A atividade dos receptores ativados por proliferadores de peroxissoma (PPAR) e receptor X hepático (LXR) são regulados por ácidos graxos. Entretanto, o papel do LNO2, um produto endógeno da nitração do ácido linoléico por espécies reativas derivadas de óxido nítrico (•NO), na via de sinalização que regula a ativação destes receptores ainda não está elucidada. Assim, considerando a propriedade do LNO2 como doador de •NO, nós investigamos a participação da via de sinalização p21Ras/Raf/ERK na ativação de PPAR e LXR por LNO2. Os resultados obtidos demonstraram que LNO2, na concentração de 0.01µM, foi um potente ativador de PPAR quando comparado ao ligante natural ácido linoléico, o qual apresentou ativação equivalente do PPAR na concentração de 10µM. O LNO2, contudo não teve efeito na ativação de LXR. LNO2 foi um potente ativador de p21Ras quando comparado ao ácido linoléico. A ativação de Ras ocorreu após 5 minutos de incubação com LNO2 em células parentais. Entretanto, em células transfectadas com p21RasC118S, o LNO2 não foi capaz de ativar Ras. A ativação de Ras e PPAR foi dependente da liberação de •NO a partir de LNO2, o que foi evidenciado na presença de C-PTIO, um seqüestrador de •NO. LNO2 ativou ERK, mas não demonstrou efeito relevante na ativação de p38 MAP kinase. A utilização de um inibidor específico de MEK, PD09895, inibiu a ativação de ERK induzida por LNO2, sugerindo que existe uma conexão entre ERK e a ativação de PPAR. Nós concluímos que a ativação do receptor nuclear PPAR por LNO2 é dependente de •NO e da via de sinalização p21Ras/Raf/ERK, a qual é capaz de ativar os subtipos α, &$946; e γ do PPAR, modulando, desse modo, a expressão de genes responsivos a este fator de transcrição. / Fatty acids bind to and regulate the activity of peroxissome proliferator-activated (PPAR) and liver X receptors (LXR). However, the role of LNO2, an endogenous product of the nitration of linoleic acid by nitric oxide (•NO)-derived reactive species, on signalling pathways regulating these nuclear receptors is poorly understood. Thus, considering the properties of LNO2 as •NO donor, we investigated the role of p21RasMAP kinases signaling pathway in the activation of PPARs and LXR by LNO2. LNO2 at physiologically relevant concentrations (0.01 µM) activates PPAR. By contrast, linoleic acid, a natural ligand for PPAR, only activated the receptor at much higher concentrations (10µM). However, it did not affect LXR activation. LNO2 is a more potent activator of p21 Ras than linoleic acid at the same conditions. Ras activation occurred within the first 5 minutes after LNO2 addition to parental cells. However, in p21RasC118s transfected cells, were unable to detect activation of Ras. Ras and PPAR activation depends on •NO released from LNO2 as evidenced by the inhibitory effect of C-PTIO, a •NO scavenger. LNO2 activated ERK but displayed no effects relevant on p38 MAP kinase. In addition, the use of specific inhibitors to MEK, PD09895, blocked PPAR activation and ERK phosphorylation by LNO2, suggesting a connection between ERK and the activation of PPAR. We conclude that LNO2 induced THP-1 cells activating Ras by S-nitrosation and recruiting the MAP kinase ERK, a downstream element of this signalling cascade and activated PPAR (α, β and γ).

A proteína P53 pode estar virtualmente alterada em todos os cânceres humanos e portanto, na ausência de mutação, uma possibilidade para a inativação da p53 é a formação de complexo com outras proteínas, tal como a proteína Mdm2. Estudos prévios realizados em nosso laboratório demonstraram a superexpressão de Mdm2 na ausência de expressão da proteína P53 em adenomas pleomórficos. O objetivo deste estudo foi analisar a expressão das proteínas Mdm2, P53, P21 e Akt em adenoma pleomórfico e o mioepitelioma através das técnicas de imunoistoquímica, western blotting e imunofluorescência. A superexpressão de Mdm2 e Akt foi encontrada na maioria das linhagens e lesões utilizadas neste estudo enquanto as proteínas P53 e P21 não demonstraram expressão nas neoplasias estudadas. As superexpressões das proteínas Mdm2 e Akt estão relacionadas à tumorigênese em neoplasias benignas de glândula salivar. / The P53 protein can be altered in virtually all human cancers and in the absence of mutations, P53 inactivation is possible via complex formation with others proteins, such as the Mdm2. Previous studies from our laboratory showed overexpression of mdm2 and lack of p53 expression in pleomorphic adenomas. The aim of this study was to analyze the expression of Mdm2, P53, P21 and Akt proteins in pleomorphic adenomas and myoepiteliomas by Western blotting, immunohistochemistry and immunofluorescence techniques. Overexpression of Mdm2 and Akt was present in the majority of cell lineages and tumors studied, while the expression of P53 and P21 proteins was considered absent. Overexpression of Mdm2 and Akt are related to the tumorigenesis of benign salivary gland neoplasms.

