Association of MDM2 expression with shorter progression-free survival and overall survival in patients with advanced pancreatic cancer treated with gemcitabine-based chemotherapy
Association of MDM2 expression with shorter progression-free survival and overall survival in patients with advanced pancreatic cancer treated with gemcitabine-based chemotherapy
Shih-Hung Yang 0 1
Jen-Chieh Lee 1
Jhe-Cyuan Guo 0 1
Sung-Hsin Kuo 0 1
Yu-Wen Tien 1
Ting-Chun Kuo 1 2
Ann-Lii Cheng 0 1
Kun-Huei Yeh 0 1
0 Departments of Oncology, National Taiwan University Hospital , Taipei, Taiwan , 2 Department of Internal Medicine, National Taiwan University Hospital , Taipei, Taiwan , 3 Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine , Taipei, Taiwan , 4 Department of Pathology, National Taiwan University Hospital , Taipei, Taiwan , 5 Graduate Institute of Oncology, National Taiwan University College of Medicine , Taipei, Taiwan , 6 Department of Surgery, National Taiwan University Hospital , Taipei , Taiwan
1 Editor: Ramon Andrade de Mello, Universidade do Algarve Departamento de Ciencias Biomedicas e Medicina , PORTUGAL
2 Department of Traumatology, National Taiwan University Hospital , Taipei , Taiwan
This study evaluated the prognostic roles of murine double minute 2 (MDM2) and p53 in pancreatic cancer patients treated with gemcitabine-based chemotherapy. A total of 137 advanced or recurrent adenocarcinoma patients who were treated with gemcitabine-based palliative chemotherapy were reviewed, selected from 957 patients with pancreatic malignancy between 2008 and 2013 at our hospital. Immunohistochemical staining for MDM2 and p53 with formalin-fixed, paraffin-embedded tumor tissues was independently reviewed. Nuclear or cytoplasmic expression of MDM2 and p53 was found in tumor cells of 30 (21.9%) and 71 (51.8%) patients, respectively. Patients with MDM2 expression had shorter median overall survival (OS) (3.7 vs 5.8 mo; P = .048) and median progression-free survival (PFS) (1.5 vs 2.5 mo; P < .001); by contrast, p53 expression was not correlated with OS or PFS. In the multivariate analysis, MDM2 expression (hazard ratio = 1.731; P = .025) was an independent and unfavorable prognostic factor of OS. Additionally, MDM2 expression was significantly associated with progressive disease (PD) and death (P = .015) following first-line gemcitabine-based therapy. In advanced pancreatic cancer patients, MDM2 expression is associated with shorter OS and PFS after gemcitabine-based chemotherapy.
Data Availability Statement: All relevant data are
within the paper and its Supporting Information
Funding: This work was supported by
MOHW103TD-B-111-04 and MOHW104-TD-B-111-04,
Ministry of Health and Welfare (http://www.mohw.
Pancreatic cancer is one of the leading causes of cancer-related mortalities in the world, resulting in more than 330000 deaths per year . The 5-year overall survival (OS) rate is only 20% among patients receiving curative surgery and adjuvant gemcitabine, and patients with
advanced diseases face even lower (< 5%) OS [
]. Gemcitabine has been the most crucial
element in the development of first-line chemotherapy since 1997 [3±6]. Following
FOLFIRINOX establishing the role in first-line therapy for advanced pancreatic cancer , gemcitabine
plus nab-paclitaxel also has become a new treatment standard for patients with favorable
performance status (PS) [
]. Regarding the mechanisms of gemcitabine activation and
metabolism, human equilibrative nucleoside transporter 1 represents the most consistent predictive
biomarker for the efficacy of gemcitabine; however, data on other markers, such as
deoxycytidine kinase and ribonucleotide reductase subunits 1 and 2, are heterogeneous [
complex genetic background may largely contribute to the biology of pancreatic cancer and limit
the utility of any single biomarker for drugs .
Gemcitabine, a nucleoside analogue, incorporates with DNA after activation, subsequently
terminating DNA elongation [
]. After gemcitabine-induced DNA damage, p53 is activated
and may contribute to apoptosis or cell cycle arrest [
]. The chemosensitivity of
gemcitabine in pancreatic cancer is enhanced after the restoration of p53 function . However, p53
is mutated in more than 50% of pancreatic cancer cases [
], and MDM2, the negative
regulator of p53, is induced and overexpressed by Ras signaling in pancreatic cancer [
suppresses the transcriptional activity of p53 by binding to the transactivation domain of p53
]. In addition, MDM2 is an E3 ubiquitin ligase for p53 to mediate its degradation [
Therefore, functional p53-mediated apoptosis and cell cycle regulation may be inefficient, thus
contributing little to gemcitabine-mediated cytotoxicity in pancreatic cancer patients.
