Summary of the common molecular subtypes of breast cancer with their characteristics, disease prevalence and treatment response [6].
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Barely three months into the new year and we are happy to announce a monumental milestone reached - 150 million downloads.
\n\nThis achievement solidifies IntechOpen’s place as a pioneer in Open Access publishing and the home to some of the most relevant scientific research available through Open Access.
\n\nWe are so proud to have worked with so many bright minds throughout the years who have helped us spread knowledge through the power of Open Access and we look forward to continuing to support some of the greatest thinkers of our day.
\n\nThank you for making IntechOpen your place of learning, sharing, and discovery, and here’s to 150 million more!
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Tumorigenesis is a multistep process that involves accumulation of genetic mutations which confer a selective growth advantage to the cancer cells. However, an emerging area of research suggests that epigenetic changes complement these genetic mutation events and direct the cancer cells towards a full blown malignancy [1–3]. Epigenetic changes refer to the modifications that do not occur on the primary nucleotide sequence of DNA (genetic mutations) but rather affect chromatin structure and function and are reversible in nature. Epigenetic changes involve histone modifications by enzymes that can “write” marks on histone tails such as acetyl and methyl transferases, enzymes that can “erase” these marks such as demethylases and deacetylases and a group of proteins that can “read” the chromatin marks and recruit other proteins to alter gene expression [4].
\nA recent study in mammary epithelial cells that are on the road to tumorigenic transformation has revealed a coordinated series of events that alter DNA methylation and deregulation of histone marks across large regions of the chromatin [5], thus underlying the need to study these epigenetic modifications to address their diagnostic as well as therapeutic potential in the context of breast cancer. Breast cancer is the most common cause of cancer in women worldwide. It is a complex, heterogeneous disease, thus posing a challenge in the diagnosis and treatment of patients. At the molecular level, based on the gene signature obtained from cDNA microarrays and global mRNA expression studies, breast cancer has been classified into four basic types, namely Luminal A, Luminal B, HER2-enriched, and triple negative/basal-like subtype [6–10]. This classification is based on the molecular characteristics displayed by the tumor, such as hormone receptor status, additional marks such as cytokeratin 5 (CK5) and cell proliferation rate (Ki67 marker1 status; summarized in Table 1). These subtypes, along with displaying unique molecular signatures, also differ in their prognosis and response to treatments. Apart from the aforementioned mRNA markers, recent studies have highlighted the importance of miRNAs in subtyping breast tumors as well as providing directions for diagnosis, prognosis and therapy [11, 12].
Breast cancer molecular subtype | Characteristics | Prevalence | Treatment response and clinical outcome |
---|---|---|---|
Luminal A | ER positive and/or PR positive HER-2-negative Low Ki67 | 30–70% | Hormone therapy, chemotherapy; good prognosis and patient survival |
Luminal B | ER positive and/or PR positive HER-2 positive (or HER-2 negative with high Ki67) | 10–20% | Hormone therapy, chemotherapy; fairly high survival rates, though not as high as Luminal A |
HER-2 | ER negative PR negative HER-2 positive | 10–15% | Trastuzumab and anthracycline-based chemotherapy; generally poor prognosis |
Triple negative/basal/basal-like | ER negative PR negative HER-2 negative | 5–15% | Platinum-based chemotherapy and PARP inhibitors; generally poor prognosis |
Summary of the common molecular subtypes of breast cancer with their characteristics, disease prevalence and treatment response [6].
However, despite several years of study, a broad-spectrum curative therapy for patients with malignant breast cancer remains elusive. This chapter will focus on key epigenetic regulators including noncoding RNAs identified in breast cancer that affect the hormonal signaling pathways and provide a perspective on combinatorial drug treatments using drugs that target these epigenetic regulators along with tamoxifen, aromatase inhibitors and other conventional therapeutics in specific sub-types of breast cancer.
Each cell in our body contains the genetic material in the form of DNA, which is the essential blueprint required for all cellular functions. DNA is packaged into chromatin by wrapping around basic histone proteins to form nucleosomes. These nucleosomes are further condensed into the nucleus to form the chromatin by enzymes that catalyze posttranslational modifications on the histone tails. The chromatin serves to not only condense the DNA within the cellular nucleus but also to control how information in the DNA is retrieved [13]. The histone components of the nucleosomes include a pair of H2A-H2B dimers and a tetramer of H3 and H4 to form the histone octamer around which the DNA is wound. These core histone proteins undergo a wide variety of posttranslational modifications such as acetylation, methylation, ubiquitination, phosphorylation, sumoylation, deamination and ribosylation, to name a few [14]. Since histones regulate accessibility of the DNA to transcription factors and DNA-modifying enzymes, alterations in the structure and posttranslational modifications of histones affects cellular gene expression to a great extent. Enzymes that covalently modify histones, acetyltransferases, methyltransferases and kinases, thus regulate multiple cellular processes that require accessibility to the DNA such as transcription, DNA replication and repair, apoptosis and cell cycle progression [15] (Figure 1). It is thus unsurprising that aberrant expression of many epigenetic regulators is prevalent in cancer tissues and contributes to the tumorigenesis process. By altering their epigenetic circuitry, cancer cells overcome the barrier of replicative senescence, accumulate genomic instability and catapult into an organized chaos that is the cancer epigenome (Figure 2). This makes it imperative to study the role and activity of proteins involved in epigenetic regulation of gene expression in the context of tumorigenesis. An important attribute of the chromatin-modifying enzymes is that the reactions catalyzed by these molecules such as histone acetylation are easily reversible and thus offer a therapeutic window of opportunity.
Epigenetic regulatory circuits in cells. A schematic representation of the epigenetic changes which regulate gene expression in normal cells.
Altered epigenetic pathways in tumorigenic cells. Schematic depiction of the altered epigenetic landscape in cancer cells. Orange nucleosome represents a variant nucleosome which could be introduced as a result of aberrant expression and function of chromatin remodelers. Altered expression and function of HATs, HDACs, DNMTs, KMTs and KDMTs (represented as different sized icons the figure) results in a widespread disarray of the epigenetic marks in cancer cells.
Emerging evidence indicates the role played by somatic mutations in the carcinogenesis process. A study by Stephens et al. highlighted the significance of these somatic mutations in the context of breast cancer [16]. Their study which sequenced the genome of 100 tumors for changes in somatic copy numbers and mutations identified point mutations and deletions in known cancer-causing “driver” genes characterized in the context of mammary carcinomas such as
This section will discuss the epigenetic signature, histone posttranslational modifications as well as DNA methylation changes, characterized thus far in the various subtypes of breast cancer and will provide an overview of targeting these chromatin modifiers as a potential combination therapy.
\nHistone acetyltransferases (HATs) conventionally play an important role in the activation of gene expression by resulting in an open chromatin structure thus providing access for the transcription machinery to the DNA. There are different families of HATs identified thus far and their role in acetylating histones has been extensively studied. Histone acetylation is regulated by the activity of HATs as well as the histone deacetylases (HDACs), which remove the acetyl moieties from lysine residues. The acetylated lysines are read by reader proteins containing bromodomains (such as BRD2, BRD3 and BRD4) and depending on the complexes recruited by these “readers,” gene expression can be switched on or off [4].
\nIn breast cancer, a study by Elsheikh et al. has identified low levels of the histone marks, H3K9Ac, H3K18Ac, H4K12Ac and H4K16Ac, to correlate with poorer prognosis and is associated with basal and HER2-positive tumors. This study has also detailed the status of methylation on H3, which will be discussed in the following sections [18]. This altered epigenetic signature is hypothesized to be due to altered enzymatic activities of the HATs and HDACs, which could be attributed to their dysregulated expression. There are multiple lines of evidence now to support this hypothesis. A ubiquitously expressed acetyltransferase p300/CBP, which is also known to function as transcriptional coactivator, was identified to be overexpressed in breast carcinoma as compared to adjacent normal mammary epithelia. Further, this study also showed that higher expression of p300 as studied by immunohistochemistry from a tissue microarray correlates with poorer prognosis-free survival and increased tumor recurrence [19]. However, it is unclear whether the role of p300 as a histone acetyltransferase or a lysine acetyltransferase (acetylating other non-histone proteins) is involved in this function and remains an interesting avenue for future studies.
\nAnother acetyltransferase, TIP60, belonging to the MYST (MOZ, Ybf1, Sas2, TIP60) family of acetyltransferases is known to undergo mono-allelic losses in breast carcinomas as well as in head and neck tumors [20]. Low nuclear expression of TIP60 as evidenced by IHC correlates with higher tumor grade in breast cancer [20], suggestive of a tumor suppressive role played by this epigenetic regulator. One of the histone targets of TIP60 is the acetylation of Histone H4 at K16. A significant global reduction in histone H4 acetylation and lysine trimethylation has been observed across most cancer types including breast cancer [21]. This loss of monoacetylation was identified to be due to a reduction in the acetylation status of K16 and not the other putative mono-acetylated lysine on Histone H4 (K5, K8, K12 which are targets of p300/CBP). Other acetyltransferases capable of acetylating K16 on H4 are MOZ (monocytic leukemic zinc finger), MOF (male absent on the first) and MORF (MOZ-related factor). This study also identified the sequence specific loss of recruitment of MOZ, MOF, MORF in cancer cells as compared to the normal cells to the DNA repetitive elements associated with loss of H4K16 acetylation (H4K16Ac) and H4K20 trimethylation (H4K20me3) [21]. In addition, independent studies have identified MOF mRNA and protein expression to be downregulated in breast carcinomas, and this was correlated with the reduced level of H4K16Ac acetylation in these tested primary breast carcinomas [22].
\nThe dysregulated histone acetylation in cancer can also be explained by changes in expression and function of histone deacetylases (HDACs). In breast cancer, HDAC1, HDAC2 and HDAC3 are identified to be differentially expressed as compared to the normal tissue and overexpression of HDAC2 and HDAC3 strongly correlates with a more aggressive tumor type, that is, negative hormone status [23]. This offers the opportunity of treating breast cancers with inhibitors of HDAC to restore acetylation level and suppress the tumorigenesis, and this approach will be detailed in the last part of this section which addresses the therapeutic implication of targeting the epigenetic regulators.
Histones can be methylated (mono, di or tri) by enzymes that catalyze the transfer of methyl moiety to the lysine or arginine residues on the histone tails. The enzymes involved are known as histone methyltransferases (HMTs), while another class of enzymes, the histone demethylases (HDMs), is involved in erasing the methyl groups from the histone tails. The dynamic regulation between the HMTs and HDMs regulates the methylation status in the cells, thereby regulating cellular gene expression.
\nStudies have identified widespread changes in histone methylation in cancer cells as compared to the nontumorigenic counterparts. There is a global reduction in H4K20me3 in multiple cancer types including breast cancer [21]. Global reduction in H4K20me3 was also observed in human breast cancer cell lines compared to the nontumorigenic cells [24]. Further, in an established model of breast cancer in rats, there was a global decrease in H3K9 trimethylation (H3K9me3) and H4K20me3 indicating that these epigenetic dysregulations play an important role in tumorigenesis [25]. In addition, another study has identified low levels of histone methyl marks, H3K4 dimethylation (H3K4me2), H4K20me3 and H4 Arginine dimethylation (H4R3me2) in human tumors, and these were found to correlate with poorer prognosis and more aggressive subtypes of breast cancer such as Luminal and HER2-positive tumors [18]. These global alterations in the level of methylation on histones are suggestive of an imbalance in the expression of methyltransferases as well as the demethylases.
\nIn support of this notion, a variety of histone methyltransferases have been identified to be aberrantly expressed in breast tumors. Frequent overexpression and amplification of the histone methyltransferase NSD3L have been observed in mammary carcinomas, and depletion of this enzyme decreased the invasiveness of breast cancer cells highlighting its potential as an oncogene. However, the targets of NSD3L-affecting tumorigenesis have not been elucidated in detail [26, 27].