Skeletal muscle atrophy is a common, debilitating consequence of muscle disuse, malnutrition, critical illness, musculoskeletal conditions, neurological disease, cancer, and organ failure. Despite its prevalence, little is known about the molecular pathogenesis of this devastating condition due in large part to an incomplete understanding of the molecular mechanisms that drive the atrophy process. In previous studies, we identified the transcription factor ATF4 as a critical mediator of skeletal muscle atrophy. We found that ATF4 is necessary and sufficient for skeletal muscle atrophy during limb immobilization. However, ATF4 mKO mice were only partially protected from skeletal muscle atrophy during limb immobilization, indicating the existence of another pro-atrophy factor that acts independently of the ATF4 pathway. Using mouse models, we identify p53 as this ATF4-independent factor. We show that skeletal muscle atrophy increases p53 expression in skeletal muscle fibers. In addition, overexpression of p53 causes skeletal muscle atrophy. Further, p53 mKO mice are partially resistant to muscle atrophy during limb immobilization. Taken together, these data indicate that like ATF4, p53 is sufficient and required for skeletal muscle atrophy during limb immobilization. Importantly, overexpression of p53 induces muscle atrophy in the absence of ATF4, whereas ATF4-mediated muscle atrophy does not require p53. Furthermore, overexpression of p53 and ATF4 induces greater muscle atrophy than p53 or ATF4 alone. Moreover, skeletal muscle lacking both p53 and ATF4 is more resistant to skeletal muscle atrophy than muscle lacking either p53 or ATF4 alone. Taken together, these data indicate that p53 and ATF4 mediate distinct and additive mechanisms to skeletal muscle atrophy. However, the precise mechanism by which p53 and ATF4 cause skeletal muscle atrophy remained unclear. Using genome-wide expression arrays, we identify p21 as a skeletal muscle mRNA that is highly induced by p53 and ATF4 during limb immobilization. Further, overexpression of p21 causes skeletal muscle atrophy. In addition, p21 is required for muscle atrophy due to limb immobilization, p53, and ATF4. Collectively, these results identify p53 and ATF4 as critical and complementary mediators of skeletal muscle atrophy during limb immobilization, and discover p21 as an essential downstream mediator of the p53 and ATF4 pathways.

Skeletal muscle atrophy is a debilitating condition that commonly occurs as a secondary consequence of many acute and chronic medical conditions, including muscle disuse, heart and renal failure, starvation, cancer, HIV/AIDS, and aging. Though it leads to weakness, falls, and fractures, and reduces independence and quality of life for millions of Americans annually, no effective pharmacologic therapies for muscle atrophy exist. This is largely due to a poor understanding of the pathogenesis of skeletal muscle atrophy at a molecular level. In this thesis, I describe my studies into the molecular pathogenesis of skeletal muscle atrophy. Using mouse models, I showed that the gene encoding the pro-atrophy nuclear protein Gadd45a is regulated by distinct pathways after muscle denervation and fasting, and also identified a novel protein regulating skeletal muscle fiber size. First, we demonstrated that denervation-induced muscle atrophy, unlike atrophy mediated by fasting, does not require the bZIP transcription factor ATF4. However, the lysine deacetylase HDAC4 is sufficient to induce Gadd45a mRNA and necessary for Gadd45a mRNA induction after denervation, but not after fasting. Taken together, these data show that Gadd45a is a central convergence point for muscle atrophy caused by several stimuli, and also demonstrate that distinct pathways mediate Gadd45a induction in different models of skeletal muscle atrophy. Second, we identified spermine oxidase as a critical regulator of muscle fiber size. We observed that spermine oxidase mRNA and spermine oxidase protein were reduced by several distinct causes of muscle atrophy (i.e. immobilization, denervation, fasting, and aging). Furthermore, spermine oxidase overexpression increased muscle fiber size, while spermine oxidase knockdown caused muscle fiber atrophy. Restoring spermine oxidase expression significantly attenuated muscle atrophy after limb immobilization, denervation, and fasting. Finally, we identified p21 as a key upstream regulator of spermine oxidase expression, and spermine oxidase as a required mediator of p21-mediated skeletal muscle fiber atrophy. Collectively, these findings greatly advance our understanding of the molecular pathogenesis of skeletal muscle atrophy. These data demonstrate that Gadd45a is a convergence point for multiple pro-atrophy pathways and identify spermine oxidase as a novel therapeutic target for the treatment of skeletal muscle atrophy. These discoveries suggest several important new areas for future research, and further our understanding of this common, debilitating condition.