Furthermore, the status of p53 is not prognostic for pancreatic cancer [19±22], and the prognostic
significance of MDM2 in resected pancreatic cancer is inconsistent [
MDM2 exerts numerous other biological effects unrelated to p53, such as the regulation of
p21, E2F1, XIAP, p73, and NF-κB/p65 [23±27]. In addition, the association between
chemotherapy and MDM2 status in pancreatic cancer is largely unknown. In this study, we evaluated
the prognostic values of MDM2 and p53 expression in advanced pancreatic cancer patients
receiving gemcitabine-based palliative chemotherapy.
Methods and materials
The cancer registry database of the Medical Information Management Office at National
Taiwan University Hospital was screened for primary pancreatic malignancy diagnoses between
2008 and 2013. The patients selected for this study were required to have received palliative
treatment with gemcitabine-containing chemotherapy (S1 Table) for advanced or recurrent
pancreatic cancer; complete available medical records and histopathological archival tissues
were also obtained. Patients with benign tumors, neuroendocrine tumors, solid
pseudopapillary neoplasm, or pancreatic malignancies other than adenocarcinoma were excluded. In total,
137 patients who met our inclusion criteria were selected for analysis (S1 Fig). This study was
approved by the Research Ethics Committee of National Taiwan University Hospital (approval
number: 201309033RINB). Written consents were waived by the Research Ethics Committee.
The dataset generated and/or analyzed during the current study was de-identified and available in the supplement.
We applied immunohistochemical (IHC) staining to formalin-fixed, paraffin-embedded
tumor tissue sections (4-μm thick), using the OptiView DAB IHC Detection Kit (Roche) and
Ventana automated slide strainers (Roche). The primary antibodies and their dilutions comprised anti-MDM2 diluted to 1:100 (#33±7100, Invitrogen Corporation) and anti-p53 diluted to 1:50 (M 7001, Dako). Stained tissue sections were reviewed and scored by a pathologist
2 / 14
(Jen-Chieh Lee) who is an expert in the interpretation of MDM2 expression [
] and was
blinded to the patients' demographic data and clinical outcomes. Expression was defined as
positive when at least 10% of the tumor cells had positive staining [
]. The positive controls
of p53 and MDM2 staining were colon adenoma and liposarcoma, respectively.
Most (n = 130) selected patients were dead before initiation of this study, and the other seven
patients without the confirmation of death also had been selected. OS was the primary
endpoint in this study and was defined from the first day of gemcitabine-based chemotherapy to
the day of death or final follow-up. Tumor response was evaluated according to the Response
Evaluation Criteria in Solid Tumors (RECIST), Version 1.1 . PFS was defined as imaging
documented PD with RECIST or death after initiation of a gemcitabine-based chemotherapy;
therefore, progression was defined as PD or death after a gemcitabine-based chemotherapy.
A Fisher's exact test was used to analyze the correlations between the discrete clinicopatho
logic characteristics and the IHC expression of MDM2 and p53. The association between
MDM2 and p53 IHC expression was analyzed using the Fisher's exact test. The prognostic sig
nificance of OS among the clinicopathologic factors and the expression of MDM2 and p53
were evaluated using univariate analysis and KaplanÐMeier survival curves (i.e., log-rank
test). The clinicopathologic factors with significance in the univariate analysis were
subsequently introduced into a multivariate analysis (i.e., Cox regression model) for OS. The cutoff
point of OS data follow-up was July 2015.
The SPSS statistical software system (IBM SPSS Statistics for Windows, Version 20.0; IBM
Corp., Armonk, NY, USA) was employed for statistical analyses, and P < .05 was considered
Our analysis included 137 patients. The median age was 62 years (range: 27±84 y), and male
patients comprised 60.6% (n = 83) of the study population. Most of the patients had favorable
PS according to the criteria of the Eastern Cooperative Oncology Group (ECOG) 0±1 (81.0%,
n = 111), and most of them were at the advanced stages of disease (stages III or IV, according
to the American Joint Committee on Cancer) (74.5%, n = 102). Initially, of the 86 patients
with stage IV disease, the most common metastatic sites were the liver (n = 69), peritoneum or
omentum (n = 30), and lungs (n = 17). Patients in the first-line gemcitabine subgroup had
comparable clinical characteristics comparing to the whole study cohort. The baseline patient
characteristics are summarized in Table 1.