\nEnhancer of zeste 2 (EZH2) a methyltransferase that is a part of the Polycomb Repressive Complex 2 (PRC2) is found to be overexpressed in breast cancer, both at mRNA and protein level. The high expression of EZH2 is correlated with more aggressive cancer and a poor prognosis for patients. Overexpression of EZH2 in normal breast epithelia promotes anchorage independent growth, cell invasion, characteristics of a neoplastic phenotype in these cells, which is dependent on the suppressor of variegation 3-9 (Su(var)3-9), enhancer of zeste (E(z)), and trithorax (Trx) (SET) domain of EZH2 and HDAC activity [28]. This study paved the way for many other groups to investigate the role of EZH2 enzymatic activity mediated by the SET domain, conventionally known to silence gene expression, in the context of breast carcinomas. H3K27 di and tri methylation are characteristic of Polycomb Group (PcG) target genes and are associated with transcriptional silencing. The PRC2 complex of which EZH2 is the catalytic subunit with the other members being EED and Suz12 is involved in dimethylation and trimethylation of H3K27. The SET domain of EZH2 can function as an N methyltransferase, that is, EZH2 by utilizing S-adenosyl methionine (SAM) as a cofactor can add methyl groups to the lysine residues of substrate proteins. SET domain containing methyltransferases bind SAM and the substrate on opposite sides of the active site of the enzyme, thus SAM can dissociate without interrupting substrate binding to enzyme, resulting in multiple methylations on the lysine residues [29, 30]. In breast cancer cell lines, increased EZH2 expression resulted in the down-regulation of a tumor suppressor, RUNX3. This was identified through chromatin immunoprecipitation to be due to the H3K27me3 at RUNX3 promoter and associated HDAC1, since depletion of EZH2 resulted in the loss of H3K27me3 and HDAC1 from this promoter and increased expression of RUNX3, which was associated with significantly lesser cell growth as compared to the siRNA control [31]. In addition, EZH2 also results in down-regulation of another potential tumor suppressor, FOXC1, a transcription factor that has a role in differentiation and reduces cell migration and invasion. By trimethylating H3K27 at the FOXC1 promoter, EZH2 shuts down the expression of this transcription factor in a highly metastatic breast cancer cell line, MDA-MB-231 [32]. EZH2 is also known to repress RAD51, a protein involved in DNA repair and
JARID1C, a histone demethylase, is also known to be upregulated and correlates with increased metastasis in breast cancer lesions compared to the normal counterparts. Mechanistically, JARID1C by modulating H3K4me3 at the promoter of breast cancer metastasis suppressor 1 (
Phosphorylation of histones is another posttranslational modification, which occurs on histone tails and involves the kinase enzymatic activity. Serine, threonine and tyrosine residues on histone tails are known to be phosphorylated. H3S10 phosphorylation which marks the entry of the cell into mitosis is catalyzed by the enzyme Aurora B Kinase. Elevated expression of this kinase in several cancers is correlated with a poor prognosis for survival; however, it is not determined if this is due to the phosphorylation of H3S10 resulting in increased proliferative ability of cancer cells [39]. Ubiquitination is yet another posttranslational modification found on histones. Mono-ubiquitination of H2B (H2Bub1) is found to be globally reduced, and this is true in the context of breast cancer as well. Proteasome inhibition can reduce ERα-mediated transcription, and this was due to reduction in H2Bub1 levels, which correlated with reduced transcription of ER target genes [40].
The chromatin compacts the DNA into the nucleus, and this regulates the accessibility of the wound DNA to transcription and repair machinery. One of the ways through which the chromatin is regulated has been discussed in the preceding section and involves extensive posttranslational modifications on histone tails. Apart from this, the locus-specific DNA methylation status can help in the recruitment of enzymes that alter chromatin structure, and this has also been discussed. Another way to regulate chromatin structure and function is by physically altering the nucleosome location or composition, and this process is known as chromatin remodeling. The groups of enzymes involved in restructuring the chromatin by this mechanism are referred to as chromatin remodelers and are further classified into different families depending on the associated cofactors. All chromatin remodelers utilize the energy of ATP hydrolysis to catalyze the reactions that affect histone-DNA interactions [41].
\nRemodelers are involved in mobilizing nucleosomes across the genome and regulate chromatin organization. They facilitate proper placement of nucleosomes whenever the DNA is accessed, for instance, before and after replication, repair and transcription. Remodelers also slide or evict nucleosomes and can replace them with a nucleosome that contains a histone variant. A common example is the histone variant H2AZ found flanking the transcription start site [41]. All these functions of remodelers suggest the important underlying role played by this group of epigenetic regulators in controlling basic cellular processes such as transcription, chromatin assembly and DNA repair. Thus, it is not surprising that the altered expression or localization of these chromatin remodelers is correlated with tumorigenesis.
\nThere are several families of chromatin remodelers such as SWI/SNF, INO80 and CHD complexes, all of which are implicated in different cellular processes. Mutations in the SWI/SNF family of chromatin remodelers are found in about 20% of cancers, and some of these mutations could have a gain-of-function phenotype while in the case of breast cancer as well as in leukemia, wild-type SWI/SNF complexes by their diverse protein interactions aid tumor progression [42]. The bipolar function of this important class of chromatin remodelers also implicates the dynamic range of functions of remodelers and the myriad of their cellular interacting partners, which assist their aberrant functions in cancer cells. In breast cancer, a member of the NuRD complex, a part of the CHD family of remodelers, is known to be aberrantly expressed. Metastasis-associated proteins (MTA-3) are associated with ER-positive breast cancer, and increased expression of these MTA-3 is correlated with increased ER expression as well as invasive behavior. MTA-3 can directly repress
ARID1A, a member of the human SWI/SNF complex, is known to undergo frequent mutations across many cancer types. In breast cancer,
Another member of the SWI/SNF complex, BAF155/SMARCC1 (
Other examples of SWI/SNF family implicated in breast carcinogenesis are the Brahma and Brahma-related gene 1 (
A genetic mutation in
DNA methylation is another form of epigenetic regulation that involves the addition of a methyl moiety to the 5′ cytosine of a CG dinucleotide, which are distributed across our genome and are enriched at the gene promoters to form the Cytosine preceding Guanine (CpG) islands. DNA methylation is conventionally associated with gene silencing due to the steric blocking of transcription factors by the methyl moieties, thereby preventing gene expression. In addition, methyl binding proteins such as MeCP2, MBD2 and MBD3 which can physically interact with both DNA methyltransferases as well as histone methyltransferases (Suv39h1 which adds H3K9me3), HDACs and Heterochromatin protein 1 (HP1), recruit this repressive complex to synergistically shut off gene expression of genes with methylated promoters [50, 51]. The enzymes involved in DNA methylation are the
Abnormal changes in DNA methylation patterns are widespread across all cancer types including the breast cancer genome. Paradoxically in cancer, there are two distinct aberrations—a global hypomethylation observed as a result of an increased expression of demethylases and gene-specific hypermethylation events possibly due to the inaccessibility of the demethylases to the chromatin structure, both of which could contribute to tumorigenesis [52, 53].
\nIn breast cancer too, a specific cohort of genes is known to be hypermethylated, and therefore, their expression is turned off. This happens at promoters of potential tumor suppressor genes involved in regulation of cellular proliferation, invasion, and metastasis. A few examples of such genes are
The importance of methylation in regulating gene expression in a cell- and tissue-specific manner becomes evident on analysis of breast tumor samples for DNA methylation. Different studies by performing methylation specific PCRs have described the concept of methylation index,3 which is a ratio of genes hypermethylated to the total number of genes studied. It is observed that a higher methylation index correlates with a poorer prognosis and increased risk of recurrence of breast cancer [55]. Of more clinical significance is the finding that promoter hypermethylation events can be detected from patient serum samples. In a study by Wong et al., the authors, from peripheral blood samples determined that
As discussed earlier, hypomethylation events in cancer are also associated with a poorer prognosis. The demethylation of tumor supportive genes that aid proliferation and metastasis such matrix metalloproteases-9 (MMP9) and urokinase plasminogen activator can in part explain this paradox about both hypomethylation and hypermethylation events in breast cancer increasing tumorigenic potential. Treatment of nonmetastatic breast cancer cells with demethylating agents increases their metastatic potential, while, in contrast, treatment with agents that reverse demethylation decreases the invasive capacity of breast cancer cells [58–60].
\nApart from 5-methylcytosine, other methylation modifications on DNA include 5-hydroxymethylcytosine (5hmC), 5-formylcytosine (5fC) and 5-carboxylcytosine (5caC), all of which are regulated by Ten-Eleven Translocation (TET) proteins. TET proteins, in an α-Ketoglutarate and Fe(II)-dependent manner, catalyze the oxidation of the methyl groups on DNA, and these modifications could also function as intermediates in the demethylation of DNA [61, 62]. There are three known TET members identified in mammals, which include TET1, TET2 and TET3. They vary in structure and thus catalyze the oxidation reactions with varying efficiencies [63]. Inactivating mutations in
In the context of breast cancer, 5hmC levels are known to be deregulated. An example is the lower level of 5hmC mark at the promoter of a prominent tumor suppressor, Leucine zipper, putative tumor suppressor 1 (
The complexity of epigenetic regulation by DNA methylation is evident from these numerous studies. All the studies indicate the possibility of using DNA methylation as well as DNA hydroxymethylation as predictive biomarker for breast cancer especially for early detection of these tumors. Evidence for this is provided by numerous studies which highlight that methylation signatures are more correlated with clinical patterns as compared to the gene expression and suggest a combination of these to expand the current classification and clinical prognosis predictions. Specifically, methylation pattern of promoters of
Breast cancer, especially the triple negative subtype, is highly aggressive and needs an exhaustive list of treatment options to be made available for the patients. Understanding the dysregulated epigenetic circuitry has now made it possible to search for cures targeting the reversible marks put by the epigenetic regulators. Furthermore, methylation and acetylation marks as discussed earlier have shown immense potential to serve as candidate biomarkers, highlighting the need to monitor their levels for early diagnosis and treatment. The use of these biomarkers and screening of patients for potential biomarkers also facilitates in improving the individualized therapy and personal medicine, moving away from the conventional “one size fits all” to cater to the needs of the individual patients.
\nCurrent treatment strategies for breast cancer include surgery for removal of local tumors, adjuvant therapy in the form of chemotherapy, hormone therapy and targeted therapy. Treatment of basal-like breast tumors involves treatment with EGFR inhibitors and PARP inhibitors [73]. However, they all suffer from drawbacks mainly due to unprecedented side effects of these drugs. The two most studied therapeutic agents, which regulate epigenetic factors, are DNA methylation inhibitors and histone deacetylase inhibitors and will be detailed in this section. The major challenge for “epi-drugs” is to recapitulate the efficient action from cell-based studies in the clinical context.
\nThe two most used DNA methylation inhibitors are 5′ Azacytidine (5-Aza) and 5-aza-2-deoxycytidine (decitabine). Treatment of ER-negative breast cancer cells with 5-Aza reactivates the expression of ER at both mRNA and protein level. In addition, preclinical evidence suggests a useful role for DNMT inhibitors (DNMTi) in breast cancer treatment. Nanomolar (nM) dose of DNMTi has resulted in reactivation of silenced tumor suppressors such as
HDAC inhibitors function by inhibiting the activity of the enzymes responsible for catalyzing the removal of acetyl moieties from proteins, the HDACs. HDACs are divided into four classes, and current HDACi therapy focuses on inhibitors for Class I and Class II HDACs that include HDACs 1–10. The only HDAC inhibitor that has FDA approval is Vorinostat. HDAC inhibitors result in increased acetylation of histones which is associated with reactivation of tumor suppressor genes such as p21 and p27 which in turn have the potential to inhibit tumor cell growth [76]. Vorinostat can inhibit the proliferation of breast cancer cells irrespective of their ER status. Treatment of vorinostat concomitantly with another HDACi, LAQ824, sensitizes ER positive cells to tamoxifen therapy by downregulating expression of phosphorylated and total Akt (also known as Protein Kinase B [PKB] and originally identified as an oncogene from the AKT-8 retrovirus). HDAC inhibitors such as Vorinostat used in combination can enhance the effect of tamoxifen in the hormonal strategies to treat breast cancer, whereas the mechanistic studies are still exploring the pathways involved in reversal of resistance to hormonal therapy. There are several ongoing phase II trials of combination of HDACs such as vorinostat, entinostat and valproic acid (VA) with tamoxifen, chemotherapeutic agents such as epirubicin and paclitaxel, which show promising results in treatment of the metastatic disease [75].
\nIn a notable exception to the use of HDAC inhibitors, a study found that HDAC inhibitor valproic acid (VA) stimulates the self-renewal and expansion of normal hematopoietic stem cells [77]. In addition to this, VA enables cells to be reprogrammed to induced pluripotent stem cells [81, 82]. VA was found to have a differential effect on breast cancer cells that were differentiated
Intriguingly, these epigenetic regulators and the key aberrantly regulated pathways in breast cancer including ERα signaling share a complex dynamic, which influences the treatment regime and also directs resistance to certain therapeutics. This interplay between epigenetic control and signaling from cell surface receptors has been detailed in the following section.
A cell’s response to external stimuli requires the activation of a signaling cascade. These signaling cascades can be either linear or multinodal where different signal transduction pathways converge resulting in the translocation and integration of these signals into the activation or repression of gene expression [78]. Signaling pathways crosstalk among each other to regulate the gene expression patterns by modulating downstream effectors such as transcription factors, cofactors and histone modifiers. This coordinated activation of signaling pathways impacts the epigenetic landscape and plays a major role in translating a signaling event into a long-lasting molecular and phenotypic change. Analyzing the relationship between cell signaling and epigenetics is of utmost importance, as it will help us extend our vision on how a cell is able to integrate information from external and/or internal stimuli to gene expression regulation through chromatin modifications.
\nThe combined action of a cell-type–specific transcription factor and signal effectors on regulatory elements of the genome is strongly influenced by the chromatin landscape of a given cell, resulting in the establishment of a dynamic interplay between signaling pathways and the epigenetic machinery leading to the development of different cancer types including breast cancer. Globally, most of the frequently mutated somatic genes are
In this section, we will discuss the interplay between signaling pathways and epigenetic regulators with special emphasis on estrogen receptor signaling. We will highlight how chromatin modifications triggered by extrinsic signaling in breast cancer play a critical role in pathological events leading to tumorigenesis.