Le gène CDKN1A a été initialement décrit comme une cible transcriptionnelle de la protéineoncosuppressive p53. Son produit, p21Cip1 (p21), supprime l'activité des kinases dépendantes descyclines et de la protéine PCNA, ce qui en fait un puissant inhibiteur du cycle et de la proliférationcellulaires. En outre, p21 est fréquemment inactivée dans les cancers épithéliaux. Or, la progressionde ces tumeurs est associée à l'altération de l'organisation tissulaire, au processus invasif et à ladissémination métastatique. Ces phénomènes résultent des modifications cytosquelettiquesconduisant à la transformation des propriétés d'adhésion et de migration cellulaires. Pourtant, le rôlede p21 dans la dynamique cytosquelettique des cellules épithéliales humaines n'a jamais été adressé.Nous montrons ici que p21 contribue à l'adhésion et la migration normale des cellules épithélialesmammaires non transformées. Nos résultats montrent également que l'inactivation de p21 provoquela suppression de l'adhésion focale et des fibres de stress. Ce phénotype est caractérisé parl'inactivation de la GTPase Rho et l'activation de la cofiline, facteur de dépolymérisation de l'actine. Enoutre, la suppression de p21 provoque une désacétylation des microtubules associée à unedéstabilisation microtubulaire globale. La réduction de l'instabilité dynamique, par inhibition de ladésacétylase HDAC6, restaure partiellement l'étalement cellulaire et l'adhésion focale altérés parl'inactivation de p21. L'ensemble de nos données démontre que la régulation de la dynamiquecytosquelettique par p21 est nécessaire au contrôle de l'adhésion des cellules épithéliales humainesnon tumorales.

The common type of myxoid soft tissue sarcomas is myxofibrosarcoma. Clinically, increased tumor grading and staging are frequently observed in myxofibrosarcomas after relentless local recurrences, which may eventually lead to metastatic diseases. However, metastatic myxofibrosarcomas are often refractory to current treatment strategies and constitute the primary cause of sarcoma-related death. Immunohistochemistry staining was applied to analyze myxoid tumors of soft tissue in our previous studies, and p21 protein (Cdc42/Rac)-activated kinase 1 (PAK1) was identified to be significantly upregulated in myxoid soft tissue sarcomas. The PAK1 is a pivotal serine/threonine kinase, which integrates stimuli from various signaling pathways to regulate cell survival, mitosis and cytoskeletal remodeling, etc. We first examined the endogenous PAK1 mRNA and total PAK1 protein levels in various myxoid sarcoma cell lines, including OH931, NMFH1 and NMFH2. This initial screening detected that upregulated PAK1 expression in OH931 and NMFH1, whereas downregulated PAK1 in NMFH2 cells. By wound healing and matrigel transwell assay, we further found that transfection of the expression plasmid carrying wild-type PAK1 gene or PAK1 T423E mutant promoted cell migration and invasion abilities in NMFH2 cells. On the other hand, knockdown of the PAK1 gene by short hairpin RNA interference inhibited the migration rate and invasion ability in NMFH1 cells. By 5-bromo-2-deoxyuridine assay and colony formation assay, we found that either exogenous expression of PAK1 protein or knockdown of PAK1 gene affected cell proliferation and transformation. Interestingly, immunofluorescence demonstrated that treatment with hepatocyte growth factor induced phosphorylation of PAK1 (Thr212) and promoted its nuclear import in NMFH2 cells. In summary, PAK1 plays oncogenic roles in myxoid sarcoma carcinogenesis.

