shan Medical University , Taichung, Taiwan , 3 Deptartment of Surgery, Chung Shan Medical University Hospital , Taichung, Taiwan , 4 Department of Biomedical Sciences, Chung Shan Medical University , Taichung, Taiwan , 5 Department of Medical Research, Chung Shan Medical University Hospital , Taichung , Taiwan
Hepatocellular carcinoma (HCC) is one of the most common malignant tumors worldwide. Human WW domain-containing oxidoreductase (WWOX) gene has been identified as a tumor suppressor gene in multiple cancers. We hypothesize that genetic variations in WWOX are associated with HCC risk.
Data Availability Statement: All relevant data are
within the paper.
Funding: This study was supported by a grant
(CSH-2016-C-016, CSH-2016-E-002-Y2) from
Chung Shan Medical University Hospital, Taiwan.
The funder had no role in study design, data
collection and analysis, decision to publish, or
preparation of the manuscript.
Competing interests: The authors have declared
that no competing interests exist.
In conclusion, genetic variations in WWOX may be a significant predictor of early HCC
occurrence and a reliable biomarker for disease progression.
Primary liver cancer, particularly hepatocellular carcinoma (HCC), has emerged as the third
leading cause of cancer-related death worldwide[
] and has been ranked as the second most
prevalent malignant cancer in Taiwan. Currently, hepatic resection and liver transplantation
are widely recognized as effective therapeutic options for HCC [
]. However, the tumor
recurrence rate at 5 years after hepatic resection is approximately 70% [
]. Etiologically, HCC
is a complex malignancy that has been associated with various risk factors, including chronic
hepatitis B (HBV) infection, excessive alcohol intake, and metabolic diseases [
]. In addition to
known etiologies, studies have also suggested that the impact of genetic factors within the
coding and noncoding regions of tumor suppressor genes decreases gene expression and increases
the carcinogenesis of HCC or intrahepatic metastasis of the primary tumor [7±9].
The human WW domain-containing oxidoreductase (WWOX) gene, located on
chromosome 16q23.3±24.1, spans one of the most active fragile sites, which contains the FRA16D.
WWOX is a bona fide tumor suppressor gene, which plays a pivotal role in regulating signaling
pathways and cellular functions [10±16]. Studies have suggested that WWOX can induce
apoptosis both in vivo and in vitro by interacting with p53, p73, and JNK1 [
Hsu et al. concluded that TGF-β1 and hyaluronan can activate HYAL-2-WWOX-SMAD4
signaling to cause cell death . Additionally, evidence from in vivo overexpression studies
suggests that WWOX might suppress the carcinogenetic effect of MDA-MB-435 breast cancer
]. However, low or decreased expression and aberrant transcription of WWOX has
been reported in several types of cancer, including nonsmall cell lung cancer (85%), prostate
cancer (84%), breast cancer (63%), and oral cancer (40%) [19±24]. Moreover, Aqeilan et al.
created mice carrying a targeted deletion of the WWOX gene to observe incidence of tumor
formation. The results shown that WWOX is a bona fide tumor suppressor [
]. In addition,
the loss of WWOX expression is correlated with higher tumor stages and less favorable
outcomes in patients [
Recently, the genetic alteration of the WWOX gene showed a high incidence of loss of
expression in squamous cell lung carcinoma [
]. Notably, single nucleotide
polymorphisms (SNPs) in various genes reportedly modulate their expression and are associated with
the risk of several cancers [
]. In addition, SNPs within the WWOX gene have been
identified as a potentially genetic risk factor for esophageal adenocarcinoma and multiple myeloma
]. Recently, genome-wide linkage analysis studies for SNPs in prostate cancer patients
have revealed that WWOX polymorphic variants may be associated with cancer susceptibility
. Of these, the WWOX polymorphism is considered to be a useful and tractable measure to
evaluate the associations between the SNPs and clinicopathological characteristics of cancers.