\nEpigenetic changes can be defined as stable molecular alterations of a cellular phenotype that are heritable during somatic cell divisions but do not involve changes in the DNA sequence. Epigenetic regulation is critical in normal growth and development and closely coordinates the transcriptional expression of genes. Estrogen refers to a family of hormones responsible for the development and regulation of the female reproductive system and secondary sexual characteristics. Estrogen is produced by the ovaries and in smaller amounts by the adrenal cortex, testes, and fetoplacental unit [80]. Although estrogen is considered to be a female hormone, it is present in both sexes. Estrogen is found in three naturally occurring forms, such as estrone (E1), estradiol (E2) and estriol (E3). Another type of estrogen called estetrol (E4) is produced only during pregnancy. The steroid 17β-estradiol is the most potent and prevalent estrogen among the group. Estrogen is known to play an important role in a variety of biological processes. It is involved in growth, differentiation, development of brain and has an important role in reproduction [87]. Estrogen plays an important role in controlling hormonal effect; therefore, high levels of estrogen increase the risk of the development of breast cancer as high levels increase the transcription of genes known to be involved in the cell cycle regulation and metabolism pathways [88, 89].
\nEstrogen diffuses across the cell membrane where it binds and activates its receptor, the estrogen receptor (ER) that plays an important role in the action of estrogen. The biological effects of estrogen are mediated by its binding to the structurally and functionally distinct estrogen receptors (ERα and ERβ) [81]. ERα is a member of the steroid/thyroid hormone and vitamin A/D nuclear receptor super family [82]. ERα plays a role in regulation of genes in a diverse set of target cells that are involved in the estrogen-activated pathway and is therefore also referred to as a nuclear receptor that is activated by ligand. In addition to playing a role in normal development, ERα and its ligand 17β-estradiol have been known to be involved and are implicated in the progression of breast cancer [91]. The function of ERβ has been detailed recently; however, studies to determine its role in breast cancer development and/or prognosis are still ongoing. The role of ERβ in breast cancer remains elusive, but the presence of ERα at the time of diagnosis is used as an indication for endocrine therapy. Pathological estrogens have been associated with a higher risk of breast cancer as estrogen stimulation induces modifications of histones at the promoter region of ERα gene such as phosphorylation, methylation and acetylation by interacting with various enzymes of the epigenetic pathway that induces these histone modifications [88, 92]. These enzymes if deregulated lead to neoplastic transformation driven by ERα [88].
\nThe transcriptional outcome of ERα is regulated by a dynamic interaction of histone-modifying enzymes and associated coregulators. The multiprotein complexes containing ERα, its coactivators such as p300/CREB-binding protein (p300/CBP), p300/CBP-associated factor (PCAF) [83] and histone-modifying enzymes such as acetylases/deacetylases and methylases/demethylases assemble in response to hormone binding, resulting in transcriptional regulation [84]. ERα exerts a positive feedback loop on expression of
ERα signaling pathway has traditionally been known to be involved in the activation of genes involved in transcription; however, recent observations using experimental techniques such as microarray and ChIP have found that in transcriptome of more than half of ERα target genes regulated by ERα are repressed [100]. Different chromatin modifications at the ERα target genes as well as recruitment of different regulators of transcription may account for differential regulation by ERα. One of the examples of this regulation is the repressor of estrogen receptor activity (REA) and its binding partner EZH2. EZH2 is an important corepressor that is upregulated during the progression of different cancers, a process accompanied by the silencing of various genes. Interestingly, EZH2-mediated repression of cellular genes was attenuated on inhibition of histone deacetylase activity, implying a dependence of EZH2 targets on acetylation status of histones as well as chromatin remodeling [87]. In another study by Jene-Sanz et al
ERα also modifies chromatin organization by affecting the acetylation and deacetylation of conserved lysine residues present in histone tails. Specifically, the coactivators of ERα possess histone acetyl transferase activity and are known to associate with and modulate functions of specific acetyl transferases. In addition, ERα-mediated deacetylation is accomplished by recruitment of histone deacetylases (HDACs), which are recruited indirectly to ERα target genes through multisubunit corepressor complexes. ERα also utilizes corepressor complexes such as nuclear receptor corepressor (NCOR) and silencing mediator of retinoid and thyroid hormone receptors (SMRT) that associate with histone deacetylases [90]. Studies employing siRNA targeting histone deacetylases and corepressors indicated that one such histone deacetylase, HDAC6 functions with a corepressor, ligand-dependent corepressor (LCOR) on some ERα target genes as part of a feedback loop to regulate estrogen-dependent gene regulation in breast cancer cells [91]. The expression levels of HDAC6 correlate with better prognosis and response to endocrine therapy in breast cancer patients. Thus, ERα is known to achieve several histone modifications at target gene promoters using several coregulators.
\nStudies on ERα target gene regulation have introduced a new degree of complexity, wherein a combination of interactions between ERα and histone acetyltransferases, histone deacetylases, histone methyltransferases, coactivators, corepressors and transcription factors reveals a complex histone code that regulates promoters involved in breast cancer cells proliferation. A dynamic process of DNA methylation is also known to be involved in the control of the cyclic expression of ERα target genes. In a significant fraction of breast cancers, the absence or loss of ER at the time of diagnosis or treatment is due to aberrant methylation of CpG islands, cytosine-guanine-rich areas that are located in the 5′ regulatory regions of the ERα gene [92, 93]. Methylation/demethylation of CpG sites on promoters following estrogen stimulation revealed the importance of DNA methyl-transferases control on estrogen-dependent gene expression. Interestingly, ERβ has been found to play a role in the establishment of new and stable methylation. All these results provide strong evidence that estrogen target gene expression is tightly regulated by multiple highly dynamic machinery affecting estrogen receptor in both a transcriptional and an epigenetic manner.
\nCurrent endocrine therapy for ERα-positive cancer involves modulating the ERα pathway using antiestrogens (AEs) or aromatase inhibitors (AIs). ERα’s ability to modulate epigenetic changes by regulating writers, erasers and readers of epigenetic modifications provides a unique therapeutic opportunity to design novel drugs and small molecular inhibitors for treating ERα-positive cancers [88] (Figure 3).
Eukaryotes utilize the chromatin landscape as its epigenetic template within the nucleus of living cells to promote gene transcription in response to environmental signals. Different classes of chromatin-associated enzymes or kinases that play important role in modulating chromatin structure within the human genome have been discovered recently. These signal transduction kinases play a pivotal role as chromatin-anchored proteins in eukaryotes, relaying signals from the cytoplasm to the nucleus and direct the association of chromatin-bound transcription complexes at activated targets in the nucleus [94]. These interactions serve to integrate the hormonal signals into a network of coordinated programs, and it is the outcome of this integration that specifies the nature, intensity and duration of the cellular response.
\nEstrogen and progesterone, two of the hormones known to play a role in breast cancer progression influence a variety of functions
Cross talk between signaling kinases and chromatin remodelers are critical for eliciting inducible transcriptional programs that include differentiation of cells, their ability to invade and migrate and to form cancer stem cells. Epigenetic approach targeting breast cancer stem cells (CSCs) may prove to be a good therapeutic option since not much has been known about the cross talk between these signaling kinases and chromatin remodelers. In an exception, one study found the chromatin-associated role of an evolutionarily conserved protein kinase C (PKC) family protein, PKC-θ. After nuclear translocation to the nucleus, PKC-θ plays a role in generating a T cell–induced immune response by influencing the transcription of genes involved in generating the response that also include some microRNAs [112]. Aberrant expression of this kinase may lead to uncontrolled cell growth leading to tumors, inflammatory disorders or an aggressive form of breast cancer leading to cancer metastasis [113].
\nPKC-θ is present mainly in ER-negative basal-like breast cancer lines, localized in the nucleus, and an increased nuclear PKC-θ results in epithelial to mesenchymal transition (EMT). Experiments such as ChIP using pan-PKC-θ-specific antibody was performed, and it was found that PKC-θ occupies the proximal promoter region of
Some other examples of signaling pathways influencing the epigenetic circuitry include the NF-κB pathway. Tumor necrosis factor α (TNF-α), an important effector of the NF-κB pathway, is known to induce expression of a lysine demethylase, KDM4D in macrophages and dendritic cells. Enzymes belonging to the demethylase family of KDM4 including KDM4D are overexpressed in breast cancer and affect cell proliferation and growth of these cells [98]. Another lysine demethylase of KDM4 family, KDM4A, has been known to be involved in transcriptional regulation, where it may either stimulate or repress gene transcription [100]. The latter function involves the association with nuclear receptor corepressor complex or association with histone deacetylases. KDM4A is also known to form complexes with ER and to stimulate its activity. Accordingly, depletion of KDM4A in ER-positive breast cancer cells leads to a decrease in the expression of ER targets such as the c-
In the case of ERα signaling, ER activates a number of kinases in the extranuclear compartment including protein kinase B (AKT) and extracellular signal-regulated protein kinase. In ER-positive breast cancers, mitogen-activated protein kinase (MAPK) pathway exerts an effect at the level of ER-induced transcription as well as at the level of the cell cycle regulation. Estrogen stimulates cell proliferation by activation of MAP kinase, either through rapid, nontranscription effects or by increasing growth factor production and consequently MAP kinase expression. Hormonal stimulation also promotes alterations in the phosphorylation of specific residues in histone tails
Sustained and increased hormone and growth factor receptor signaling in breast cancer cells contributes to resistance toward endocrine therapy. It has become important to modulate the signaling pathways so as to design an attractive strategy in overcoming potential resistance to endocrine therapy. In the case of breast cancer, down regulation of ERα expression is one of the mechanisms behind the acquisition of endocrine resistance. Histone deacetylases (HDACs) are important epigenetic regulators and are overexpressed in multiple cancers, including breast cancer. Specifically, histone deacetylase 1 (HDAC1) is an important epigenetic regulator involved in transcriptional regulation through modification of chromatin organization [82]. Although, HDACs are primarily known to repress gene expression as part of corepressor complexes, recent findings by Smith et al. have established a link between HDACs inhibition and repression of gene expression, suggesting that they might also function as coactivators [108]. In some cases, as for the regulation of ERα, HDACs inhibitors (HDACi) can have both positive and negative impact on transcription, depending on the cell context. In breast cancer cells, trichostatin A (TSA), a potent and reversible HDACi, produced a strong decrease in ERα accumulation independent of the presence or absence of ER ligands. The effect was dose dependent and was not restricted to TSA since a similar regulation was obtained with different HDACi, suberoylanilide hydroxamic acid (SAHA), which is structurally similar to TSA [109]. Regulation by TSA takes place at the transcriptional level and therefore the use of different HDACi decreases the expression of
The phosphoinositide 3-kinase (PI3K)/mammalian target of rapamycin (mTOR) pathway plays a critical role in multiple cellular functions including metabolism, proliferation, growth, and survival [113]. Studies have found PI3K/mTOR pathway to be a promising target in breast cancer [114]. The p70 S6 kinase (S6K1) is one of the best-characterized downstream targets of mTOR and plays an important role in protein translation and cell proliferation [115]. The mTOR inhibitor rapamycin, tested as an anticancer drug, rapidly dephosphorylates and inactivates S6K1. S6K1 is amplified in 10–30% of breast cancer cell lines, and its overexpression is associated with poor prognosis in breast cancer patients. PI3K inhibitors are able to regulate the expression of ERα through the activity of S6K1, as in cells that have S6K1 overexpression, rapamycin can increase both mRNA and protein levels of ERα, promoting the acetylation of its promoter [114].
\nIn some cases, HDAC1 activity and its binding to the
Regulation of epigenetic modifications by ERα
Mitogen-mediated HDAC1 phosphorylation and ERα transcriptional regulation. PI3K/mTOR pathway is activated by the RTK. Subsequently, S6K1 activation controls HDAC1 phosphorylation and thereby reduces acetylation of the ERα promoter and gene expression. In the case of cell starvation or when rapamycin is present, S6K1 is not active and is not able to phosphorylate HDAC1, promoting acetylation of ERα and its gene expression.
Corepressors are associated with deacetylase activity through the recruitment of HDACs, and these HDACs possess different functional domains responsible for deacetylase activity and interaction with other proteins. The amount of histone acetylation is therefore determined by an equilibrium between acetyltransferases and deacetylases, and that the ratio of corepressors to coactivators is the modulator of transcription in any given context [112]. The ligand-dependant activation of steroid hormones receptor regulates a variety of gene expression. Binding of an agonist leads to the activation of transcription, whereas an antagonist does the opposite, leading to inhibition. ERα bound to an anti-estrogen is unable to activate transcription, and this may be due to the recruitment of a repressor complex with HDAC activity [117] making the use anti-estrogens a feasible treatment option. However, the use of anti-estrogens is limited due to the associated side effects or the development of resistance. Moreover, HDAC activity has also been associated with gene silencing in some eukaryotes [117]. This gene silencing associated with HDAC binding at the
DNA methylation profiles of many genes have been linked with cancer initiation and progression [119]. As discussed earlier, in the case of DNA methylation, the most extensively studied mechanism of epigenetic control is global hypomethylation that leads to genome instability. At the same time, hypermethylation of promoter regions has been detected in a vast majority of tumor suppressor genes, which are strongly associated with tumor development. Hypermethylation events can occur early in tumorigenesis, involving the disruption of pathways that may predispose cells to malignant transformation. Gene silencing by hypermethylation of promoter genes is an important mechanism of carcinogenesis and has great potential for cancer prevention and therapy [120].