In total, 26 patients received curative operations, 5 of whom were given adjuvant therapy with 5-FU-based chemotherapy and/or concurrent chemoradiotherapy; all patients experienced recurrence. As for palliative chemotherapy, gemcitabine had been used in the first-, second-, third-, or later-line therapy in 121, 39, 6, and 6 patients, respectively.
IHC expression of MDM2 and p53 versus clinical characteristics
Nuclear or cytoplasmic expression of MDM2 and p53 was found in tumor cells of 30 (21.9%)
and 71 (51.8%) cases, respectively (Fig 1A, 1B, 1C and 1D). The associations of MDM2 and
p53 expression with patient clinical characteristics are presented in S2 Table. MDM2 or p53
expression was not significantly associated with any clinical factors. The association between
the expression of MDM2 and p53 was not significant (P = .215). The positive rates of MDM2
3 / 14
n = 121 (%)
n = 16 (%)
4 / 14
n = 121 (%)
n = 16 (%)
*Stage: TNM system of the American Joint Committee on Cancer (7th edition)
¶Hematology and biochemistry: WBC, white blood cell; PMN, polymorphonuclear granulocyte; Mono, monocyte; Lym, lymphocyte; CRP, C-reactive protein
#Missing data (patient number) in the whole study group: PMN, Mono, Lym (n = 8); CRP (n = 107); Albumin (n = 16)
and p53 expression stratified by the status of curative surgery did not show significant
difference (S3 Table).
For the entire study group, patients with MDM2 expression had significantly poorer prognosis
than those without MDM2 expression did as calculated from the start of a gemcitabine-based
regimen (median OS = 3.7 vs 5.8 mo; P = .048) (Fig 2A). By contrast, p53 expression had no
prognostic significance (median OS = 5.3 vs 4.1 mo; P = .192) (Fig 2B). After stratification of
all the patients into four subgroups (MDM2+/p53-, MDM2+/p53+, MDM2-/p53+, and
MDM2-/p53-), the median OS following the start of a gemcitabine-based regimen was 1.6, 4.2,
5.8, and 5.6 months, respectively (P = .003; Fig 2C); within the same subgroups, patients with
unresectable diseases (n = 111) demonstrated a median OS of 0.9, 4.2, 5.8, and 7.4 months (P =
5 / 14
Fig 1. Representative cases of IHC expression (magnification 400X). Cases of IHC expression with (A)
MDM2+, (B) MDM2-, (C) p53+, and (D) p53- were demonstrated. The positive staining was predominantly
nuclear for both MDM2 and p53.
.001), respectively, following the start of a gemcitabine-based regimen. The association
between MDM2 and poor OS was similar irrespective of surgery status (S4 Table).
In patients with stage III or IV pancreatic cancer and receiving first-line gemcitabine
monotherapy (n = 36), MDM2 but not p53 was a poor prognostic factor (S5 Table).
In addition to MDM2 expression, age (P = .032), ECOG PS (P < .001), initial
carcinoembryonic antigen (CEA) level (P = .024), and initial albumin level (P = .038) were all
significantly associated with median OS from the start of any gemcitabine-based regimen in the
univariate analyses (Table 2). Notably, the poor prognostic factors in the univariate analysis
were not associated with any MDM2 or p53 subgroup. Moreover, after the significant clinical
Fig 2. Survival curves in patients stratified with MDM2 and p53. The OS curves stratified with (A) MDM2 expression, (B) p53
expression, and (C) MDM2 and p53 statuses were demonstrated. The dots represented censored observation. The OS was worse in
patients with MDM2+ IHC staining (P = .048). The OS did not differ significantly between p53+ and p53- patients (P = .192). After
stratification of MDM2 and p53 status, patients with MDM2+/p53- staining had the shortest OS (P = .003).
6 / 14
characteristics were introduced into the multivariate analysis (Table 3), only ECOG PS
(HR = 5.032; P < .001) and expression of MDM2 (HR = 1.731; P = .025) remained unfavorable
prognostic factors for OS from the start of a gemcitabine-based regimen.
IHC expression of MDM2 and p53 versus chemotherapy outcomes
We analyzed the association of best response to gemcitabine-based regimens and the expression of MDM2 and p53, but no significant association was observed in the entire study population (Table 4). The median PFS after initiation of any gemcitabine-based therapy in the entire
7 / 14
study population was 2.3 months; furthermore, MDM2 expression was significantly associated
with shorter median PFS (positive vs negative = 1.5 vs 2.5 mo; P < .001; Fig 3A) but p53
expression was not (positive vs negative = 2.3 vs 2.2 mo; P = .630; Fig 3B).
