Survivin expression and serum levels in pancreatic cancer
© Dong et al. 2015
Received: 14 March 2015
Accepted: 13 May 2015
Published: 28 May 2015
Survivin, an inhibitor of apoptosis, is overexpressed in pancreatic ductal adenocarcinoma (PDAC). Its expression is known to be associated with poor clinical outcome. However, to our knowledge, there has been no study to characterize its usefulness as a serum marker for human pancreatic cancer. Furthermore, the relation between survivin expression and the serum level of survivin has not been widely studied in PDAC. We performed this study to investigate the expression and serum level of survivin in PDAC and its clinical significance as a prognostic factor.
We performed immunohistochemical staining for survivin in formalin-fixed, paraffin-embedded blocks from 80 PDAC tissues. The serum level of survivin from the patients (n = 80) and age-matched healthy volunteers (n = 80) were analyzed by enzyme-linked immunosorbent assays (ELISAs) prior to surgical resection. Levels of expression were correlated with clinicopathological parameters.
Serum survivin concentrations were significantly elevated in patients with PDAC when compared with healthy sera (P < 0.001). High serum survivin levels were significantly associated with perineural invasion, venous invasion, lymph node status (N stage), cell differentiation, and recurrence but not with the tumor size, age, gender of the patients, or tumor location. The median overall survival time of the group with normal serum survivin levels was longer than that of the group with elevated serum survivin. The independent factors associated with overall survival were advanced pancreatic cancer and elevated serum survivin level. Of the 80 cases of PDAC, 65 (81.25 %) were positive for survivin expression. There were significant associations between survivin expression and perineural invasion, venous invasion, and lymph node status. A significant difference in overall survival was associated with survivin expression.
Patients with elevated serum survivin level and high survivin expression at diagnosis demonstrated a poor outcome. Detection of serum survivin or tissue survivin expression may predict the prognosis of patients with PDAC.
Pancreatic ductal adenocarcinoma (PDAC) is the fourth leading cause of cancer-related death in Western countries and has the poorest survival rate (<5 %) among the common malignancies [1, 2]. Although surgical resection shows promise as an effective treatment for PDAC, a lack of effective tools for diagnosis in the earliest stages results in low 5-year survival rates, which drop rapidly from >50 % in patients with stage I to <5 % in patients with more advanced stages of the disease [3–5]. Both imaging techniques and serological markers, such as carbohydrate antigen 19-9 (CA19-9) and carcinoembryonic antigen (CEA), have used for many years for diagnosis of PDAC, however, it is still difficult to distinguish patients with chronic pancreatitis (CP), a high-risk population for PDAC, from those with PDAC [6–9]. Therefore, to improve the prognosis of PDAC, the development of specific and noninvasive biomarkers for PDAC diagnosis is required and especially for early-stage tumors.
Survivin is a member of the inhibitor of apoptosis protein (IAP) family originally discovered in the baculovirus . Structurally, survivin is a unique IAP protein , organized as a stable dimer  containing only one baculoviral IAP repeat domain and a –COOH terminus coiled-coil domain . Survivin is unique for its expression in a wide range of embryonic and fetal tissues but is undetectable in terminally differentiated normal adult tissues. However, it is re-expressed in transformed cell lines and several human cancer cells at a frequency of 34–100 % [13, 14]. As a prognostic factor, survivin expression is significantly associated with poor clinical outcome in cancers such as neuroblastoma, colorectal cancer, breast cancer, lung cancer, esophageal cancer, medulloblastoma, and pediatric acute lymphoblastic leukemia [15–22].
Survivin expression in pancreatic cancer has been widely studied. Satoh et al. reported that expression of survivin may be upregulated during an early stage of tumorigenesis, and it may be involved in the development of cancer by reducing cancer cell apoptosis . Kami and Ekeblad et al. reported that expression of survivin in pancreatic cancer tissues could be a useful prognostic marker in patients with this cancer [24, 25]. Lee et al. found that survivin expression seems to have potential as a predictive marker for the response to chemotherapy .
Although elevated expression of survivin has been found in many cancer tissues, including PDAC tissues, and its association with tumor behavior and patient prognosis has been reported, few studies have analyzed the serum levels of survivin in patients with PDAC. Furthermore, the relationship between survivin expression and serum survivin level has not been widely studied in PDAC.
In the present work, we determined the serum levels of survivin in patients with PDAC, then performed immunohistochemical staining for survivin in PDAC tissues. Survivin expression and serum survivin levels were correlated with clinicopathological parameters.