\nIn the case of breast cancer, the distribution of aberrantly methylated regions in the genome was found to be nonrandom and concentrated in relatively small genomic regions spanning up to several hundred kilobases. DNA hypermethylation also leads to aberrant regulation of the Wnt pathway in breast cancer, and an overstimulated Wnt signaling is a hallmark of different breast cancer tumor subtype [121]. Functional loss of negative Wnt regulators by epigenetic gene silencing, through DNA methylation of the tumor suppressor gene-associated promoters, has been found to contribute to the activation of aberrant WNT/β-catenin signaling [122]. Recent studies have also found impaired regulation of Wnt-antagonists by promoter hypermethylation in breast cancer. The growing list of epigenetically silenced WNT antagonists involved in human cancers indicates an important role for epigenetic inactivation events in tumor initiation and progression [123]. For examples, some Wnt proteins like WNT1, WNT2 and WNT3A are overexpressed in breast cancer, acting as oncogenic activators for canonical Wnt signaling [124]. In contrast, WNT5A acts as a tumor suppressor inhibiting tumor cell proliferation, antagonizing the WNT/β-catenin signaling and is thereby silenced by tumor-specific methylation [125]. In parallel, epigenetic inactivation of Wnt gene family members,
In addition, hypermethylation of the gene promoters of Wnt repressors was observed in various cell lines and tissues. The epithelial adhesion molecule E-cadherin (encoded by
Histone methylation is also known to play a key role in ERα-mediated activation of target genes. Recent studies found that histone demethylase KDM1 and ERα coregulator proline-, glutamic acid- and leucine-rich protein-1 (PELP1) plays a role in regulating histone methyl marks at ERα target genes [128]. PELP1 deregulation alters histone methylation at ERα target genes, contributing to hormone-driven tumor progression and resistance to treatment.
\nPatients who have ER-negative breast cancer seldom respond to endocrine therapy. One of the mechanisms to explain the loss of estrogen receptors expression is the methylation of cytosine at the 5′ regulatory region of the gene at the CpG island [133]. CpG island in ERα genes is highly methylated in ER-negative breast cancer but remain unmethylated in normal breast tissue and many ER-positive tumors as well as ER-positive cancer cell lines. This abnormal methylation pattern could account for transcriptional inactivation of the ER gene and subsequent hormone resistance in some human breast carcinomas. The functional importance of this finding is demonstrated by the fact that treatment of ER-negative human breast cancer cells with the demethylating agent, 5-aza-2′-deoxycytidine (AZA), led to reactivation of
An abundant chromosomal methyl CpG-binding protein was the first protein identified to link methylated DNA and a HDAC-containing transcriptionally repressive complex for gene silencing. More recently, the well-known maintenance methyltransferase, DNMT1, was found to interact physically with HDAC through its N terminus, thereby leading to a transcriptionally inactive complex that represses transcription [130]. Thus, the loss of ER expression in some breast cancers is associated with transcriptional repression through HDAC activity on the methylated
Recent studies also demonstrated that combination therapy involving HDAC inhibitors with DNA methyltransferase-1 (DNMT1) inhibition is synergistically effective in inducing apoptosis, differentiation and/or cell growth arrest in many cancer types including breast cancer. The combination was also synergistic in inducing re-expression of
The genetic signature identified from gene expression arrays has been incorporated into five different breast cancer prognostic platforms. As an improvement over the classical ER/PR/HER2 status, a panel of eight genes has been identified to classify the different breast cancer subtypes [131]. This panel includes the genes
Less than 2% of the human genome is translated into proteins. However, around 97% of the genome is transcribed, indicating that most of transcripts are not translated. Initially described as “transcriptional noise,” increasing evidence in the past few years has helped identify the regulatory functions of these “noncoding RNAs.” Noncoding RNAs are classified as small noncoding RNAs and long noncoding RNAs (lncRNAs). Small noncoding RNAs include miRNAs, small-interfering RNAs (siRNAs) and piwi-interacting RNAs measuring <200 nt in length. LncRNAs as the name suggests are “long,” ranging in length from 200 nt to 200 kb. Noncoding RNAs, both small and long, have been shown to regulate critical cellular functions such as transcriptional and posttranscriptional regulation which in turn modulate cell growth and differentiation [136]. Thus, it is no surprise that the aberrant expression of several noncoding RNAs has been observed and attributed to various diseases, including cancer.
\nGiven that noncoding RNAs comprise the vast majority of the human transcriptome and evidence of their essential role in gene regulation, it is important that this largely unexplored class of molecules be studied in the cancer context more closely. Some miRNAs and lncRNAs implicated in breast cancer initiation, progression and metastasis have been summarized in Figure 5.
MiRNAs and lncRNAs implicated in breast cancer initiation, progression and metastasis. Several miRNAs and lncRNAs controlling key oncogenes such as
MiRNAs are 18–24 nt in length noncoding RNA molecules that regulate gene expression by mRNAs degradation or inhibition of protein synthesis. MiRNAs have been shown to regulate numerous physiological processes such as differentiation, development and cell death as well as pathophysiological processes such as cancer biology, progression and prognosis. The aberrant expression of miRNAs in cancers can lead to an abnormal expression of their target genes thereby contributing to cancer etiology. Mounting evidence suggests a significant role of miRNAs in breast cancer classification, prognosis, as potential biomarkers for disease progression as well as treatment [137].
\nMammary gland epithelia comprise different cells including mammary stem cells (MaSCs)/basal cells, luminal progenitors and mature luminal cells. Several subtypes have been described among breast cancers, including claudin-low, basal, luminal, normal-like and ERBB2-enriched subtypes. These distinct molecular subtypes derive from different “cells of origin,” that is, cells that acquire the first oncogenic events in the initiation of breast tumorigenesis [138, 139]. The close association between cell lineage targeting and the resulting cancer phenotype suggests that lineage-restricted mechanisms that normally operate during the mammary gland development and homeostasis may contribute to tumorigenesis. Some miRNAs have been recently identified as potential “keepers” of this lineage-restricted identity. Thereby, aberrant expression of these miRNAs has been implicated in breast cancer molecular subtypes. Unique miRNA signatures characterize each step of the mammary differentiation hierarchy in the normal mammary gland (MaSCs/basal cells, luminal progenitors, mature luminal and stromal cells). MiRNA networks, also known as miRNome, are responsible for governing lineage commitment and cellular differentiation in the mammary tissue. MiRNAs act by targeting lineage-specific mRNAs thus regulating lineage-specific gene expression [140]. For example, the expression of miRNAs implied in MaSCs functions and pathways (WNT, NOTCH and Polycomb groups) such as miRNA-10a, miRNA-200a/b, miRNA-203 and miRNA-148a is restricted to the luminal subpopulation. Conversely, miRNA-146a, miRNA-221/222 and miRNA-205, known to regulate genes expressed in the luminal lineages (
Due to amplification of chromosomal regions of miRNAs, certain miRNAs may be overexpressed in cancer. If these miRNAs target TSGs, it would downregulate the TSGs leading to malignant growth. Hence, such potentially cancer-causing miRNAs are called oncomiRs. Conversely, oncosuppressor miRNA genes are frequently located in fragile loci, which are hotspots for deletions, mutations and promoter methylation. Genetic aberrations in such loci may result in downregulated miRNA expression and a concomitant increase in expression of oncogenes. These alternations of miRNA lead to tumor formation by inducing cell proliferation, invasion, loss of apoptosis, and angiogenesis. Thus, miRNAs can act both as oncogenes as well as TSGs [144, 145].
\nMiR-21 is a prominent oncomiR which is upregulated in breast cancer. The targets of miRNA-21 include
Let-7 is an important tumor suppressor miRNA with a decrease in expression in breast cancer. It targets the Ras pathway and regulates cell proliferation, adhesion and migration [149]. Targets of let-7 include
Metastasis is a complex multistep process, which includes the formation of tumors at sites distant from the primary site of the cancer. The term ‘metastamiR’ refers to as a metastasis-associated miRNA [152]. Several miRNAs such as miR-10b, miR-21, miR-30a, miR-30e, miR-125b, miR-141, miR-200b, miR-200c and miR-205 have been implicated in controlling metastasis in breast cancer [152]. Different metastamiRs have been shown to both promote and inhibit metastasis and regulate key steps in the metastatic program. Key players of the miRNA biogenesis pathway are also targeted by miRNAs thereby controlling metastasis. For instance, in breast cancer patients, it was found that miR-103/107 family targets
MiR-21 is a metastamiR targeting several TSGs in breast cancer. MiR-21 downregulates TSGs
Tavazoie et al
Among the two classes of estrogen receptors, the estrogen receptor-α (ERα) is overexpressed in approximately 75% of breast cancer cases. Increased signaling through ERα in mammary stem cell induces continuous replication of these cells, thereby increasing the risk of tumorigenesis. Tumor-suppressive miRNAs, such as miR-145 [168], miR-17/20 family, miR-193b, miR-206 and mir-302c, inhibit the ER signaling activated proliferation of mammary epithelia, by targeting either the ER receptor α or its coactivator AIB1 [169, 170]. MiR-206 is upregulated in ER-negative breast cancer but downregulated in ER-positive breast cancer [171]. MiR-17-5p targets AIB1, a coactivator of ERα [172]. The let-7 family of miRNAs is known to regulate the expression of both ERα66 and ERα36 (a novel short form of the ERα protein) in breast cancer. In breast cancer, let-7 is known to be downregulated, resulting in an upregulation of its targets, ERα66 and ERα36. ERα66 is predominantly nuclear in expression, where it regulates the transcription of
In breast cancer, ERBB2/HER2 is found to be amplified and/or overexpressed in up to 30% of patients, correlating with poor prognosis. Further, abnormal HER signaling induces cell proliferation [174]. HER2 and HER3 are targeted by miR-125a/b thereby inhibiting breast cancer growth [175]. HER3 receptor is also targeted by miR-205 inducing cell cycle arrest thereby inhibiting cell proliferation in breast cancer [176].
Human breast cancer stem cells (BCSCs) were first isolated by Al-Hajj et al
Several miRNAs have been described as controlling genomic stability of breast cancer cells. DNA double-strand breaks are lesions induced by ionizing radiation (IR) and can be efficiently repaired by DNA homologous recombination, a system that requires RAD51 recombinase. Overexpression of miR-155 in human breast cancer cells reduces the level of
Several studies have evaluated the role of specific miRNAs in breast cancer spread and survival. A screen identified five upregulated miRNAs (miR-30b, miR-148a, miR-150, miR-450a and miR-155) and six downregulated miRNAs (miR-24, miR-99a, miR-99b, miR-125b, miR-130b and miR-205) in primary breast cancer tumors versus corresponding lymph nodes [189]. Further, miR-373 was identified as being overexpressed in lymph-node metastases as compared to primary tumors [158], indicating the prognostic value of these miRNAs. Other miRNAs such as miR-187 [190], miR-27b and miR-103/107 [191] have also been found to have a prognostic value in breast cancer. Moreover, in ER-positive lymph node-negative (LNN) breast cancer patients, 12 miRNAs have been identified with early relapse versus late relapse (miR-205, miR-22, miR-516-3p, miR-7, miR-34b, miR-151, miR-210, miR-193b, miR-489 miR-449, miR-145 and miR-128a). Indeed, four of these 12 miRNAs (miR-7, miR-128a, miR-210 and miR-516-3p) have been positively linked to breast cancer aggressiveness while miR-210 has also been associated with metastatic ability of TNBC [192].
MiRNAs can serve as biomarkers for breast cancer based on their expression profile from RNA sequencing or tissue microarray assays. This can be achieved by mapping the global mRNA and miRNA expression from tumor tissues using high-throughput platforms, such as microarray chips and deep sequencing. Also, other techniques such as in-situ hybridization (ISH) can be used to detect mRNAs and miRNAs from fresh frozen or archived paraffin-embedded (FFPE) tumor tissue samples and protein expression can be evaluated using immunohistochemistry (IHC) [193]. The use of miRNA biomarkers has several advantages over protein coding genes: (1) miRNAs are more stable than mRNA and thus enable easier and reliable detection in FFPE samples (2) the presence of mere 1000 miRNAs makes the human miRNome much easier to screen and evaluate with less demanding bioinformatic analysis than the mRNA transcriptome [194]. The expression of a number of miRNAs closely correlates with the ER, PR and HER2 status in breast cancer, highlighting their use as biomarkers of disease progression and treatment response [141, 195]. MiR-210 has been validated as a prognostic biomarker in breast cancer since elevated miR-210 levels have been associated with poor outcome both in ER-positive and ER-negative cases [196]. Moreover, miR-210 has been developed to predict outcome in ER-positive cases that received adjuvant tamoxifen treatment for 5 years [197]. Other miRNA biomarkers include miR-205, which is used as a prognostic marker for the triple negative (TN) subtype since a positive correlation has been observed between miR-205 expression and favorable clinical outcome in TN cases [198].