Considering the potential function of the WWOX gene in the neoplastic process, SNPs in
this gene may be associated with HCC risk. To test this hypothesis, we performed a
hospitalbased study to evaluate the impact of gene variations of WWOX on the development of HCC
and observed an association of a WWOX SNP (rs12918952) with the risk and progression of
Materials and methods
In 2007±2015, for the case group, we recruited 354 patients (252 men and 102 women; mean
age = 62.97 ± 11.60 years; age range = 30±90 years) at Chung Shan Medical University Hospital
in Taichung, Taiwan. During the same study period, the 708 individuals (504 men and 204
women) were enrolled as these subjects received a physical examination at the same hospital.
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Patients with only HCC were recruited. Patients and normal controls were excluded if having
any history of other cancers. For both groups, we administered a questionnaire to obtain
information on their exposure to tobacco use, and alcohol consumption. Medical information of
the patients, including TNM clinical staging, primary tumor size, and lymph node
involvement was obtained from their medical records. Before commencing the study, approval was
obtained from the Institutional Review Board of Chung Shan Medical University Hospital,
and informed written consent was obtained from each individual.
Sample preparation and DNA extraction
The whole blood specimens, collected from controls and HCC patients, were placed in tubes
containing EDTA and were immediately centrifuged. The genomic DNA was extracted from
buffy coats using a QIAamp DNA blood mini kits as described in detail previously [
was dissolved in TE buffer and used as the template in polymerase chain reactions.
SNP selection and genotyping
In this study, the selection of 5 well-characterized common polymorphisms from WWOX
gene is based on their wide associations with the development of cancer [
]. We included
rs11545028 in the 5'UTR region. Rs12918952 and rs3764340, which are located in the exon of
WWOX, were selected in this study since these 2 SNPs may result from amino acid changes
and thus the loss of the tumor suppression function of WWOX . The allelic discrimination
of WWOX rs11545028 (Assay ID: C_2813530_10), rs12918952 (Assay ID: C_57888_20),
rs3764340 (Assay ID: C_25654217_20), rs73569323 (Assay ID: C_25761998_10), and rs383362
(Assay ID: C_2395473_20) polymorphisms were assessed using an ABI StepOne TM
RealTime PCR System (Applied Biosystems, Foster City, CA) and analyzed using SDS v3.0
software (Applied Biosystems, Foster City, CA).
Several semi-automated bioinformatics tools were applied to assess whether WWOX
rs12918952 SNPs are associated with a putative function that might affect patient outcomes.
] from the ENCODE project [
] were used to identify the regulatory
potential of candidate functional variants. The GTEx data were used to identify correlations between
SNPs and whole blood-specific gene expression levels.
Mann±Whitney U-test and Fisher's exact test were used to compare the age, gender differences
and demographic characteristic distributions between the controls and patients with HCC.
The odds ratio and 95% CIs of the association between the genotype frequencies and HCC risk
and the clinical pathological characteristics were estimated using multiple logistic regression
models. p < 0.05 was considered significant. The data were analyzed on SAS statistical software
(Version 9.1, 2005; SAS Institute, Cary, NC).
Characteristics of study participants
The demographic characteristics and clinical parameters of the 2 study groups, including age,
sex, and alcohol and tobacco consumption, are shown in Table 1. A significant difference in
the alcohol consumption (p < 0.001) was observed between healthy controls and HCC
patients, whereas no such significant between-group difference was observed in the tobacco
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consumption (p = 0.350). However, neither age (p = 0.287) nor sex (p = 1.000) elevated the
Association between WWOX gene polymorphisms and HCC
Correlation between polymorphic genotypes of WWOX and clinical status of HCC
The distributions of the clinicopathological characteristics and WWOX genotypes in HCC
patients were further explored (Tables 3 and 4). As shown in Table 3, patients with at least one
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The odds ratios (ORs) and with their 95% con®dence intervals (CIs) were estimated by logistic regression models. The adjusted odds ratios (AORs) with
their 95% con®dence intervals (CIs) were estimated by multiple logistic regression models after controlling for alcohol consumption.