We also stratified the patients according to their progression through gemcitabine-based
therapy. MDM2 was significantly associated with progression after first-line
gemcitabinebased therapy (P = .015) (Table 4).
In this study, MDM2 was determined to be a prognostic factor for poor prognosis and progression under gemcitabine-based chemotherapy in addition to other poor prognostic factors identified in a previous study, such as old age, poor ECOG PS, high CEA level, and low albumin level . Although it was not clearly linked to any baseline characteristics associated
¶CR, complete response; PR, partial response; SD, stable disease; PD, progressive disease
8 / 14
Fig 3. PFS curves in patients stratified with MDM2 and p53. The PFS curves were stratified with (A) MDM2 expression and (B)
p53 expression. The median PFS was worse in patients with MDM2+ IHC staining (P < .001). The median PFS did not differ
significantly between p53+ and p53- patients (P = .630). The dots represented censored observation.
with poor prognosis, MDM2 had borderline significance associated with negative regional
lymph node involvement, which is generally a favorable prognostic factor. However, the
lymph node status was not indicative of prognostic significance, regardless of curative
resection. Previous studies have suggested that E-cadherin is a target for MDM2-mediated
ubiquitination and degradation in breast cancer cells [
]; additionally, overexpression of MDM2 can
inhibit cellÐcell contact and increase cell motility [
]. Thus, although MDM2 may mediate
distant nonregional lymph node metastasis through the downregulation of E-cadherin, the
poor efficacy of systemic chemotherapy in the palliative setting actually outweighs the
significance of regional lymph node metastasis.
The percentages of MDM2 and p53 IHC expression in this study were similar to those from
previous reports [
19, 21, 22
]. Under ordinary conditions, MDM2 and p53 form a negative
regulation loop [
]. MDM2 expression has been activated through the RasÐRafÐMEK pathway
], but the inverse relationship between MDM2 and p53 levels has not been observed in
our study and in pancreatic cancer cell lines with mutant p53 . Although MDM2 regulates
the stability of mutant p53 in transgenic animal models [
], it also ubiquitinates mutant p53
less efficiently [
]. Therefore, both active Ras signaling and p53 mutation may partially
contribute to the protection and decoupling of mutant p53 from MDM2-mediated degradation.
Furthermore, we determined that MDM2 expression, but not p53 expression, was associated
with disease progression, poor PFS, and poor OS after gemcitabine-based chemotherapy.
Notably, the shortest OS was observed in patients with MDM2+/p53- expression. Previous studies
have also indicated that mutant p53 is associated with short OS, irrespective of curative
]. Recently, Fiorini et al observed that CDK1 and CCNB1 were induced after
gemcitabine treatment in PANC1 cells expressing mutant p53 protein; however, they also noted that
the effects were reversed after the downregulation of mutant p53 . Conversely, in AsPC1
cells without expression of mutant p53 protein, the induction of CDK1 and CCNB1 expression
9 / 14
occurred after the transfection of the mutant p53 (i.e., R273H) plasmid [
]. Therefore, the
function gain that accompanies p53 mutation not only reverses cell cycle inhibition of
wildtype p53 but also induces chemoresistance to gemcitabine in pancreatic adenocarcinoma cells.
In addition, p53 expression is not correlated with mutational status; this is also true of
PANC1 and AsPC1 cells [
]. Because we did not incorporate p53 mutation analysis into the
present study, we could not deduce the p53 mutation status of individual patients from the
p53 IHC expression data. The four subgroups stratified by MDM2 and p53 IHC expression
were not associated with poor prognostic factors. Notably, the two subgroups with extreme OS
difference had opposite status of MDM2 and p53 expression. Therefore, we can assume that
the balance between MDM2 and p53 mediates the tumor aggressiveness; as prior research
similarly revealed, the downregulation of MDM2 in SW1990HM pancreatic adenocarcinoma cells
increases levels of E-cadherin and decreases levels of matrix metallopeptidase 9 and Ki-67 [
Downregulation and induction of the autoubiquitination of MDM2 with SP141 inhibit pan
creatic adenocarcinoma both in vitro and in vivo. Additionally, the induction of apoptosis,
p21, and Bax, accompanied by a reduction of cyclin E and Bcl-2, occurs after SP141 treatment
. Although MDM2 amplification is among the mechanisms of MDM2 expression in
specific malignancies [
], a typical pattern of the phenomenon was not found in this study (S2
Fig). Therefore, MDM2 amplification was not the major mechanism of MDM2 expression in
our patient population, which aligns with previous studies reporting rare MDM2 amplification
in pancreatic adenocarcinoma [
There were some missing data in Table 1 due to the limitation of retrospective study. Most
patients did not have baseline data of CRP. Although the level of CRP may be associated with
prognosis, it was not a routine test at the diagnosis of pancreatic cancer. The distribution of
baseline characteristics, MDM2 and p53 expression was similar among the entire study
population and subjects without missing data of CEA, CA 19±9, polymorphonuclear granulocyte
(PMN) count, monocyte count, and lymphocyte count (S6 Table). In addition, the multivariate
analysis of the subjects without missing data (S7 Table) was comparable to the original analysis
In summary, MDM2 expression is associated with poor prognosis and progression after gemci
tabine-based chemotherapy in advanced pancreatic adenocarcinoma. The major limitation of
our study was the heterogeneous patient population, comprising patients both with and without
curative resection. However, all of these patients had been previously treated with gemcitabine.