Circulating miRNAs are ideal for clinical use, since they are highly stable and can be detected by a noninvasive manner in a blood sample. Serum or plasma miRNAs have been shown to be resistant to RNases and DNases thus are more stable than their cellular counter parts as well as mRNAs. Serum and plasma miRNAs can be easily isolated and quantified by RT-qPCR analysis. Moreover, specific miRNAs have also been demonstrated as being indicative of the breast cancer stage and/or ER/PR status. Numerous studies have documented the presence and quantified serum miRNAs from breast cancer patient samples. Asaga et al. assayed circulating miR-21 of 102 breast cancer patients and 20 healthy controls and found higher concentrations in these patients, especially in metastatic cases [199]. A study that quantitatively profiled the expression of seven miRNAs by real-time PCR, in tissue and blood samples of patients with breast cancer at different clinical stages and age-matched healthy individuals found that, while the expression of two miRNAs, miR-195 and let-7a was significantly higher in blood samples of breast cancer patients in comparison to control subjects, their circulating levels remarkably decreased after surgical resection in a subset of 29 cases, reaching levels comparable with control subjects [200, 201]. 26 circulating miRNAs with two-fold differential expression have been identified from the plasma of early stage breast cancer patients as compared to healthy controls [202].
\nThis mounting evidence generates the hypothesis for a signature of circulating miRNAs that could be a reliable biomarker for disease progression.
The most common miRNA therapeutic approach to inhibit the functions of miRNAs involve, targeting by using antisense miRNAs (antagomiRs) capable of knocking down these miRNAs. AntagomiRs are synthetic RNA molecules with favorable stability, resistance to RNase and pharmacologic properties that allow
Another approach of ablating miRNAs function is by using anti-miRNA oligonucleotides (AMOs) with 2-O-methyl groups and AMOs based on locked nucleic acid (LNA). AMOs are stable synthetic antisense oligonucleotides that can rapidly, selectively and irreversibly bind endogenous miRNAs, sequester and make them functionally inactive [206, 207]. Targeting oncomirs
In addition to knocking down miRNAs, upregulating the expression and activity of tumor suppressor miRNAs has potential in ameliorating breast cancer. Tumor suppressor miRNAs can be upregulated using miRNA mimics, which are synthetic molecules with short double-stranded synthetic oligonucleotides with sequence similarity to the particular miRNA under consideration. Overexpression of TS miRNAs using miRNA mimics has been shown to decrease cancer cell proliferation as well as induce chemosensitivity in breast cancer cell lines [208, 209].
Peptide nucleic acid (PNA) is an artificially synthesized oligonucleotide similar to DNA and RNA with a backbone consisting of repeats of 2-aminoethylglycine units [210]. The absence of phosphate groups renders a neutral charge to the PNA resulting in stronger and specific bonds between complementary PNA/DNA and PNA/RNA as compared to DNA/DNA or RNA/RNA. Owing to its synthetic nature, PNA is resistant to degradation by DNases and proteases leading to increased intracellular stability. Inactivation of miR-221 with PNA has been successful in aggressive breast cancer cell lines where miR-221 is overexpressed [211]. An anti-miR-221 PNA (R8-PNA-a221) conjugated with polyarginine-peptide (R8) could inactivate miR-221 and upregulate its target mRNA,
Long noncoding RNAs are endogenous RNA molecules with a mature length of more than 200 bases that do not code for functional proteins [213]. LncRNAs are epigenetic regulators, and they control gene expression at both the transcriptional and posttranscriptional levels. LncRNAs utilize a variety of mechanisms to regulate gene expression. They can recruit chromatin modifiers to impair access to targeted genes, they can act as scaffolds to assemble complexes that do not have interacting domains, they can interact with transcription factors to directly regulate gene expression, and they can serve as ‘miRNA sponges’ to trap miRNAs and regulate translation. Moreover, lncRNAs can be involved in the regulation of the expression of either their neighboring genes in cis or more distant genes in trans. LncRNAs act as coactivators, binding to transcription factors and enhancing their transcriptional activity [214].
\nH19 is among the first discovered lncRNAs and displays elevated expression in breast cancer [215]. This upregulation of expression is on account of increased binding of the transcription factor
HOTAIR is remarkably overexpressed in metastatic breast cancer. Upregulated HOTAIR in breast cancer cells provides a scaffold for
Urothelial cancer–associated 1 (UCA1) has been identified as an oncogene in breast cancer. Huang et al
MALAT1 (metastasis-associated lung adenocarcinoma transcript 1) or NEAT2 is a conserved nuclear noncoding RNA. The role of MALAT1 in breast cancer was controversial with reports indicating an oncogenic role by promoting cell proliferation, migration and invasion during breast cancer development [223] while a loss of MALAT1 was shown to promote EMT
SRA (steroid receptor RNA activator protein) gene generates both a coding as well as noncoding form of
Long stress-induced noncoding transcripts (LSINCTs) are a group of lncRNAs upregulated in breast cancer tumor tissues and cell lines. LSINCT5 has been shown to mediate cellular proliferation and is aided by lncNEAT-1 and
The lncRNAs that are downregulated in cancer and whose enforced expression is associated with the suppression of cell proliferation or cell death are termed as tumor suppressor lncRNAs.
\nMaternally expressed gene 3 (MEG3) is a tumor suppressor lncRNA with a decrease in expression in breast cancer, especially in the most aggressive TNBC subtype [232, 233]. MEG3 forms a RNA-DNA triplex structure to regulate the TGF-β pathway genes in breast cancer cells [234]. Since TGF-β is an inducer of EMT and invasiveness in breast cancer, inhibition of this pathway
GAS5 (growth arrest specific 5), in breast cancer, the expression level of GAS5 has been shown to be significantly reduced in tumor samples as compared to surrounding normal breast epithelia [235]. This decrease in GAS5 expression was observed in grade I and II breast cancer patients, indicating that the GAS5 downregulation is an early event in breast cancer progression. Further, this observation also indicates that GAS5 expression may be used as a biomarker to predict cancer stage. GAS5 has additional roles in drug resistance and will be discussed in the next part.
\nNKILA (NF-κB interacting lncRNA) binds to the NF-κB/IKB complex masking the phosphorylation site on IKB. Thus, IKK is unable to phosphorylate IKB resulting in IKB remaining bound to NF-κB, rendering NF-κB inactive. Expression of NKILA was observed to increase apoptosis and reduce invasion in MDA-MB-231 cells. Moreover, ectopic expression of NKILA decreases invasion and metastasis in breast cancer mouse models. Also, low NKILA expression is associated with poor patient prognosis [236]. Thus, inhibiting NF-κB through NKILA may be a mechanism to suppress breast cancer metastasis.
A number of lncRNAs have been implicated in maintaining stemness of breast cancer stem cells, thus promoting the spread of the cancer. The lncRNA HOTAIR has been shown to downregulate miRNA-7 associated with EMT and STAT3 activity [237]. The stemness factor SOX2 is upregulated by lncRNAs such as SOX2OT [238] and linc00617 [239]. Further, the self-renewal hedgehog (HH) pathway is activated by lncRNAs including lncRNA-Hh, which promotes CSCs maintenance through the activation of the HH-GLI1-SOX2 axis [240].
The lncRNA BCAR4 (breast cancer antiestrogen resistance 4) was identified from a screen designed to find mechanisms of estrogen resistance in breast cancer. Ectopic expression of BCAR4 in tamoxifen-sensitive ZR-75-1 breast cancer cells inhibited the cancer cell death mediated by tamoxifen, thereby making
Trastuzumab resistance is a major impediment in the clinical management of HER2-positive breast cancer. LncRNA GAS5 is downregulated in trastuzumab-treated breast cancer patient specimens, breast tumors in animal model
LncRNAs are being evaluated to have potential as breast cancer biomarkers, for breast cancer subtype classification and developing diagnostics and therapies, owing to their cell-type specific expression and correlation with patient response to chemotherapy. In a recent study, more than 1300 lncRNAs and 2800 mRNAs were found to be enriched in HER
Similar to miRNAs, circulating lncRNAs have been detected in plasma of cancer patients [246]. Recently, increased expression of lncRNA RP11-445H22.4 was detected in the plasma of breast cancer patients as compared to healthy individuals [247]. Further, HOTAIR DNA has been established as a potential biomarker for breast cancer as these patients displayed an upregulated expression of HOTAIR DNA as compared to healthy individuals. Moreover, the expression level of HOTAIR DNA correlated with the progress of the cancer [248].
\nIn conclusion, noncoding RNAs including miRNAs and lncRNAs represent a significant resource of novel cancer biomarkers including noninvasive circulating noncoding RNAs, prognostic aids and potential therapeutic targets to be used in conjunction with chemotherapy and adjuvant therapy. However, significant research is required, especially in the lncRNA field, to take these RNA molecules from the bench to bedside.
In summary, due to the advances in sequencing techniques and novel methods to study chromatin organization, the repertoire of information about the significant role played by the chromatin architecture, and its dysregulation in cancer cells is slowly being uncovered. The knowledge that the epigenetic landscape shapes the underlying genetic information is revolutionizing the field of cancer biology, the organized chaos in the genome of cancer cells now can be attributed at least in part to the aberrant regulation of chromatin modifiers and remodelers. The way in which cell-signaling pathways interact with epigenetic elements in the genome appears to be wide spread and complex. Integrating both networks is important not only for the comprehension of complex processes such as development, cell differentiation, cell regulation and cell plasticity but also toward the study of the relationship between signal transduction pathways and its targeted effect over diverse epigenetic processes. The therapeutic implication of targeting the epigenetic regulators has been discussed in detail and is the focus of many ongoing clinical trials as well as research. An integrative research platform will help in curating the information and translating the current epigenetic discoveries into useful diagnostic and therapeutic tools.