* p value < 0.05 as statistically signi®cant.
polymorphic allele of rs11545028 (C/T or T/T genotype) were less prone to develop large
tumors (p = 0.039). In addition, we observed that the trend of G/A+G/G genotype of WWOX
rs12918952 for vascular invasion risk (p = 0.024) was higher in male patients with HCC.
Furthermore, we also examined the potential association between WWOX gene polymorphisms
and the clinicopathological markers of HCC, including α-fetoprotein, aspartate
aminotransferase (AST), alanine aminotransferase (ALT), and the AST/ALT ratio. However, we observed
significantly lower α-fetoprotein and ALT levels in patients who carried the rs11545028 C/T
or T/T genotypes (p = 0.013 and 0.041, respectively; Table 5). Furthermore, in HCC patients,
compared with the C/C genotype, the C/G and G/G genotype of WWOX rs3764340 were
associated with higher AST and ALT levels (both p < 0.05).
Functional analysis of the WWOX rs12918952 locus
To validate whether the Ala-179-Thr substitution influenced gene expression levels, we used
multiple sequence alignment and 3-dimensional (3D) structures to understand the locations
of amino acid residues and protein structures for the preliminary assessment of the putative
functional roles of SNPs. Multiple alignment data showed the portion of the amino acid
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The ORs with analyzed by their 95% CIs were estimated by logistic regression models.
> T2: multiple tumor more than 5 cm or tumor involving a major branch of the portal or hepatic vein(s)
* p value < 0.05 as statistically signi®cant.
sequence of the WW domain within WWOX, and the Ala-179-Thr variation, which was
located near the key amino acid of the cofactor binding site in human WWOX like SDR c-like
domain (Fig 1A±1C). The homology-based 3D protein structure of WWOX shows the putative
coenzyme NAD (P)-binding pocket and predicts the active site using the SWISS-MODEL base
on the M. abscessus short chain dehydrogenase or the reductase crystal structure as a template.
The rs12918952 variants are positioned within the functional cofactor binding of the WWOX
gene (Fig 1D). In addition, given the association of WWOX genetic substitution with gene
expression, we used the Genotype±Tissue Expression (GTEx) database to explore whether
rs12918952 was associated with the expression of WWOX in human HCC. Individuals
carrying rs121918952-variant genotypes (GA or AA) showed a trend of decreased expression of
WWOX compared with that of the wild-type homozygous GG genotype (Fig 1E). The
rs12918952 G to A substitution probably affects catalytic activity, decreases WWOX mRNA
expression, and subsequently enhances the vascular invasion of HCC.
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The ORs with analyzed by their 95% CIs were estimated by logistic regression models.
> T2: multiple tumor more than 5 cm or tumor involving a major branch of the portal or hepatic vein(s)
* p value < 0.05 as statistically signi®cant.
Several studies have suggested that WWOX polymorphic variants are consistently associated
with more aggressive phenotypes and poor outcomes in numerous malignant diseases,
including esophageal squamous cell carcinoma, thyroid carcinoma, pancreatic cancer, and lung
cancer [36, 40±42]. In the current study, we evaluated variations in the WWOX gene and the
clinicopathological development of HCC across 2 independent individuals. Furthermore, we
reported the additional finding that WWOX expression was downregulated in HCC, which
strengthened the evidence of a link between polymorphic variations and susceptibility to
Alcohol consumption, HBV or HCV infection, history of liver cirrhosis, and family history
of HCC are the major etiologic factors for HCC in Taiwan [
]. Our data show that the
number of individuals with a history of alcohol consumption was higher among the HCC
patient group (36.7%) than among the control participants (15.7%), indicating that alcohol
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AST/ALT ratio a
consumption is highly associated with increased HCC risk. Alcohol abuse is known to be
carcinogenic in humans and causes oxidative stress in hepatic cells, which play a pivotal role in
the etiology of liver damage [
]. Chronic alcohol abuse accelerates hepatobiliary tumors by
upregulating miR-122-mediated HIF-1α activity and stemness [
]. Interestingly, moderate
alcohol intake altered autophagy- and apoptosis-signaling networks in a pig model [
Indeed, exposure to such carcinogens frequently altered genes at fragile sites, which led to the
loss of WWOX suppressor function. Consistent with our data, patients with alcohol
consumption had a higher risk of developing HCC. Moreover, in the current study, our result shown
that SNP rs12918952 in WWOX conferred higher risk of vascular invasion, however, no
difference was found regarding the HBsAg and anti-hepatitis C virus (Table 4). WWOX is known to
regulate virus-associated immunodeficiency and various cancers, including HCC [9, 48±51].