To the best of our knowledge, this is the first clinical study to evaluate the association of chemotherapy with MDM2 in pancreatic cancer. Future basic or clinical studies applying chemotherapy and MDM2-targeted therapy with a non-p53 dependent mechanism are warranted.
S1 Fig. Consort diagram of eligible patients. The process of patient selection was
S2 Fig. FISH patterns in patients with polysomy of chromosome 12. FISH patterns in the
three patients with polysomy of chromosome 12 with concomitant increase numbers of the
centromere and mdm2 staining [
] were demonstrated; red = MDM2; green = centromere
10 / 14
S1 Table. Summary of first-line and second-line gemcitabine-based chemotherapy.
S2 Table. Association of MDM2 and p53 with clinical characteristics.
S3 Table. Association of MDM2/p53 expression and surgery status.
S4 Table. Association of MDM2/p53 expression, surgery status, and OS after
S5 Table. Association of MDM2/p53 and PFS/OS in stage III/IV patients with first-line
gemcitabine (N = 36).
S6 Table. Clinical characteristics and missing data.
S7 Table. Multivariate analysis for OS in subjects without missing data.
S1 File. Supplement original dataset.
Parts of the data in this manuscript were presented in the 2015 International Symposium of
Cancer Center of Excellence: Frontiers on Cancer Research and Treatment, Taipei, Taiwan.
Data curation: SHY.
Formal analysis: SHY JCL JCG.
Funding acquisition: SHY YWT ALC KHY.
Investigation: SHY JCL JCG SHK.
Methodology: SHY JCL JCG SHK TCK.
Project administration: SHY JCL JCG.
Resources: JCL SHK ALC KHY.
Software: SHY JCG TCK.
Supervision: YWT ALC KHY.
Visualization: SHY JCG JCL.
Writing ± original draft: SHY TCK.
Writing ± review & editing: KHY.
11 / 14
12 / 14
13 / 14
1. Torre LA , Bray F , Siegel RL , Ferlay J , Lortet-Tieulent J , Jemal A . Global cancer statistics, 2012 . CA Cancer J Clin. 2015 ; 65 ( 2 ): 87 ± 108 . https://doi.org/10.3322/caac.21262 PMID: 25651787
2. Oettle H , Neuhaus P , Hochhaus A , Hartmann JT , Gellert K , Ridwelski K , et al. Adjuvant chemotherapy with gemcitabine and long-term outcomes among patients with resected pancreatic cancer: the CONKO-001 randomized trial . JAMA . 2013 ; 310 ( 14 ): 1473 ± 1481 . https://doi.org/10.1001/jama. 2013 . 279201 PMID: 24104372
3. Burris HA 3rd, Moore MJ , Andersen J , Green MR , Rothenberg ML , Modiano MR , et al. Improvements in survival and clinical benefit with gemcitabine as first-line therapy for patients with advanced pancreas cancer: a randomized trial . J Clin Oncol . 1997 ; 15 ( 6 ): 2403 ± 2413 . https://doi.org/10.1200/JCO. 1997 . 15 .6.2403 PMID: 9196156
4. Heinemann V , Quietzsch D , Gieseler F , Gonnermann M , SchoÈnekaÈs H , Rost A , et al. Randomized phase III trial of gemcitabine plus cisplatin compared with gemcitabine alone in advanced pancreatic cancer . J Clin Oncol . 2006 ; 24 ( 24 ): 3946 ± 3952 . https://doi.org/10.1200/JCO. 2005 . 05 .1490 PMID: 16921047
5. Poplin E , Feng Y , Berlin J , Rothenberg ML , Hochster H , Mitchell E , et al. Phase III, randomized study of gemcitabine and oxaliplatin versus gemcitabine (fixed-dose rate infusion) compared with gemcitabine (30-minute infusion) in patients with pancreatic carcinoma E6201: a trial of the Eastern Cooperative Oncology Group . J Clin Oncol . 2009 ; 27 ( 23 ): 3778 ± 3785 . https://doi.org/10.1200/JCO. 2008 . 20 .9007 PMID: 19581537