Abbreviation used | Full form |
---|---|
5caC | 5-carboxylcytosine |
5fC | 5-formylcytosine |
5hmC | 5-hydroxymethylcytosine |
AE | Antiestrogens |
AI | Aromatase inhibitor |
Amplified in breast cancer 1 | |
AKT8 virus oncogene cellular homolog | |
AMO | Anti-miRNA oligonucleotides |
Adenomatous polyposis coli | |
AT-rich interactive domain-containing protein 1 A/B | |
ASOs | Antisense oligonucleotides |
ATP | Adenosine triphosphate |
Aza | 5-aza-2′-deoxycytidine |
B-cell receptor-associated protein 31 | |
Breast cancer antiestrogen resistance 4 | |
Bcl-2 | B-Cell CLL/Lymphoma 2 |
B lymphoma Mo-MLV insertion region 1 homolog | |
Breast cancer gene 1 | |
Brahma-related gene 1 | |
Brahma | |
Breast cancer metastasis suppressor 1 | |
CARM1 | Coactivator associated arginine methyltransferase 1 |
CBP | Cyclic amp response element binding protein |
CD44 | Cluster of differentiation 44 |
E-cadherin | |
cDNA | Complimentary deoxyribonucleic acid |
CHD | Chromodomain helicase DNA-binding |
ChIP | Chromatin Immunoprecipitation |
CK5/CK14 | Cytokeratin-5/14 |
CoREST | RE1-silencing transcription factor corepressor complex |
CpG | Cytosine preceding Guanine |
CSC | Cancer stem cells |
CYP19A1 | Cytochrome P450 family 19 subfamily A member 1 |
DNA | Deoxyribonucleic acid |
DNMT | DNA methyltransferase |
Transcription factor activating adenovirus E2 gene | |
EED | Embryonic ectoderm development |
EGFR | Epidermal growth factor receptor |
ELF5 | E74-like ETS transcription factor 5 |
EMT | Epithelial mesenchymal transition |
ER | Estrogen receptor |
Erb-B2 receptor tyrosine kinase 2 | |
ERE | Estrogen-responsive elements |
ERK1/2 | Extracellular signal-regulated protein kinase 1/2 |
EZH2 | Enhancer of zeste 2 |
FFPE | Formalin-fixed paraffin-embedded |
Forkhead Box C1 | |
GAS5 | Growth Arrest Specific 5 |
GATA | Transcription factors that can bind to the DNA sequence (A/T)GATA(A/G). |
GATA3 | GATA binding protein 3 |
Glioma-associated oncogene homolog 1 (Zinc Finger Protein) | |
GSK3B | Glycogen synthase kinase 3 Beta |
HAT | Histone acetyltransferases |
HDAC | Histone deacetylases |
HER2 | Human epidermal growth factor receptor 2 |
HH | Hedgehog |
HMGA2 | High mobility group AT-hook2 |
HMT | Histone methyl transferase |
hnRNP I | Heterogeneous nuclear ribonucleoprotein I |
Homeobox A | |
HP1 | Heterochromatin Protein 1 |
HRE | Hormone-responsive elements |
IHC | Immunohistochemistry |
IL-6 | Interleukin 6 |
IR | Ionizing radiation |
IRAK1 | Interleukin 1 receptor-associated kinase 1 |
ISH | |
Integrin β 3 | |
JARID1C | Jumonji, AT Rich Interactive Domain 1C |
KDM/HDM | Lysine/histone demethylase |
KIT | v-kit Hardy–Zuckerman 4 feline sarcoma viral oncogene homolog |
LCOR | Ligand-dependent corepressor |
LNA | Locked nucleic acid |
lncRNAs | Long noncoding RNAs |
LNN | Lymph node-negative |
LSINCTs | Long stress-induced noncoding transcripts |
Leucine zipper, putative tumor suppressor 1 | |
MAL | MyD88-adapter-like |
Metastasis associated lung adenocarcinoma transcript 1 | |
MAPK | Mitogen-activated protein kinases |
MaSCs | Mammary stem cells |
MBD2/3 | Methyl-CpG binding domain protein 2/3 |
MeCP2 | Methyl-CpG binding protein 2 |
MEG3 | Maternally expressed gene 3 |
miRNA | microRNA |
MMP | Matrix metalloprotease |
MOF | Male absent on the first |
MORF | MOZ-related factor |
MOZ | Monocytic leukemic zinc finger |
mRNA | Messenger ribonucleic acid |
MSK1 | Mitogen and stress activated protein kinase 1 |
MTA | Metastasis-associated proteins |
mTOR | Mammalian target of rapamycin |
MYST | Moz, Ybf1, Sas2, TIP60 |
NCOR | Nuclear receptor corepressor |
NEAT-1 | Nuclear Paraspeckle Assembly Transcript 1 |
NFκB | Nuclear factor κB |
NKILA | NF-κB interacting lncRNA |
NOTCH1 | Notch Homolog 1, translocation-associated |
NSD3L | Nuclear SET domain-containing protein 3 long isoform |
NuRD | Nucleosome remodeling and histone deacetylation |
OHT | Hydroxytamoxifen |
ORM2 | Orosomucoid 2 |
p27 | Cyclin-dependent kinase inhibitor 1B (p27, KIP1) |
PARP | Poly (ADP-ribose) polymerase |
PCAF | p300/CBP-associated factor |
Protocadherin 10 | |
Protocadherin Beta 5 | |
PCR | Polymerase chain reaction |
PDCD4 | Programmed cell death 4 |
PDXP | Pyridoxal phosphate phosphatase |
Phosphatidylethanolamine binding protein 1 | |
PELP1 | Proline, glutamate and leucine-rich protein 1 |
PI3K | Phosphoinositide 3 kinase |
piRNA | piwi-interacting RNA |
Piwi | P-element induced WImpy testis in |
PKB | Protein kinase B |
PKC | Protein kinase C |
PNA | Peptide Nucleic Acids |
PP1 | Phosphoprotein phosphatase 1 |
PP2A | Phosphoprotein phosphatase 2A |
PR | Progesterone receptor |
PRC2 | Polycomb repressive complex 2 |
Gene which codes for Trefoil factor 1 (TFF1) | |
Paraspeckle component 1 | |
PTEN | Phosphatase and tensin homolog |
Retinoic acid receptor beta | |
Ras association domain family member 1 | |
RB1 | Retinoblastoma 1 |
REA | Repressor of estrogen receptor activity |
RNA | Ribonucleic acid |
RUNX3 | Runt related transcription factor 3 |
S6K1 | Ribosomal protein S6 kinase beta-1 |
SAHA | Suberoylanilide hydroxamic acid |
SAM | S-adenosyl methionine |
SET domain | Suppressor of variegation 3-9 (Su(var)3-9), enhancer of zeste (E(z)), and trithorax (Trx) domain |
SFRP1 | Secreted frizzled-related protein 1 |
SHR | Steroid hormone receptors |
siRNA | Small interfering RNA |
SMARCD1 | SWI/SNF related, matrix associated, actin dependent regulator of chromatin, subfamily D, member 1 |
SMRT | Silencing mediator of retinoid and thyroid hormone receptors |
SOX-2 | SRY (sex determining region Y)-box 2 |
SRA | Steroid receptor RNA activator protein |
Src | Rous sarcoma oncogene cellular homolog |
SRC | Steroid receptor coactivator |
Suz12 | Suppressor of zeste 12 protein homolog |
SWI/SNF | Switch/sucrose nonfermentable |
TET | Ten-eleven translocation |
TGF-β | Transforming growth factor β |
TIMP3 | Tissue inhibitor of metalloproteinases 3 |
TIP60 | TAT interactive protein 60 KDa |
TNBC | Triple negative breast cancer |
TNF-α | Tumor necrosis factor α |
TP53 | Tumor protein 53 |
Tropomyosin 1 | |
TRAF6 | TNF receptor associated factor 6 |
TSA | Trichostatin A |
TSG | Tumor suppressor gene |
UBC9 | Ubiquitin conjugating enzyme 9 |
UCA1 | Urothelial cancer–associated 1 |
VA | Valproic acid |
Vascular endothelial growth factor receptor 2 | |
Wnt | Wingless-type MMTV integration site family member |
ZEB1/ZEB2 | Zinc finger E-box binding homeobox 1/2 |
Abbreviations used in the text.
Cataract represents a significant burden in the management and visual outcome of uveitis patients. Up to 40% of the visual loss seen in these patients is either solely or largely due to cataract [1]. Lens opacification is caused by repeated episodes or sustained intraocular inflammation characterized by the release of free oxygen radicals, lysosomal enzymes, immune complex deposition on the lens capsule, hypoxia, and altered composition of the aqueous humor [2]. The development of cataract depends on the type of uveitis, the degree and duration of the inflammatory process, and on the prolonged and excessive use of corticosteroids [3, 4, 5].
Cataract surgery in patients with uveitis represents a serious challenge for the anterior segment surgeon [6, 7]. Nowadays, clear cornea phacoemulsification with intraocular lens (IOL) implantation is the standard of care for most patients with uveitis [8, 9]. However, despite remarkable progress on surgical techniques and IOL materials, certain specific considerations should be taken into account regarding patient selection, preoperative preparation, as well as perioperative and postoperative management for successful long-term results [10, 11]. Nearly one-third of all uveitic eyes have small pupils, which represent a surgical technical difficulty [2]. In such cases, higher rates of additional intraoperative maneuvers are required to obtain proper visualization and phacoemulsification of the cataract [4, 12, 13]. And, while surgery is associated with an improvement in best corrected visual acuity (BCVA), higher rates of both, intraoperative and postoperative complications have been reported [14, 15]. Moreover, it has been shown that the final BCVA in uveitic eyes is worse than in non-uveitic ones [14]. Therefore, identifying the cause of uveitis and pre-existing pathologic changes that affect the visual outcome, achieving absolute control of inflammation before surgery, careful surgical planning, and solving intraoperative and postoperative complications are crucial to obtain a successful result (BCVA ≥ 20/40).
Cataract is the most common ocular complication in children with chronic uveitis with an estimated rate from 35 to 52.0% [16]. In juvenile idiopathic arthritis (JIA)-associated uveitis, the prevalence varies from 40 to 60% and the incidence of new-onset cataract formation has been estimated as 0.04/eye-year [17, 18]. On the other hand, in adult patients it is one of the most frequent complications of uveitis with a prevalence rate as high as 50% as seen in Fuchs uveitis [6, 14, 19, 20]. In HLA-B27-associated anterior uveitis, the most common cause of uveitis in adults, cataract formation is the third most frequent complication with an estimated prevalence of 14%, and an incidence rate of 0.091 during follow-up time (Table 1) [21]. Cataract prevalence varies among different causes of uveitis and depends on multiple factors including etiology, localization of the inflammatory process, time elapsed between the onset and diagnosis of uveitis, the degree of inflammation, the clinical course, and the use of corticosteroids [1, 18, 22, 23].
Cause of uveitis | Cataract prevalence range (median) | Successful outcome BCVA ≥ 20/40 (Snellen) | Frequent complications | References |
---|---|---|---|---|
Fuchs uveitis | 15–75% (50%) | 83% | Intraoperative AC hemorrhage (3.6–76%) Hyphema Ocular hypertension (glaucoma) (3–35%) PCO (14.6%) Progressive vitreous opacification | [20, 27, 48, 49] |
Herpetic uveitis | 15–75% (24%) | 72.2% | Viral reactivation Iris posterior synechiae Secondary glaucoma | [63, 151, 152, 153] |
Juvenile idiopathic arthritis-associated uveitis | 40–60% (50%) | 60–70% (67%) | Exuberant postoperative inflammation Iris posterior synechiae Secondary glaucoma (25%) CME Cyclitic membrane Hypotony (Phthisis bulbi) | [4, 17, 18, 25, 26, 81, 95, 97, 98, 99, 101, 110] |
HLA-B27 associated uveitis | 9.2–20.1% | NA | Recurrent uveitis CME Iris synechiae | [21] |
Pars planitis | 36–42% (40%) | 50–83% | Persistent vitritis (haze) CME (50%) Glaucoma (10%) PCO (10%) IOL Cocooning (29%) ERM Optic nerve atrophy | [23, 28, 140, 154] |
Adamantiades-Behcet disease | 21–26% (38.5%) | 72.5% (42.4%) | Exuberant inflammation (12.5%) Iris posterior synechiae (17.5%) CME (12.5%) ERM (7.5%) Papillitis (optic nerve atrophy) (5%) PCO (37.5% most common) | [148, 155, 156] |
Vogt-Koyanagi-Harada disease | 10–35% | 68% | Exuberant inflammation Iris anterior and posterior synechiae Pupillary membrane PCO (76%) Macular scarring | [135, 157] |
Sympathetic ophthalmia | 31.8% | 67.79% (72.2%) | PCO (77.7%) Glaucoma | [158] |
Sarcoidosis | 21% | 61% | PCO (57.1%) Recurrent uveitis CME Glaucoma | [159] |
Prevalence, visual outcome, and complications of cataract surgery in uveitis.
AC = anterior chamber; PCO = posterior capsule opacification; CME = cystoid macular edema; ERM = epiretinal membrane.
In general, the uveitic population differs from the general population suffering from cataract in that they are younger and have a higher rate of comorbidities [15]. However, the rates of inflammatory sequelae vary markedly among uveitic entities [7, 24]. For this reason, each uveitis syndrome must be analyzed separately with respect to ocular complications and visual outcome [6, 14] (Table 1). While Fuchs uveitis regularly has the best visual prognosis and the least postoperative complications, JIA-associated uveitis has one of the most fear prognosis due to frequent pre-existing pathology, difficulties in reaching absolute control of inflammation, and multiple intraoperative and postoperative complications [4, 25, 26, 27].
A correct classification and etiologic diagnosis of the uveitic entity is very helpful to establish the appropriate surgical strategy and to determine the prognosis [8]. Moreover, a complete preoperative ophthalmologic examination is essential since pre-existing pathology will have significant therapeutic and prognostic visual implications [16, 28]. For instance, corneal opacity, vitreous haze, macular edema, and optic nerve atrophy usually result in a poor visual outcome [6, 19]. Therefore, it is very important that the patient and/or their relatives have an objective report on the status of the eye to be operated in order to have a realistic expectation of the final visual result. Ancillary diagnostic tests are always necessary to detect pre-existing pathologic changes that will allow us to render a more accurate visual prognosis. In most cases, it is helpful to perform a macular function test. Several methods are available for this purpose including the potential acuity meter (PAM), the laser interferometer (LI), and the focal electroretinogram (fERG) [29, 30]. The PAM test has proven an accuracy of 84% in patients with poor visual acuity (<20/40) [30]. On the other hand, LI has shown a lower accuracy (65%) and a tendency for over-predicting vision compared to the PAM in these patients [29, 30]. Focal cone ERG is very sensitive for detecting macular pathology, showing 91% accuracy in eyes with poor visual acuity [30].
Linear A-B ultrasound is necessary to identify vitreous hemorrhage and opacity, as well as posterior segment changes like, retinal detachment, optic nerve swelling, and sclerochoroidal thickness [31]. Another very useful device is high-frequency ultrabiomicroscopy (UBM), which generates high-resolution images at an almost histological level.
Retina fluorescein angiography (FA) allows the detection of many different forms of posterior segment inflammatory changes. It is used to evaluate the activity and extent of chorioretinitis and optic nerve involvement; identify macular edema and choroidal neovascularization; diagnose certain posterior uveitic entities with typical features; evaluate retinal vascular involvement and neovascularization; and to monitor the therapeutic response [34]. However, many inflammatory changes occur in the peripheral retina where visualization may be difficult with conventional angiography. Wide field scanning laser ophthalmoscopy performs ultra-wide angle FA allowing clear identification of peripheral lesions and accurate documentation of disease progression [35]. This recently new image technology has replaced conventional angiography for the diagnosis and monitoring of intermediate and many forms of posterior uveitis [35].
Indocyanine green angiography (ICGA) allows the detection of choroidal inflammation. Two patterns of choroidal vasculitis have been described: primary inflammatory choriocapillaropathy and stromal inflammatory vasculopathy [36]. The first pattern is characterized by non-perfusion of the choriocapillaris found in entities like, multiple evanescent white dot syndrome, acute posterior multifocal placoid pigment epitheliopathy, multifocal choroiditis, and serpiginous choroidopathy [36]. The choroidal stromal inflammatory vasculopathy pattern is seen in active Vogt-Koyanagi-Harada disease (VKH), ocular sarcoidosis, tuberculosis, and birdshot chorioretinopathy [37]. In Behcet’s disease, as in other forms of uveitis, both ICGA vascular patterns may be seen at different stages of inflammation [38].