Les principaux régulateurs de la prolifération cellulaire sont les Cdk (cyclin dependent kinase), dont l'activité dépend de leur association avec leurs partenaires, les cyclines. Le contrôle du niveau d'expression des cyclines représente le premier mécanisme par lequel l'activité des Cdk est régulée. Cette régulation est essentielle pour maintenir l'équilibre prolifération/différenciation de la peau. Cependant, les mécanismes mis en jeu restent peu connus.<br />Nous avons montré que Brm, protéine des complexes de remodelage de la chromatine SWI/SNF, est responsable de la répression de la cycline A par la mise en place ou le maintien de deux nucléosomes situés sur les sites d'initiation de la transcription. De plus, nous avons mis en évidence que l'absence de brm conduit à accélérer la progression des cellules dans le cycle cellulaire en jouant sur le déroulement de la phase S. Cependant, les cellules dépourvues de brm présentent également une mitose rallongée et des aberrations chromosomiques. Ceci pourrait être la conséquence de la dérégulation de trois oncogènes : c-myc, cycline A et cycline E et pourrait expliquer pourquoi brm est mutée dans de nombreux cancers.<br />Enfin, nous avons montré que l'entrée en différenciation des kératinocytes s'accompagne d'une forte expression de p21 qui entraîne un arrêt en G2/M en inhibant les complexes Cycline A/Cdk. Cependant, les kératinocytes en différenciation ne peuvent maintenir cet arrêt et entre dans un état G1 à 4N, caractérisé par une forte expression de la Cycline E et l'absence de Cyclines de G2/M.

Noncovalent factors, such as shape complementarity and electrostatic driving forces, almost exclusively cause the affinity and specificity for which two or more biological macromolecules organize into a functioning complex. The human oncoprotein p21Ras (Ras) and a structurally identical but functionally distant analog, Rap1A (Rap), exhibit high selectivity and specificity when binding to downstream effector proteins that cannot be explained through structural analysis alone. Both Ras and Rap bind to Ral guanine nucleotide dissociation stimulator (RalGDS) with affinities that differ tenfold instigating diverse cellular functions; it is hypothesized that this specificity of RalGDS to discriminate between GTPases is largely electrostatic in nature. To investigate this hypothesis, electrostatic fields at the binding interface between mutants of RalGDS bound to Rap or Ras are measured using vibrational Stark effect (VSE) spectroscopy, in which spectral shifts of a probe oscillator’s energy is related directly to that probe’s local electrostatic environment and measured by Fourier transform infrared spectroscopy (FTIR). After calibration, the probe is inserted into a known position in RalGDS where it becomes a highly local, sensitive, and directional reporter of fluctuations of the protein’s electrostatic field caused by structural or chemical perturbations of the protein. The thiocyanate (SCN) vibrational spectroscopic probe was systematically incorporated throughout the binding interface of RalGDS. Changes in the absorption energy of the thiocyanate probe upon binding were directly related to the change of the strength of the local electrostatic field in the immediate vicinity of the probe, thereby creating a comprehensive library of the binding interactions between Ras-RalGDS and Rap-RalGDS. The measured SCN absorption energy on the monomeric protein was compared with solvent-accessible surface area (SASA) calculations with the results highlighting the complex structural and electrostatic nature of protein-water interface. Additional SASA studies of the nine RalGDS mutants that bind to Ras or Rap verified that experimentally measured thiocyanate absorption energies are negatively correlated with exposure to water at the protein-water interface. By changing the solvent composition, we confirmed that the cyanocysteine residues that are more exposed to solvent experienced a large difference in absorption energy. These studies reinforce the hypothesis that differences in the electrostatic environment at the binding interfaces of Ras and Rap are responsible for discriminating binding partners. / text

Thesis (Ph. D.)--University of Washington, 1997. / Vita. Includes bibliographical references (leaves [74]-91).