Patients and clinical data
Patients’ clinicopathological characteristics
n = 80
Body and tail
The 80 healthy controls were recruited at the Healthy Physical Examination Center of the affiliated hospital of the medical college of Qingdao University. The health condition checkup included a detailed history; physical, radiological, and endoscopic examinations; blood tests; tumor marker tests (CA19-9, CEA); and abdominal sonography. Participants with no evidence of pancreatic disease or other abnormalities were enrolled as cancer-free controls.
The study was approved by the Ethics Committee of the affiliated hospital of the medical college of Qingdao University. Written consent for using the samples for research purposes was obtained from all patients and controls prior to surgery or blood sample collection.
Formalin-fixed, paraffin-embedded blocks from the 80 patients with surgically resected PDAC tissues and 24 samples of normal pancreas tissue were studied. Consecutive tissue sections were stained for survivin. Known positive and negative control slides were used to determine the acceptability of the staining reaction. For the stains, cytoplasmic immunoreactivity was considered a positive reaction. Samples with <10 % positive cells were recorded as showing negative expression and those with ≥10 % positive cells were recorded as showing positive expression. All samples were reviewed independently by two pathologists.
Measurement of serum survivin levels
Survivin (Quantikine Human survivin Immunoassay, R&D System, USA) concentrations were determined by using an enzyme-linked immunosorbent assay (ELISA) method according to the manufacturer’s instructions. All specimens were assayed twice .The minimum detectable dose (MDD) of survivin ranged from 1.58 to 9.96 pg/ml.
All statistical analyses were performed using SPSS statistical software (Chicago, IL, USA). Data are presented as means (SE). We used Mann–Whitney U-test to compare differences in the serum survivin concentrations between the cancer patients and the control group. The relationship between serum and tissue survivin level was assessed by Fisher exact test. The relationship between serum or tissue survivin level with the clinicopathological parameters was assessed by χ2 analysis. For continuous variables not normally distributed, the variables are given as median (25th–75th percentile) and they were compared using the Mann–Whitney U-test. Survival curves were plotted using the Kaplan–Meier method. The difference in survival between groups was compared using the log-rank test.
The prognostic factors were examined by univariate and multivariate analyses (Cox proportional hazards regression model). P < 0.05 was considered to indicate statistical significance.
Serum levels of survivin
Expression of survivin in PDAC
Relation between tissue survivin and serum survivin
Relation between tissue and serum survivin
≥72.58 pg/ml (n = 51)
<72.58 pg/ml (n = 29)
Positive (n = 65)
Negative (n = 15)
Serum and tissue survivin levels and clinicopathological features in patients with PDAC
Relationship between serum levels or tissue survivin expression and clinicopathological factors
<50(n = 32)
>50(n = 48)
M(n = 62)
F(n = 18)
Head(n = 55)
Body(n = 3)
Tail(n = 7)
Body and tail(n = 15)
I(n = 17)
II(n = 37)
III(n = 18)
IV(n = 8)
Positive(n = 47)
Negative(n = 33)
Yes(n = 55)
No(n = 25)
Yes(n = 50)
No(n = 30)
Well(n = 10)
Moderate(n = 57)
Poor(n = 8)
Others(n = 5)
Yes(n = 56)
No(n = 24)
Spearman correlation analysis between serum survivin levels and clinicopathological factors
Serum survivin level
Of the samples examined for survivin immunohistochemical staining, survivin was significantly associated with lymphatic invasion, perineural invasion, and venous invasion (Table 3). Spearman analysis revealed a correlation between positive survivin expression and TNM stage, perineural invasion, and venous invasion (Table 4). These observations support the hypothesis that the progression of PDAC is associated with positive survivin expression.
Association between serum level and tissue expression of survivin and prognosis and survival rates for patients with PDAC
More specifically, the median survival time of patients with high serum levels of survivin was only 9 months (positive tissue survivin was 8.8 months), whereas the median survival time of those with low levels of survivin was 26 months (negative tissue survivin was 26.3 months). The cumulative 5-year survival rate was 38.4 % in the group with low serum levels of survivin (n = 29) and 37.6 % in the group whose tissues were negative for survivin. In the group with high serum levels of survivin (Fig. 3a), the 5-year survival rate was only 9.28 %, and it was 9.63 % in the group whose tissues were positive for survivin (Fig. 3b).
Univariate and multivariate analysis of various prognostic variables in patients with PDAC
HR (95 % CI)
Identification of targets for early detection of PDAC is important to improve the prognosis of patients with this pernicious disease. Currently, carcinoembryonic antigen and cytokeratin-19 fragments are routinely used as serum markers for detection of PDAC. Owing to the low sensitivity and specificity of detection of these markers, additional serum markers must be established for early detection and diagnosis of PDAC.