Today, the most frequently used imaging technique to detect and monitor macular inflammatory changes is optical coherence tomography (OCT). With an axial resolution in the 5–7 μm range, it provides close to an
Once the preoperative evaluation is completed, a postoperative visual prognosis may be assumed, therapeutic adjustments may be applied, and a surgical plan is prepared based on pre-existing pathologic findings.
The key to surgical success in patients with uveitic cataract is the absolute control of inflammation, meaning no cells in the anterior chamber for at least 3 months prior to surgery [7]. This requisite is crucial to obtain an optimal surgical result and to minimize postoperative complications [7, 24]. Active uveitis at the time of cataract surgery has been associated with worse visual outcomes [15, 47]. Moreover, postoperative cystoid macular edema (CME) is more likely to develop in eyes with active inflammation within a 3-month period before surgery (relative risk 6.19) than those under control [41]. However, this general consensus of no cells in the anterior chamber prior to surgery has its exemptions [2]. In Fuchs uveitis, minimal but persistent anterior chamber cells and flare are frequently found despite intensive and sustained treatment with topical corticosteroids [48]. Hence, anti-inflammatory treatment is not indicated for the low-grade anterior chamber reaction seen in Fuchs uveitis and only occasionally, a short-course of corticosteroids is indicated for symptomatic exacerbations [49]. Other exemptions are related to the necessity for prompt surgical intervention in cases like, lens-induced uveitis, cyclitic membrane formation with hypotony, persistent vitreous opacity or hemorrhage, and retinal detachment [50, 51].
Preoperative management depends specifically on the type and etiology of uveitis. For inactive idiopathic anterior non-granulomatous uveitis as for Fuchs uveitis, topical administration of prednisolone acetate 1% four times a day, starting 3–7 days before surgery may be sufficient to avoid an outburst of postoperative inflammation [24]. On the contrary, patients with JIA-associated uveitis, anterior granulomatous uveitis, intermediate, posterior, and panuveitis also require oral prednisone (1.0 mg/kg/day) starting 3 days before surgery and continued for a week after cataract removal and then tapered slowly according to the inflammatory status [52, 53]. Preoperative oral steroids have been shown to be effective in reducing the risk of CME [41]. If patients are on immunosuppressive chemotherapy and/or biologics, they should be continued at current dosage [11]. In case that systemic corticosteroids are contraindicated (e.g., diabetes mellitus, metabolic disease, acid-peptic disease, obesity, or osteoporosis), periocular administration (transseptal or sub-Tenon’s) of triamcinolone acetonide (40 mg/ml) should be considered [54, 55]. Alternative immunosuppressive agents like, cyclosporin-A, tacrolimus, or anti-metabolites may be administered to these patients considering that most of these medications require a longer period of time (usually 4–6 weeks) to reach an optimal therapeutic effect [56].
The use of topical non-steroidal anti-inflammatory drugs (NSAIDs) like, ketorolac 0.4%, nepafenac 0.15%, or bromfenac 0.09%, have become a standard of care practice for the perioperative management of inflammation, pain, surgical-induced miosis, and cystoid macular edema in uneventful and also in uveitic cataract surgery [57, 58, 59]. A systematic review found high-quality evidence that topical NSAIDs are more effective than topical steroids in preventing the short-term pseudophakic CME in non-uveitic cataract surgery [60]. On the other hand, a recent evidence-based review conducted by the American Academy of Ophthalmology found that the claimed made about the synergistic effect of combined topical steroids and NSAIDs remains unproven [61]. In addition, NSAIDs have only a short-term therapeutic effect on prompt visual recovery and reduction of established CME, but no effect on the long-term visual outcome [57, 58, 61]. There is good collective clinical evidence and rationale that the application of a topical NSAID 3 days before surgery reduces CME and improves vision in the short-term [61]. Because the COX-2 enzyme is inducible and mostly responsible for the inflammatory process, the selective inhibitory effect of nepafenac and bromfenac makes them more suitable for this purpose [62]. Nepafenac has shown the shortest time to reach maximal concentration and the greatest aqueous humor peak concentration compared to ketorolac and bromfenac in eyes having cataract surgery [62]. After the surgical procedure, topical NSAIDs use is usually extended for 4–6 weeks [1, 10].
There are other special conditions in uveitis in which certain specific actions should be taken before cataract extraction is performed. Such is the case of herpetic uveitis in which prophylactic anti-viral therapy with acyclovir or valacyclovir should be administered at least 1 week before surgery in order to avoid recurrent viral infection [63, 64]. Other special consideration is the preoperative management of prominent band keratopathy interfering with cataract visualization which may be treated with EDTA 1–2% calcium chelation, or Excimer laser PTK before cataract surgery [65, 66].
Cataract and glaucoma frequently coexist as uveitis complications, and a combined surgical procedure may be associated with an increased risk of glaucoma surgery failure [67, 68]. In such cases, it may result better to perform a clear cornea small-incision cataract extraction first, followed later on by filtration surgery or a valve implantation with anti-metabolites [69, 70]. One must consider that uveitic glaucoma eyes operated for trabeculectomy with mitomycin-C which had previous cataract surgery or granulomatous uveitis, have a higher risk of surgical failure (RR = 2.957, P = 0.0344, and RR = 3.805, P = 0.0106, respectively) [71]. A higher risk of glaucoma surgical failure has also been associated with idiopathic, intermediate, and Fuchs uveitis; active intraocular inflammation at the time of surgery; and relapse of uveitis [72]. Moreover, the success rate of filtration surgery in uveitic eyes is significantly lower than that of non-uveitic, and many patients with successful intraocular pressure (IOP) control still require anti-glaucoma therapy to maintain adequate IOP levels in the postoperative period [72].
Posterior vitrectomy and cataract extraction may be an alternative for patients with prominent posterior segment pathology including vitreous opacity, hemorrhage, cystoid macular edema, and tractional retinal detachment [73]. There is reasonable evidence that cataract phacoemulsification combined with posterior vitrectomy has a favorable visual outcome for some patients with refractory inflammation, particularly those with significant vitreous opacity and chronic macular edema [13, 74]. In children, this combined surgical approach has been used for JIA-associated uveitis, pars planitis, and other forms of posterior uveitis [75]. However, this technique is not exempt of serious postoperative complications like, glaucoma, macular edema, and exuberant inflammation [75, 76]. For specific cases with various ocular complications, multiple combined surgical strategies have been postulated including phacoemulsification with IOL implantation, posterior vitrectomy, intravitreal sustained-release corticosteroid injection, and glaucoma tube implantation with promising results [77].
Nowadays, small clear corneal incision phacoemulsification surgery is preferred over extracapsular cataract extraction (ECCE) and lensectomy for most patients with uveitis [78, 79]. Since cataract surgery in these patients is frequently complicated by corneal opacification, iris synechiae, pupillary and cyclitic membranes, among others, the surgical technique should be minimally invasive with precise and delicate maneuvers [10, 24] (Figure 1). Most studies report a higher rate of additional maneuvers, notably iris and pupillary manipulation within a range between 19 and 67% of eyes [4, 5, 6, 25].
Anterior segment appearance of a patient with Vogt-Koyanagi-Harada disease showing extensive peripheral anterior and posterior synechiae, shallow anterior chamber and a pupillary membrane in front of a secondary cataract.
Dealing with unexpected intraoperative complications like, corneal stromal edema; anterior chamber hemorrhage; pigment dispersion; posterior capsule rupture with vitreous exposure is key to achieve the best surgical outcome possible [6, 19, 75]. The first challenge that the surgeon faces is an adequate exposure and visualization of the cataract. Iris synechiolysis, pupillary membrane removal, and pupil distension with iris hooks or iris stretch devices are frequently required for proper cataract visualization [80, 81]. There is no general consensus on what is the best way to deal with the pathologic changes of the anterior segment encountered in uveitic eyes. However, it is generally agreed that attempts should be made to minimize surgical maneuvers in order to lessen tissue manipulation and trauma as possible [6, 24, 26].
The capsulorhexis should measure between 5 and 6 mm in diameter because smaller apertures are frequently associated with capsular phimosis and posterior iris synechiae to the anterior capsule remnant [82, 83, 84] (Figure 2). On the other hand, larger diameter capsulorhexis may affect the IOL centration and stability [83]. The phacoemulsification technique may vary depending on the density and zonular status of the cataract, but an effort should be made to use the less ultrasound power and time possible, to perform vigorous cortical and posterior capsule cleaning, and to avoid posterior capsule rupture [11, 19]. Avoiding the latter is crucial to obtain a good postoperative result, especially in chronic and recurrent uveitis like, herpetic uveitis, pars planitis, VKH disease, toxoplasmosis, among others [6, 24, 85]. In these cases, posterior capsule rupture with vitreous exposure may be a contraindication for IOL implantation due to a high probability of postoperative excessive and persistent inflammation [12, 86]. In uveitic eyes with encapsulated and subluxated IOLs with extensive fibrosis, IOL removal may be necessary at some point of the postoperative period to control severe inflammation and reduce its consequences [87, 88, 89]. For eyes with extensive membrane formation in the anterior vitreous, vitrectomy after performing a posterior central capsulorhexis must be considered [90].
Patient with ankylosing spondylitis and HLA-B27-associated uveitis after cataract surgery showing capsular phimosis and partial adherence of the pigmentary epithelium of the iris to the anterior capsule remnant.
Decision making regarding the type of IOL to be used; anterior or posterior chamber IOL implantation; possible IOL sulcus fixation; combined filtration surgery, MIGS, or valve implantation; central posterior capsulorhexis after PC-IOL implantation with anterior vitrectomy; lensectomy, as well as posterior vitrectomy with or without retinal surgery are frequently met during uveitic cataract surgery, and the surgeon must be prepared to make the best decision for the particular case [91, 92, 93, 94]. The implantation of a foldable IOL “in the bag” is ideal for most cases of uveitis with certain exceptions [4, 95]. Until now, it is not clear how to proceed in children with uveitic cataract, and randomized controlled trials (RCT) are necessary to elucidate this matter [4, 25, 26, 81]. Historically, uveitic cataract surgery during childhood has been associated with a higher rate of surgical complications, particularly excessive postoperative inflammation [6, 10]. In the past, this situation made that the preferred surgical techniques for cataract extraction in this group including ECCE with posterior pars plana vitrectomy or lensectomy [4, 95]. However, recent evidence favors the implantation of foldable PC-IOLs in children with uveitis, including patients with JIA-associated iridocyclitis [25, 26, 96, 97, 98, 99, 100, 101].
Intraocular corticosteroids can be administered during surgery. Intracameral dexamethasone phosphate (400 μg/0.1 ml) or intravitreal triamcinolone (4 mg/0.1 ml) injection (IVTA) may be administered intraoperatively, except in advanced secondary glaucoma or known steroid-responsive patients [4, 102]. A prospective and comparative RCT between oral corticosteroids and preservative-free IVTA injection showed no differences in postoperative anterior chamber reaction, IOP levels, and central macular thickness (CMT) [103]. Another study found a better effect of IVTA versus orbital floor TA on macular edema and postoperative inflammation after cataract surgery in patients with uveitis [55]. However, IVTA injections have a temporary effect therefore, may require repeated injections which are not exempt of serious ocular complications like, elevated IOP (30–43% eyes), bacterial endophthalmitis, vitreous hemorrhage, and retinal detachment [104]. For those eyes at higher risk for intravitreal injection, sub-Tenon’s or transseptal TA can be administered at the end of surgery [19].
Intravitreal steroid sustained-release devices containing fluocinolone acetonide 0.59 mg or dexamethasone phosphate 0.7 mg have proven to be beneficial for the control of inflammation, prevention of CME, or reduction of CMT if applied a few days to weeks before or during cataract surgery [105]. Although no general consensus exists on the appropriate surgical time, it seems reasonable to perform the cataract surgery within 4–6 weeks from the last steroid implantation [105, 106, 107]. The most fear complication of sustained-release steroid devices is ocular hypertension (OHT). A meta-analysis found that 66% of eyes develop OHT after the implantation of the 0.59 mg fluocinolone acetonide device, compared to 32% following 4 mg IVTA, and only 15% with the 0.7 mg dexamethasone implant [108]. Risk factors for developing OHT include, pre-existing glaucoma, higher baseline IOP, younger age, OHT following previous injection, uveitis, higher steroid dosage, and fluocinolone implant [108]. A new sustained-release implant containing 0.19 mg fluocinolone acetonide has shown promising results improving visual acuity and reducing CMT with a significant reduction of IOP compared to the dexamethasone implant and IVTA [109].