Κατά τη διάρκεια του κυτταρικού κύκλου ένας από τους σημαντικότερους μηχανισμούς ρύθμισης της ομοιόστασης των πρωτεϊνικών μορίων είναι η ελεγχόμενη στο χώρο και στο χρόνο αποδόμηση τους. Οποιαδήποτε ανωμαλία στη ρύθμιση των μηχανισμών αποδόμησης των πρωτεϊνών μπορεί να προκαλέσει σημαντική βλάβη στη λειτουργία του κυττάρου και να οδηγήσει σε κακοήθη εξαλλαγή του. Η αποδόμηση των κύκλινο-εξατώμενων αναστολέων του κυτταρικού κύκλου, p27 και p21, έχει δειχθεί να αυξάνει κατά την καρκινογένεση. Αν και η πρωτεόλυση των p27 και p21 έχει δειχθεί να μεσολαβείται από διαφορετικά μονοπάτια ωστόσο το περισσότερο γνωστό και καλύτερα τεκμηριωμένο είναι το μονοπάτι μέσω του συμπλόκου SCF (Skp2-cul1-Skp1) Ε3 λιγάσης της ουβικουιτίνης. Αρχικά οι πρωτεΐνες p27 και p21 φωσφορυλιώνονται από το σύμπλκο κυκλίνης Ε/Α-CDK2 στη θρεονίνη 187 (Thr187) και στη σερίνη 130 (Ser130) αντίστοιχα, και εν συνεχεία αναγνωρίζονται από το σύμπλοκο SCFSkp2, το οποίο διευκολύνει την πολύ-ουβικουιτινυλίωση και την αποδόμηση των πρωτεϊνών στο πρωτεόσωμα. Στη παρούσα εργασία μελετήθηκε η έκφραση των πρωτεϊνών: p27, p21, Skp2, cul1, pThr187-p27, κυκλίνη Α, κυκλίνη Ε και CDK2 σε 135 περιπτώσεις Β-λεμφωμάτων με Επιθετική [66 ΔΛΜΒΚ (35 λεμφαδενικά και 31 εξωλεμφαδενικά), 13 ΛΚΜ (8 κλασσικά και 5 βλαστικά) και 5 με ΛΛ βαθμού 3α/β)] και Ήπια βιολογική συμπεριφορά [9 ΛΛ (3 βαθμού 1, 6 βαθμού 2), 20 ΛΟΖ (12 λεμφαδενικά 6 εξωλεμφαδενικά, 2 σπληνικά) και 22 ΛΜΚ]. Η έκφραση της p27 παρατηρήθηκε μέγιστη στα ήπια λεμφώματα. Ωστόσο σε αρκετές περιπτώσεις επιθετικού λεμφώματος, κυρίως ΔΛΜΒΚ (~40%, >30%), η έκφραση της p27 βρέθηκε αυξημένη. Επιπλέον, σε όλες τις περιπτώσεις λεμφωμάτων εκτός του λεμφοζιδιακού και της οριακής ζώνης, παρουσιάστηκε αδυναμία αρνητικής συσχέτισης μεταξύ της p27 και της Skp2. Η μέγιστη έκφραση της p21, αντίθετα με την p27, παρατηρήθηκε στα ΔΛΜΒΚ, γεγονός που συνδέει την p21 με επιθετικότερη νόσο. Η πρωτεΐνη p21 δεν έδειξε να συσχετίζεται με τις πρωτεΐνες που είναι υπεύθυνες για την αποδόμηση της, γεγονός που πιθανόν να υποδεικνύει ότι στα Β-λεμφώματα που μελετήθηκαν η p21 δεν πρωτεολύεται από το σύμπλοκο SCFSkp2. Η υπερέκφραση της Skp2 στα ΔΛΜΒΚ, ΛΚΜ (κυρίως βλαστικά) και ΛΛ (βαθμού 3) καθώς και η ισχυρή θετική συσχέτιση με το δείκτη πολλαπλασιασμού, την κυκλίνη Α και τη CDK2 προσδίδουν στη πρωτεΐνη χαρακτηριστικά δείκτη επιθετικότητας. H cul1 έδειξε τα υψηλότερα επίπεδα έκφρασης και μία ισχυρή θετική συσχέτιση με την Skp2 στα ΔΛΜΒΚ, υποδεικνύοντας την παρουσία ενεργού SCF συμπλόκου, ωστόσο δεν παρατηρήθηκε παρόμοια συσχέτιση στους άλλους τύπους λεμφώματος. Υπερέκφραση της φωσφορυλιωμένης μορφής της p27 (pThr187-p27), δείχθηκε στα επιθετικότερα λεμφώματα. Επιπλέον, ισχυρή θετική συσχέτιση με το δείκτη πολλαπλασιασμού έδειξε η pThr187-p27, σε όλους τους τύπους λεμφώματος, δείχνοντας μία πιθανή σύνδεση της pThr187-p27 με την επιθετικότητα της νόσου. Συσχέτιση των παραπάνω πρωτεϊνών με τα κλινικά και εργαστηριακά ευρήματα των των ασθενών δείχνουν ότι στα επιθετικά λεμφώματα η υπερέκφραση των Skp2 και pThr187-p27 συνδέεται με βραχύτερο διάστημα ελεύθερο νόσο, ενώ η υπερέκφραση της pThr187-p27 έδειξε να συνδέεται και με πτωχότερη ολική επιβίωση. Επίσης κατά την πολυπαραγοντική ανάλυση, δείχθηκε για πρώτη φορά ότι η έκφραση της pThr187-p27 αποτελεί ανεξάρτητο προγνωστικό παράγοντα για τη συνολική