Further investigation is warranted to explore the potential role of WWOX polymorphism and
viral regulation of HCC progression.
WWOX, a protein bearing the WW domain, interacts with several proteins and plays a
principle role in preventing tumorigenesis. Decreased expression or genetic alteration of
WWOX has been detected in various malignant tumors. The influence of WWOX expression
on the regulation of carcinogenesis, cell cycle, and apoptosis has also been recently reported
[52±54]. However, these initial associations were not consistent with our expectation that the
genetic variants rs73569323 (C1442T) and rs11545028 (C121T) would be significantly
associated with a lower risk of HCC and tumor size. Furthermore, the 2 SNPs, C121T in the Kozak
translation initiation site and C1442T in a closely micro-RNA target region in 3'-UTR, did not
alter critical residues of the WW or SDR domain. Nevertheless, we have previously observed
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Fig 1. Structural characterization and SNP (rs12918952) in human WWOX protein (NP_057457.1). Alignments of conserved
domainbased sequences of (A) two conserved tryptophans domain (WW; cd00201) and (C) classical-like SDR domain
(human_WWOXlike_SDR_c-like; cd09809) by use of multiple sequence alignment format and numbered according to the human WWOX is shown above
the sequences. Strick consensus amino acids in the putative active centers of compact structural units are shown: the key amino acids of
active site and cofactor binding site are highlighted in red star and blue pound signs, respectively. The WWOX-relative sequences are as
follows: human (H. sapiens, NP_057457.1); mouse (M. musculus, NP_062519.2); chicken (G. gallus, NP_001025745.1); fish (D. rerio,
NP_957207.1) and fly (D. melanogaster, NP_609171.1). (B) Schematic representation of the overall human WWOX protein; domain
symbols are drawn approximately to scale. The rectangle represents the WW and human_WWOX-like_SDR_c-like domain; the key
residues of active site and cofactor binding site are highlighted in red and triangle sign, respectively. The N-terminal and C-terminal ends are
indicated (N' and C', respectively). (D) Ribbon diagram showing the homologous 3D model of the SDR_c-like domain of human WWOX
using the SWISSMODEL server based on M. abscessus short chain dehydrogenase or reductase crystal structure (PDB ID: 3RIH). The side
chains of the amino acids characterized catalytic tetrad of Asn232-Thr266-Tyr293-Lys297 are shown as sticks and labeled which aligned
well with the `classical' type of short-chain dehydrogenase/reductase (SDR) enzyme. The blue spheres represent the putative coenzyme
NAD (P)-binding pocket is drawn to illustrate the location of the cofactor binding site. The ribbons indicate the backbone course of human
WWOX and the arrows represent b-strands, and cylinders indicate a-helices. The figure was prepared using ViewerLite™ 5.0 software. (E)
Expression quantitative trait locus association between rs12918952 genotype and WWOX expression in whole blood (GTEx data set).
Numbers in parentheses indicate the number of cases.
that C121T represents an oncogenic target for the translational dysregulation of WWOX
expression in OSCC [
]. The clinicopathological implications of micro-RNA targeting the
3'UTR region and the regulation of gene expression are well determined. Previously,
genomewide studies have investigated the link among WWOX genetic variations, such as SNPs and
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diseases, and have identified a cis-regulatory variation in the intron of WWOX [
results suggest that the polymorphic variants C121T and C1442T seen in HCC are driven by
potential enhancer elements within the noncoding regions rather than the variants in the
protein-coding regions; this finding indicates that natural variants may be the key primary
contributors to WWOX protein expression.