Survivin, an IAP, has been studied as a prognostic marker in various cancers. Adida et al. reported that survivin expression in neuroblastoma correlated with unfavorable histology and aggressive and disseminated disease . In colorectal cancer and breast cancer, patients with surviving-positive tumors had a decreased apoptotic index and worse survival rates than those with survivin-negative tumors [17, 27]. In addition, survivin expression was correlated with poor prognosis in esophageal cancer and non-small cell lung cancer [19, 20]. Survivin expression in pancreatic cancer tissues could also be a useful prognostic marker in patients with this disease [24, 25].
In the present study, we showed that survivin levels in serum samples from patients with PDAC are significantly higher than those in a control population of healthy blood donors. Notably, serum survivin levels were higher in patients with perineural invasion, poor lymph node status, and venous invasion, compared with those without. We also found that positive survivin expression was higher in patients with PDAC with perineural invasion, poor lymph node status, and venous invasion, compared with those without. Thus, survivin concentrations and tissue survivin expression may be suitable as routine serum and tissue markers for the detection of metastatic disease in PDAC.
In addition, the serum survivin level was much higher in patients with PDAC at advanced stages and those with recurrence and poor differentiation; no significant differences in the serum levels of survivin were found in PDAC patients with different ages, genders, and tumor sizes. Thus, measurement of the serum level of survivin is useful for predicting the prognosis of patients with PDAC. However, no relation was found between survivin expression, TNM stage, recurrence, and tumor differentiation. This may have been caused by a small sample size.
Evaluation of the survival data showed that survival time was significantly shorter in patients with positive survivin expression and survivin concentrations >72.58 pg/ml. Thus, high survivin concentrations and positive survivin expression predicted a poor prognosis for patients with PDAC, especially in those presenting with metastasis. In addition, the uni- and multivariate analyses in the present study showed the prognostic significance of clinicopathologic factors such as TNM and tumor differentiation. These findings indicate that the results obtained from the present series of cases agree to PDAC in other counties. In addition, Cox regression analysis showed that survivin was an independent prognostic variable.
In the present study, we assessed the prognostic value of serum survivin in patients with PDAC and identified survivin as an independent prognostic factor. Owing to the limited number of controls and patients in this study, further studies are required. In addition, studies with serum samples and tissue survivin expression measured at different phases of PDAC progression could further elucidate the role of survivin in the growth and metastasis of PDAC.
Our findings provide evidence that survivin has important roles at different phases of metastatic spread of PDAC, and that measurement of serum survivin or detection of survivin expression could be of clinical value when identifying patients at high risk for disease progression.
This work was supported by funding from the Shandong natural science research foundation (No: 2014ZRB01198).
- Jemal A, Siegel R, Ward E, Hao Y, Xu J, Murray T, et al. Cancer statistics, 2008. CA Cancer J Clin. 2008;58:71–96.PubMedView ArticleGoogle Scholar
- Warshaw AL, Fernandez-del CC. Pancreatic carcinoma. N Engl J Med. 1992;326:455–65.PubMedView ArticleGoogle Scholar
- Li HY, Cui ZM, Chen J, Guo XZ, Li YY. Pancreatic cancer: diagnosis and treatments. Tumour Biol. 2015;36:1375–84.PubMedView ArticleGoogle Scholar
- Surlin V, Bintintan V, Petrariu FD, Dobrin R, Lefter R, Ciobică A, et al. Prognostic factors in resectable pancreatic cancer. Rev Med Chir Soc Med Nat Iasi. 2014;118:924–31.PubMedGoogle Scholar
- Wagner M, Redaelli C, Lietz M, Seiler CA, Friess H, Buchler MW. Curative resection is the single most important factor determining outcome in patients with pancreatic adenocarcinoma. Br J Surg. 2004;91:586–94.PubMedView ArticleGoogle Scholar
- Lowenfels AB, Maisonneuve P, Cavallini G, Ammann RW, Lankisch PG, Andersen JR. Pancreatitis and the risk of pancreatic cancer. International Pancreatitis Study Group. N Engl J Med. 1993;328:1433–7.PubMedView ArticleGoogle Scholar