6. Ueno H , Ioka T , Ikeda M , Ohkawa S , Yanagimoto H , Boku N , et al. Randomized phase III study of gemcitabine plus S-1, S-1 alone, or gemcitabine alone in patients with locally advanced and metastatic pancreatic cancer in Japan and Taiwan: GEST study . J Clin Oncol . 2013 ; 31 ( 13 ): 1640 ± 1648 . https://doi. org/10.1200/JCO. 2012 . 43 .3680 PMID: 23547081
7. Conroy T , Desseigne F , Ychou M , BoucheÂ O , Guimbaud R , BeÂcouarn Y , et al. FOLFIRINOX versus gemcitabine for metastatic pancreatic cancer . N Engl J Med . 2011 ; 364 ( 19 ): 1817 ± 1825 . https://doi.org/ 10.1056/NEJMoa1011923 PMID: 21561347
8. Von Hoff DD , Ervin T , Arena FP , Chiorean EG , Infante J , Moore M , et al. Increased survival in pancreatic cancer with nab-paclitaxel plus gemcitabine . N Engl J Med . 2013 ; 369 ( 18 ): 1691 ± 1703 . https://doi. org/10.1056/NEJMoa1304369 PMID: 24131140
9. 10 . Wei CH , Gorgan TR , Elashoff DA , Hines OJ , Farrell JJ , Donahue TR . A meta-analysis of gemcitabine biomarkers in patients with pancreaticobiliary cancers . Pancreas . 2013 ; 42 ( 8 ): 1303 ± 1310 . https://doi. org/10.1097/MPA.0b013e3182a23ae4 PMID: 24152955
Waddell N , Pajic M , Patch AM , Chang DK , Kassahn KS , Bailey P , et al. Whole genomes redefine the mutational landscape of pancreatic cancer . Nature . 2015 ; 518 ( 7540 ): 495 ± 501 . https://doi.org/10.1038/ nature14169 PMID: 25719666
11. Huang P , Chubb S , Hertel LW , Grindey GB , Plunkett W. Action of 2',2'-difluorodeoxycytidine on DNA synthesis . Cancer Res . 1991 ; 51 ( 22 ): 6110 ± 6117 . PMID: 1718594
12. Achanta G , Pelicano H , Feng L , Plunkett W , Huang P. Interaction of p53 and DNA-PK in response to nucleoside analogues: potential role as a sensor complex for DNA damage . Cancer Res . 2001 ; 61 ( 24 ): 8723 ± 8729 . PMID: 11751391
13. Galmarini CM , Clarke ML , Falette N , Puisieux A , Mackey JR , Dumontet C . Expression of a non-functional p53 affects the sensitivity of cancer cells to gemcitabine . Int J Cancer . 2002 ; 97 ( 4 ): 439 ± 445 . https://doi.org/10.1002/ijc.1628 PMID: 11802204
14. CascalloÂ M , CalboÂ J , Capellà G , Fillat C , Pastor-Anglada M , Mazo A . Enhancement of gemcitabineinduced apoptosis by restoration of p53 function in human pancreatic tumors . Oncology . 2005 ; 68 ( 2 ±3): 179 ± 189 . https://doi.org/10.1159/000086772 PMID: 16006755
15. Redston MS , Caldas C , Seymour AB , Hruban RH , da Costa L , Yeo CJ , et al. p53 mutations in pancreatic carcinoma and evidence of common involvement of homocopolymer tracts in DNA microdeletions . Cancer Res . 1994 ; 54 ( 11 ): 3025 ± 3033 . PMID: 8187092
16. Sui X , Shin S , Zhang R , Firozi PF , Yang L , Abbruzzese JL , et al. Hdm2 is regulated by K-Ras and mediates p53-independent functions in pancreatic cancer cells . Oncogene . 2009 ; 28 ( 5 ): 709 ± 720 . https:// doi.org/10.1038/onc. 2008 .423 PMID: 19029954
17. Oliner JD , Pietenpol JA , Thiagalingam S , Gyuris J , Kinzler KW , Vogelstein B. Oncoprotein MDM2 conceals the activation domain of tumour suppressor p53 . Nature . 1993 ; 362 ( 6423 ): 857 ± 860 . https://doi. org/10.1038/362857a0 PMID: 8479525