The aforementioned abnormality of WWOX expression contributes to HCC tumorigenesis,
which may be associated with all-cause mortality, particularly in people with high AST and
ALT levels [
]. Moreover, serum α-fetoprotein level was found to be a pathological
biomarker of inflammation and fibrosis in chronic hepatitis B patients . With regard to the
clinical status, our results showed that compared with those who carried the CC genotype, the
rs11545028 of patients who carried the CT or TT genotype was significantly correlated with
low α-fetoprotein and ALT levels; this finding may be related to the cis-enhancing effect within
the 5'-flanking region. However, α-fetoprotein levels are an independent predictor for the
severity of inflammation and prognosis of HCC, even in chronic hepatitis B patients whose
normal or low α-fetoprotein levels still indicated a severe condition [
]. By contrast, the
serum ASL and ALT levels in polymorphic rs3764340 are significantly higher in the CG+GG
composition with CC. The rs3764340 SNP has been predicted to cause an alteration of the
protein structure at codon 282 of WWOX, where an α-helix is disrupted, and this is associated
with an elevated risk of developing multiple neoplasias, thereby reflecting the contribution of
rs3764340 C>G substitution to high AST and ALT levels [
35, 41, 42, 61
]. According to these
criteria, α-fetoprotein, AST, and ALT are promising biomarkers for the diagnosis of HCC on
the basis of the genetic variations of WWOX rs11545028 and rs3764340.
In addition, we identified one synonymous variant, rs12918952, in exon 6, which was
significantly associated with the vascular invasion of HCC. Further exploration using the
GTEx dataset for liver tissue and expression quantitative trait loci analysis revealed that the
rs12918952 A allele was associated with decreased WWOX expression. A clinical study of 101
primary bladder tumor samples demonstrated that the low expression of WWOX was
correlated with advanced cancer stages and tumor progression [
]. A similar proportion of
WWOX downregulation associated with aggressive phenotypes and poor prognosis has been
observed in many cancers. Intriguingly, we showed that rs12918952 was mapped in the coding
region near the typical coenzyme binding site within the SDR domain. Single-nucleotide
substitution in coding or regulatory sequences affects the protein structure, and conformation has
been demonstrated. To the best of our knowledge, no previous evidences have revealed that
rs12918952 G>A substitution has the potential to modify the biological activity and protein
stability of WWOX. Recently, the deletion of WWOX exon 6±8 was identified in lung cancer,
resulting in a loss of the tumor suppressor function [
]. In the present study, the missense
polymorphism rs12918952 G>A located in exon 6 conferred a decreased expression of
WWOX, which is partially responsible for the higher vascular invasion of HCC. However, the
direct testing of this hypothesis beyond the purpose of the current study is difficult.
Nevertheless, it is a unique feature and warrants further investigation.
In conclusion, the present study reports a potential clinically significant finding that several
variants of WWOX are associated with the clinical status and susceptibility of HCC. Although
the clinical and pathological features differ among the various polymorphisms of WWOX, our
findings still provide a deeper insight into the genetic variations. Additional bioinformative
analyses should be conducted to evaluate the clinical utility of predicting the likelihood of
patient susceptibility to HCC. Comprehensive variant detection and analysis are prerequisites
for developing optimal therapeutic approaches that can eventually ameliorate the clinical
phenotype in patients harboring the corresponding lesions.
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Conceptualization: S-FY Y-EC.
Data curation: H-LL.
Formal analysis: H-LC Y-FL.
Funding acquisition: S-FY.
Investigation: H-LL S-FY.
Writing ± original draft: H-LL H-LC S-FY.
Writing ± review & editing: H-LL Y-EC S-FY.
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