- Talamini G, Falconi M, Bassi C, Sartori N, Salvia R, Caldiron E. Incidence of cancer in the course of chronic pancreatitis. Am J Gastroenterol. 1999;94:1253–60.PubMedView ArticleGoogle Scholar
- Maisonneuve P, Lowenfels AB. Chronic pancreatitis and pancreatic cancer. Dig Dis. 2002;20:32–7.PubMedView ArticleGoogle Scholar
- Dzeletovic I, Harrison ME, Crowell MD, Pannala R, Nguyen CC, Wu Q, et al. Pancreatitis before pancreatic cancer: clinical features and influence on outcome. J Clin Gastroenterol. 2014;48:801–5.PubMedView ArticleGoogle Scholar
- Deveraux QL, Reed JC. IAP family proteins–suppressors of apoptosis. Genes Dev. 1999;13:239–52.PubMedView ArticleGoogle Scholar
- Salvesen GS, Duckett CS. IAP proteins: blocking the road to death’s door. Nat Rev Mol Cell Biol. 2002;3:401–10.PubMedView ArticleGoogle Scholar
- Verdecia MA, Huang H, Dutil E, Kaiser DA, Hunter T, Noel JP. Structure of the human anti-apoptotic protein survivin reveals a dimeric arrangement. Nat Struct Biol. 2000;7:602–8.PubMedView ArticleGoogle Scholar
- Ambrosini G, Adida C, Altieri DC. A novel anti-apoptosis gene, survivin, expressed in cancer and lymphoma. Nat Med. 1997;3:917–21.PubMedView ArticleGoogle Scholar
- Cheung CH, Huang CC, Tsai FY, Lee JY, Cheng SM, Chang YC, et al. Survivin—biology and potential as a therapeutic target in oncology. Onco Targets Ther. 2013;6:1453–62.PubMed CentralPubMedView ArticleGoogle Scholar
- Ito R, Asami S, Motohashi S, Ootsuka S, Yamaguchi Y, Chin M, et al. Significance of survivin mRNA expression in prognosis of neuroblastoma. Biol Pharm Bull. 2005;28:565–8.PubMedView ArticleGoogle Scholar
- Islam A, Kageyama H, Takada N, Kawamoto T, Takayasu H, Isogai E, et al. High expression of Survivin, mapped to 17q25, is significantly associated with poor prognostic factors and promotes cell survival in human neuroblastoma. Oncogene. 2000;19:617–23.PubMedView ArticleGoogle Scholar
- Goossens-Beumer IJ, Zeestraten EC, Benard A, Christen T, Reimers MS, Keijzer R, et al. Clinical prognostic value of combined analysis of Aldh1, survivin, and EpCAM expression in colorectal cancer. Br J Cancer. 2014;110:2935–44.PubMed CentralPubMedView ArticleGoogle Scholar
- Xu C, Yamamoto-Ibusuki M, Yamamoto Y, Yamamoto S, Fujiwara S, Murakami K, et al. High survivin mRNA expression is a predictor of poor prognosis in breast cancer: a comparative study at the mRNA and protein level. Breast Cancer. 2012;23:209–13.Google Scholar
- Kato J, Kuwabara Y, Mitani M, Shinoda N, Sato A, Toyama T, et al. Expression of surviving in esophageal cancer: correlation with the prognosis and response to chemotherapy. Int J Cancer. 2001;95:92–5.PubMedView ArticleGoogle Scholar
- Rosato A, Menin C, Boldrin D, Dalla Santa S, Bonaldi L, Scaini MC, et al. Survivin expression impacts prognostically on NSCLC but not SCLC. Lung Cancer. 2013;79:180–6.PubMedView ArticleGoogle Scholar
- Abdel-Aziz A, Mohamed MA, Akl FM, Taha AN. Survivin expression in medulloblastoma: a possible marker for survival. Pathol Oncol Res. 2013;19:413–9.PubMedView ArticleGoogle Scholar
- Esh AM, Atfy M, Azizi NA, El Naggar MM, Khalil EE, Sherief L. Prognostic significance of survivin in pediatric acute lymphoblastic leukemia. Indian J Hematol Blood Transfus. 2011;27:18–25.PubMed CentralPubMedView ArticleGoogle Scholar
- Satoh K, Kaneko K, Hirota M, Masamune A, Satoh A, Shimosegawa T. Expression of survivin is correlated with cancer cell apoptosis and is involved in the development of human pancreatic duct cell tumors. Cancer. 2001;92:271–8.PubMedView ArticleGoogle Scholar
- Kami K, Doi R, Koizumi M, Toyoda E, Mori T, Ito D, et al. Survivin expression is a prognostic marker in pancreatic cancer patients. Surgery. 2004;136:443–8.PubMedView ArticleGoogle Scholar
- Ekeblad S, Lejonklou MH, Stålberg P, Skogseid B. Prognostic relevance of survivin in pancreatic endocrine tumors. World J Surg. 2012;36:1411–8.PubMed CentralPubMedView ArticleGoogle Scholar
- Ren YQ, Zhang HY, Su T, Wang XH, Zhang L. Clinical significance of serum survivin in patients with pancreatic ductal adenocarcinoma. Eur Rev Med Pharmacol Sci. 2014;18:3063–8.PubMedGoogle Scholar
- Li Y, Ma X, Wu X, Liu X, Liu L. Prognostic significance of survivin in breast cancer: meta-analysis. Breast J. 2014;20:514–24.PubMedView ArticleGoogle Scholar
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.