18. Honda R , Tanaka H , Yasuda H. Oncoprotein MDM2 is a ubiquitin ligase E3 for tumor suppressor p53 . FEBS Lett . 1997 ; 420 ( 1 ): 25 ± 27 . https://doi.org/10.1016/S0014- 5793 ( 97 ) 01480 - 4 PMID: 9450543
19. Ruggeri BA , Huang L , Berger D , Chang H , Klein-Szanto AJ , Goodrow T , et al. Molecular pathology of primary and metastatic ductal pancreatic lesions: analyses of mutations and expression of the p53, mdm-2, and p21/WAF-1 genes in sporadic and familial lesions . Cancer . 1997 ; 79 ( 4 ): 700 ± 716 . https:// doi.org/10.1002/(SICI) 1097 - 0142 ( 19970215 )79: 4 < 700 : :AID-CNCR7>3.0 .CO;2 -H PMID : 9024708
20. Gerdes B , Ramaswamy A , Ziegler A , Lang SA , Kersting M , Baumann R , et al. p16INK4a is a prognostic marker in resected ductal pancreatic cancer: an analysis of p16INK4a, p53, MDM2, an Rb . Ann Surg . 2002 ; 235 ( 1 ): 51 ± 59 . PMID: 11753042
21. Dong M , Ma G , Tu W , Guo KJ , Tian YL , Dong YT . Clinicopathological significance of p53 and mdm2 protein expression in human pancreatic cancer . World J Gastroenterol . 2005 ; 11 ( 14 ): 2162 ± 2165 . https://doi.org/10.3748/wjg. v11.i14.2162 PMID: 15810085
22. Hermanova M , Karasek P , Nenutil R , Kyr M , Tomasek J , Baltasova I , et al. Clinicopathological correlations of cyclooxygenase-2, MDM2, and p53 expressions in surgically resectable pancreatic invasive ductal adenocarcinoma . Pancreas . 2009 ; 38 ( 5 ): 565 ± 571 . https://doi.org/10.1097/MPA. 0b013e31819fef8b PMID: 19346994
23. Zhang Z , Wang H , Li M , Agrawal S , Chen X , Zhang R . MDM2 is a negative regulator of p21WAF1/CIP1, independent of p53 . J Biol Chem . 2004 ; 279 ( 16 ): 16000 ± 16006 . https://doi.org/10.1074/jbc. M312264200 PMID: 14761977
24. Martin K , Trouche D , Hagemeier C , Sørensen TS , La Thangue NB , Kouzarides T. Stimulation of E2F1/ DP1 transcriptional activity by MDM2 oncoprotein . Nature . 1995 ; 375 ( 6533 ): 691 ± 694 . https://doi.org/ 10.1038/375691a0 PMID: 7791903
25. Gu L , Zhang H , Liu T , Zhou S , Du Y , Xiong J , et al. Discovery of Dual Inhibitors of MDM2 and XIAP for Cancer Treatment . Cancer Cell . 2016 ; 30 ( 4 ): 623 ± 636 . https://doi.org/10.1016/j.ccell. 2016 . 08 .015 PMID: 27666947
26. Zeng X , Chen L , Jost CA , Maya R , Keller D , Wang X , et al. MDM2 suppresses p73 function without promoting p73 degradation . Mol Cell Biol . 1999 ; 19 ( 5 ): 3257 ± 3266 . https://doi.org/10.1128 /MCB.19.5.3257 PMID: 10207051
27. Gu L , Findley HW , Zhou M. MDM2 induces NF-kappaB/p65 expression transcriptionally through Sp1- binding sites: a novel, p53-independent role of MDM2 in doxorubicin resistance in acute lymphoblastic leukemia . Blood . 2002 ; 99 ( 9 ): 3367 ± 3375 . https://doi.org/10.1182/blood. V99.9.3367 PMID: 11964305
28. Lee JC , Fletcher CD . Malignant fat-forming solitary fibrous tumor (so-called "lipomatous hemangiopericytoma"): clinicopathologic analysis of 14 cases . Am J Surg Pathol . 2011 ; 35 ( 8 ): 1177 ± 1185 . https:// doi.org/10.1097/PAS.0b013e318219cd0b PMID: 21716088
29. Eisenhauer EA , Therasse P , Bogaerts J , Schwartz LH , Sargent D , Ford R , et al. New response evaluation criteria in solid tumours: revised RECIST guideline (version 1.1) . Eur J Cancer . 2009 ; 45 ( 2 ): 228 ± 247 . https://doi.org/10.1016/j.ejca. 2008 . 10 .026 PMID: 19097774