The general consensus regarding cataract surgery in patients with uveitis is that implantation of IOLs may be safely performed when ocular inflammation is completely abolished for a minimum period of 3 months [4, 7]. However, a debate still exists if an IOL should be implanted in specific circumstances like, lens-induced uveitis, JIA-associated iridocyclitis, young children with posterior or panuveitis, and intraoperative rupture of the posterior capsule with vitreous exposure [25, 26, 91, 110]. The implantation of an IOL triggers different intraocular responses including inflammation and foreign body reaction, as well as activation of the complement and coagulation cascades [83, 111, 112, 113]. These reactions along with the breakdown of the blood-aqueous barrier induced by surgery may increase cellular adhesion and lens epithelial cell (LEC) proliferation on the anterior surface of the IOL, resulting in anterior capsule phimosis, fibrosis, and posterior capsule opacification (PCO) [114]. With the advent of technologic development, many advances have been made to reduce IOL-induced reactions and to improve their biocompatibility [115]. The inflammatory response induced by IOLs is inversely related to its biocompatibility, so the higher the biocompatibility, the lower the inflammatory response [15, 83, 115]. Even though they were considered biologically inert, the first IOLs made of polymethyl-methacrylate (PMMA) were capable of producing foreign body reaction, as well as activate the complement and coagulation cascades [113, 116].
Different strategies have been used to reduce the host response, including the modification of the IOL surface by making it hydrophilic, like in heparin-coated PMMA IOLs, or hydrophobic such as surface passivated [83]. Heparin surface-modified IOLs have improved biocompatibility compared with unmodified PMMA IOLs in eyes at risk for severe postoperative inflammation, including those with uveitis [117, 118].
Foldable IOLs may be hydrophobic, including silicone IOLs or hydrophilic, and both surfaces have demonstrated to be relatively inert [114, 119]. Hydrophobic surfaces resist cell adhesion while hydrophilic ones reduce electrostatic forces and cellular adhesion, preventing the attraction of inflammatory cells and their activation, as well as adherence of fibroblasts to the IOL surface [120, 121].
Anterior capsule phimosis has been related to the degree of fibrotic reaction produced by pro-inflammatory cytokines released by residual LEC [122, 123]. Careful vacuuming the undersurface of the anterior capsule helps to reduce the number of LEC [82, 124]. Capsular phimosis has been reported more frequently with hydrogel (poly-HEMA) than acrylic, and silicone IOLs [83, 125]. Foreign body giant cell precipitates are less frequently seen in hydrophilic than on hydrophobic IOL surfaces and heparin-coated PMMA IOLs [115, 126]. The frequency of posterior capsule opacification (PCO) is highest with PMMA IOLs, less with silicone and minimal with acrylic IOLs [124, 127].
Few studies have evaluated the visual outcome following cataract surgery in uveitis with silicone IOL implantation. Overall, only 30% of eyes have achieved 20/40 of better vision with silicone IOLs, fewer than any other type of IOL [15]. Silicone was the first material available for foldable IOLs, but its use has declined particularly because it cannot be used for a monobloc open-loop designed, the preferred choice for preloaded injectors that allow implantation through small corneal incisions [128].
With the advent of acrylic foldable IOLs, the biocompatibility issue has become a minor concern, but controversy still exists of which material, hydrophilic or hydrophobic is best suitable for patients with uveitis [120, 126, 129]. Since the lens is surrounded by aqueous humor, it was thought that hydrophilic materials were more biocompatible than hydrophobic for patients with uveitis [89, 92]. However, there is insufficient evidence to determine the effects of different types of IOL materials, including hydrophobic and hydrophilic acrylic IOLs in patients with uveitis [129]. Results from the largest RCT provide only preliminary evidence that acrylic IOLs may perform better than silicone IOLs in terms of improving vision and reducing the chances of postoperative inflammation and complications [129, 130]. A large multicenter RCT with standardized outcome measurements is necessary to properly address the surgical outcome of patients with uveitic cataract.
The postoperative management is as important as the preoperative preparation and the surgical procedure itself. Since the first postoperative moments, intense topical corticosteroids (1% prednisolone acetate hourly), topical NSAIDs (anti-COX-2 selective), topical wide spectrum antibiotics (fourth generation fluoroquinolones), overnight steroid ointment, as well as mydriatic-cycloplegic combinations (e.g., 1% tropicamide + 5% phenylephrine every 6-hours × 5–7 days) should be administered [11, 24, 131]. Topical corticosteroids are wined down according to the grade of anterior chamber inflammatory reaction, the presence of glaucoma, or OHT in steroid-responders [54]. In case the patient was given systemic corticosteroids, they should be maintained at immunosuppressive levels (1 mg/kg/day) for 7–10 days before reducing them slowly to a minimum dose of 7.5 mg/day [56]. In case the patient is on immunosuppressive chemotherapy or biologic therapy, it should be continued at maintenance dose [19, 131]. Systemic anti-virals used for herpetic uveitis should be kept at therapeutic dose for 7–14 days postoperative, and then reduced to prophylactic levels (acyclovir, 600–800 mg/day and valacyclovir 500–1000 mg/day) for several weeks to months before stopping them [63, 64, 132].
Postoperative complications after cataract surgery in patients with uveitis are relatively frequent [8]. The reported prevalence of complications is higher in ECCE than in phacoemulsification [78, 79, 133]. The risk for postoperative complications also depends on the type of uveitis and the degree of ocular involvement [8, 12, 85] (Table 1). Despite all preventive measurements taken before and during surgery, the most frequent and fear postoperative complication is the outburst of inflammation out of expected proportions [5]. Significant inflammation characterized by >2+ anterior chamber cells, extensive protein exudation with fibrin and plasmoid bodies formation, as well as fibrinoid membranes covering the pupil, and hypopyon may be seen [7, 19, 24, 134]. This aggressive inflammatory response is commonly associated with early postoperative iris synechiae formation and pupillary inflammatory membranes, particularly in disorders like JIA-associated uveitis, and VKH, among others [4, 6, 131, 135]. The best way to deal with this unexpected postoperative inflammatory response consists on avoiding it by previous absolute control of inflammation and the implementation of perioperative measurements discussed before. Nevertheless, in those cases in which a significant inflammatory reaction occurs, an adjustment to the systemic prednisone dose and the administration of atropine 1% will help to control the inflammation [52, 53, 54].
Other immediate postoperative complications that may be seen are hyphema and significant pigment dispersion throughout the anterior segment [19, 24]. Pigment dispersion is related to a variety of factors including, surgical trauma, small pupil, and age [24, 83, 91]. In both cases, regular tonometry is mandatory for opportune detection of severe OHT related to clogging of the trabecular meshwork by ghost cells or pigment, respectively [6]. If anti-glaucoma therapy is required, prostaglandin analogs as well as alpha-adrenergic drugs should be avoided as possible because they may exacerbate the inflammatory process [69]. In some patients with corneal stromal edema and Descemet folds due to high IOP, oral carbonic anhydrase inhibitors (e.g., acetazolamide 250 mg, 3–4 times a day) may be administered [69]. If the IOP becomes uncontrollable with medical therapy, filtration surgery or valve implantation should be considered to avoid further optic nerve damage [69, 136]. Finally, an excessive postoperative inflammatory process may produce significant vitreous opacity and membrane formation [5]. Once acute infectious endophthalmitis has been ruled out in such cases, aggressive anti-inflammatory therapy with systemic, periocular, and even intravitreal corticosteroids should be administered [52, 54, 55, 106]. If vitreous condensation and organization persist, a pars plana vitrectomy with or without intravitreal corticosteroid injection should be performed [13, 73, 75, 137].
In the late postoperative period, ocular complications are usually related with recurrent intraocular inflammation occurring from 8.3 to 53% of cases [8, 12, 85, 133]. Recurrent postoperative uveitis may produce anterior and/or posterior iris synechiae which may cause an angle or pupillary block glaucoma, respectively [69].
Certainly one of the most frequent ocular complications observed in this late period is posterior capsule opacification seen in up to 58% of cases [82, 83, 85, 124, 133]. Nd-Yag laser capsulotomy usually resolves this problem, but in some cases retrolental hyaloid-vitreous opacification or significant deposition of pigment and inflammatory debris on the IOL surface may occur therefore, recurrent low-energy Nd-Yag laser and other operative procedures may be needed for polishing the IOL [82, 138]. It must be considered that Nd-Yag laser capsulotomy in patients with uveitis is associated with a higher risk for vision-threatening complications, including OHT, CME, IOL damage or luxation, as well as retinal detachment [40, 139].
Another very important visual-threatening postoperative complication is macular edema occurring from 33 to 56% after ECCE and from 12 to 59% after phacoemulsification [12, 85, 133, 140]. The appearance of CME depends on multiple factors including the cause of uveitis and the type of surgical procedure performed [41]. Treatment of uveitic macular edema (UME) includes the administration of periocular injections of depot corticosteroids [54, 141]. However, as stated before, IVTA has shown to be superior to orbital floor injection for the treatment of UME [55, 142]. OHT is a potential complication of both types of steroid administration and should always be considered, particularly after repeated intravitreal injections [55, 108, 143]. Sustained-delivery corticosteroid devices may also be administered for this purpose [105, 106, 144]. In patients with bilateral UME, steroid-responders or those who do not accept periocular or intravitreal corticosteroid injections, oral prednisone along with oral carbonic anhydrase inhibitor (e.g., acetazolamide 250 mg every 12 hours) may be administered [54]. Epiretinal membrane formation is more commonly seen in patients with chronic UME with a prevalence ranging from 15 to 56% [12, 145, 146]. Treatment consists of pars plana vitrectomy and internal limiting membrane delamination [73, 146, 147].
Other less common, but serious complications is retinal detachment and hypotony [5, 26]. Hypotony may be related to the retinal detachment per se, or to a low aqueous humor production due to inflammation of the ciliary process, or tractional detachment of the ciliary body due to cyclitic membrane formation [26]. Postoperative hypotony may evolve to pthisis bulbi [10, 88]. Both complications should be attended immediately by retinopexy, and/or posterior vitrectomy with cyclitic membrane and sometimes intraocular lens removal, as well as peri- or intraocular corticosteroid administration [87, 88].
The outcome of cataract surgery in patients with uveitis is less predictable than in other causes of cataract. Many factors may contribute to this uncertainty including, pre-existing pathologic changes, intraoperative technical challenges, the impact of postoperative exuberant inflammation, and the reversibility of postoperative complications derived from it [14]. Vision-limiting pathology related to pre-existing uveitis complications, especially macular edema and optic neuropathy are probably the major contributing factors for limited postoperative visual outcome [8, 15, 85].
Different studies suggest that visual prognosis varies according to uveitis subtypes [5, 15, 26]. For instance, the proportion of eyes achieving 20/40 or better vision is better in Fuchs uveitis and worse in Behcet’s disease, VKH disease, or sympathetic ophthalmia [20, 27, 47, 148]. In general, diseases that spare the posterior segment have a better prognosis than those affecting it, particularly macular and optic nerve involvement [5, 6, 8, 85]. In addition, acute uveitic entities tend to be associated with better outcome than chronic ones [12].
Uveitic cataract surgery has been associated with worse postoperative visual acuity, higher IOP, and more than double prevalence of UME when compared with non-uveitic cataract surgery [14]. Moreover, the visual outcome following uveitic cataract extraction is not as good as that of age-related cataract surgery with the exception of Fuchs uveitis [27, 149]. Systematic reviews found a successful visual outcome (20/40 or better) in 96% of eyes with age-related cataract surgery compared to 70% in uveitic eyes undergoing either phacoemulsification or ECCE [15, 149]. ECCE and phacoemulsification seem to have similar visual outcomes compared to half less successful rate after pars plana lensectomy [15]. With respect to the comparable visual results reported between ECCE and phacoemulsification, it must be taken into account that most ECCE trials have more exclusion criteria than phacoemulsification studies, favoring better visual outcomes [15, 85, 150].
Finally, regarding IOL implantation, more eyes (71%) undergoing cataract surgery with IOL implantation than eyes left aphakic (52%) achieved a BCVA ≥ 20/40 vision postoperatively [14]. Eyes receiving acrylic IOLs or heparin surface-modified PMMA had better visual outcomes than those receiving non-heparin-PMMA or silicone IOLs [14, 15, 83, 94].
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\\n"}]'},components:[{type:"htmlEditorComponent",content:'Copyright is the term used to describe the rights related to the publication and distribution of original Works. Most importantly from a publisher's perspective, copyright governs how Authors, publishers and the general public can use, publish, and distribute publications.
\n\nIntechOpen only publishes manuscripts for which it has publishing rights. This is governed by a publication agreement between the Author and IntechOpen. This agreement is accepted by the Author when the manuscript is submitted and deals with both the rights of the publisher and Author, as well as any obligations concerning a particular manuscript. However, in accepting this agreement, Authors continue to retain significant rights to use and share their publications.
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LICENSE | \n\t\t\tUSED FROM - | \n\t\t\tUP TO - | \n\t\t
\n\t\t\t Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported (CC BY-NC-SA 3.0) \n\t\t\t | \n\t\t\t\n\t\t\t 1 July 2005 (2005-07-01) \n\t\t\t | \n\t\t\t\n\t\t\t 3 October 2011 (2011-10-03) \n\t\t\t | \n\t\t
Creative Commons Attribution 3.0 Unported (CC BY 3.0) | \n\t\t\t\n\t\t\t 5 October 2011 (2011-10-05) \n\t\t\t | \n\t\t\tCurrently | \n\t\t
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\n\n© {year} {authors' full names}. Originally published in {short citation} under {license version} license. Available from: {DOI}
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\n\nPolicy last updated: 2016-06-08
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