επιβίωση όχι μόνο ανάμεσα στις υπό μελέτη πρωτεΐνες αλλά και σε συνάρτηση με τις κλινικές παραμέτρους στα επιθετικά Β-λεμφώματα / Cell cycle is tightly regulated by a functionally conserved group of proteins which together constitute the basic cell division machinery that controls cell cycle progression. Altered expression of these proteins are almost always detected in human cancer cells. However, aberrant expression of these proteins can be the cause of malignant transformation but also in some cases, can be the consequence of cancer progression. The cell cycle regulators p27 and p21 play a central role in the suppression of tumorigenesis in a variety of human cancers. Of particular importance for the development of human cancers is the ubiquitin dependent degradation of p27 and p21 by the proteasome. This pathway is controlled by many complexes, however the most well studied is the SCFSkp2 complex. p27 and p21 proteins are phosphorylated at a conserved Threonine (T187) and Serine (Ser130) residue by cyclin E/A-cdk2 complexes, respectively, and the Skp2 protein facilitates the polyubiquitylation of p27 and p21 by the SCF complex. In the present study was examined the immunoexpression of p27, p21, Skp2, cul1, pThr187-p27, cyclin Α, cyclin Ε and CDK2 in 135 cases with B-cell Lymphoma with aggressive [66 DLBCL (35 nodal and 31 extranodal), 13 MCL (8 classical and 5 blastic) and 5 FL grade 3α/β)] and indolent biological behaviour [9 FL (3 G1, 6 G2), 20 MZL (12 nodal, 6 extranodal, 2 splenic) and 22 SLL]. P27 was overexpressed in indolent B-cell lymphomas. However, many cases with aggressive B-cell lymphoma, mainly DLBCLs (~40%, >30%),, showed increased expression of p27. In addition, all lymphoma cases except the FLs and MZLs failed to show an inverse correlation between p27 and Skp2. The highest expression of p21 was observed in DLBCL, indicating that p21 expression is associated with more aggressive neoplasias. The levels of p21 expression did not correlate with Skp2 and cul1, indicating that SCFSkp2 complex might not be capable for p21 degradation in B-cell lymphomas. Overexpression of Skp2 in DLBCLs, MCLs (mainly blastic type) and FL (Grade 3), as well as the strong positive correlation with cyclin A and CDK2, indicate that Skp2 may be a putative biomarker of tumor aggressiveness. The expression of cul1 was higher in DLBCLs, and correlate well with the expression of Skp2, indicating the presence of active SCFSkp2 complex. However, a similar correlation was not observed in other lymphoma groups. The phosphorylated form of p27 (pThr187-p27) was overexpressed in aggressive cases. Furthermore, a strong positive correlation between pThr187-p27 and the proliferation index, was observed in all lymphoma cases. This correlation may indicate that pThr187-p27 could be used as a marker of tumor aggressiveness. The correlation of the studied proteins with the clinical and laboratory data showed that in the aggressive lymphomas the expression of Skp2 and pThr187-p27 is associated with poor disease free survival rate, and pThr187-p27 is also associated with shorter overall survival. In the present study, the multivariant cox analysis showed that the expression of pThr187-p27 is an independent prosgnostic factor for the overall survival among other clinical parameters.