30. Yang SH , Guo JC , Yeh KH , Tien YW , Cheng AL , Kuo SH . Association of radiotherapy with favorable prognosis in daily clinical practice for treatment of locally advanced and metastatic pancreatic cancer . J Gastroenterol Hepatol . 2016 ; 31 ( 12 ): 2004 ± 2012 . https://doi.org/10.1111/jgh.13395 PMID: 27059987
31. Yang JY , Zong CS , Xia W , Wei Y , Ali-Seyed M , Li Z , et al. MDM2 promotes cell motility and invasiveness by regulating E-cadherin degradation . Mol Cell Biol . 2006 ; 26 ( 19 ): 7269 ± 7282 . https://doi.org/10. 1128/ MCB . 00172 -06 PMID: 16980628
32. Ries S , Biederer C , Woods D , Shifman O , Shirasawa S , Sasazuki T , et al. Opposing effects of Ras on p53: transcriptional activation of mdm2 and induction of p19ARF . Cell . 2000 ; 103 ( 2 ): 321 ± 330 . http://dx. doi.org/10.1016/S0092- 8674 ( 00 ) 00123 - 9 PMID: 11057904
33. Terzian T , Suh YA , Iwakuma T , Post SM , Neumann M , Lang GA , et al. The inherent instability of mutant p53 is alleviated by Mdm2 or p16INK4a loss . Genes Dev . 2008 ; 22 ( 10 ): 1337 ± 1344 . https://doi.org/10. 1101/gad.1662908 PMID: 18483220
34. Lukashchuk N , Vousden KH . Ubiquitination and degradation of mutant p53 . Mol Cell Biol . 2007 ; 27 ( 23 ): 8284 ± 8295 . https://doi.org/10.1128/ MCB . 00050 -07 PMID: 17908790
35. Nakamori S , Yashima K , Murakami Y , Ishikawa O , Ohigashi H , Imaoka S , et al. Association of p53 gene mutations with short survival in pancreatic adenocarcinoma . Jpn J Cancer Res . 1995 ; 86 ( 2 ): 174 ± 181 . PMID: 7730141
36. Weyrer K , Feichtinger H , Haun M , Weiss G , Ofner D , Weger AR , et al. p53, Ki-ras, and DNA ploidy in human pancreatic ductal adenocarcinomas . Lab Invest . 1996 ; 74 ( 1 ): 279 ± 289 . PMID: 8569192
37. Fiorini C , Cordani M , Padroni C , Blandino G , Di Agostino S , Donadelli M. Mutant p53 stimulates chemoresistance of pancreatic adenocarcinoma cells to gemcitabine . Biochim Biophys Acta . 2015 ; 1853 (1): 89 ± 100 . https://doi.org/10.1016/j.bbamcr. 2014 . 10 .003 PMID: 25311384
38. Shi W , Meng Z , Chen Z , Hua Y , Gao H , Wang P , et al. RNA interference against MDM2 suppresses tumor growth and metastasis in pancreatic carcinoma SW1990HM cells . Mol Cell Biochem . 2014 ; 387 ( 1 ±2): 1±8 . https://doi.org/10.1007/s11010-011 -1208-4 PMID: 22200978
Wang W , Qin JJ , Voruganti S , Wang MH , Sharma H , Patil S , et al. Identification of a new class of MDM2 inhibitor that inhibits growth of orthotopic pancreatic tumors in mice . Gastroenterology . 2014 ; 147 ( 4 ): 893 ± 902 . https://doi.org/10.1053/j.gastro. 2014 . 07 .001 PMID: 25016295
40. Kimura H , Dobashi Y , Nojima T , Nakamura H , Yamamoto N , Tsuchiya H , et al. Utility of fluorescence in situ hybridization to detect MDM2 amplification in liposarcomas and their morphological mimics . Int J Clin Exp Pathol . 2013 ; 6 ( 7 ): 1306 ± 1316 . PMID: 23826411
41. Birnbaum DJ , AdeÂlaïde J , Mamessier E , Finetti P , Lagarde A , Monges G , et al. Genome profiling of pancreatic adenocarcinoma . Genes Chromosomes Cancer . 2011 ; 50 ( 6 ): 456 ± 465 . https://doi.org/10.1002/ gcc.20870 PMID: 21412932