{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,15]],"date-time":"2026-09-15T01:32:25Z","timestamp":1789435945027,"version":"build-2803163510"},"reference-count":52,"publisher":"MDPI AG","issue":"1","license":[{"start":{"date-parts":[[2025,12,25]],"date-time":"2025-12-25T00:00:00Z","timestamp":1766620800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Cancers"],"abstract":"<jats:p>Background\/Objectives: Colorectal cancer (CRC) is the third most commonly occurring cancer. Apoptosis is a fundamental cellular process of programmed cell death, and although many pathways for inducing apoptosis may exist, only the intrinsic and the extrinsic pathways have been demonstrated in detail. This study investigated the expression of BAD, BID, BCL2, MDM2, p53, Ki-67, and PUMA in primary CRC, paired lymph node metastases, and adjacent normal mucosa and explored their associations with clinicopathologic features and patient outcomes. Methods: One hundred thirty patients who underwent surgery for resectable CRC were included in the study. FFPE tumor tissue samples were prospectively collected and used for the construction of the TMA blocks from the primary tumor, paired lymph node metastasis, and paired normal mucosa. Immunohistochemistry for BAD, BID, BCL2, MDM2, p53, Ki-67, and PUMA antibodies was performed. Results: Univariate analysis showed reduced cancer-specific (CSS), disease-free (DFS), and overall survival (OS) in patients with lymphatic invasion, \u22654 positive lymph nodes, poorly differentiated tumors, older age (\u226565), right-sided tumors, stage IIIC disease, or no chemotherapy. Multivariate analysis identified lymphovascular invasion, \u22654 metastatic nodes, and high Ki-67 as independent predictors of worse DFS and CSS, with low BAD expression additionally predicting DFS. For OS, adverse predictors included nodal burden, tumor location, absence of chemotherapy, and high p53, MDM2, and Ki-67 expression. Notably, combined high PUMA and low p53 expression independently predicted poorer CSS and OS. Conclusions: High expression of PUMA combined with low expression of p53 and a high expression of Ki-67 were independent unfavorable prognostic indicators for both OS and CSS. Further studies are required to clarify the prognostic and therapeutic role of these markers in CRC.<\/jats:p>","DOI":"10.3390\/cancers18010072","type":"journal-article","created":{"date-parts":[[2025,12,26]],"date-time":"2025-12-26T02:07:58Z","timestamp":1766714878000},"page":"72","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["PUMA\u2013p53 Dysregulation and Ki-67 Overexpression Define Unfavorable Prognostic Signatures in Colorectal Cancer"],"prefix":"10.3390","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-6839-370X","authenticated-orcid":false,"given":"Alexandros","family":"Mekras","sequence":"first","affiliation":[{"name":"Department of General and Visceral Surgery, SHG-Klinikum Merzig, Academic Hospital of University of Saarland, 66663 Merzig, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6403-999X","authenticated-orcid":false,"given":"Dimitrios","family":"Tsavdaris","sequence":"additional","affiliation":[{"name":"First Propaedeutic Surgery Department, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dimosthenis","family":"Mekras","sequence":"additional","affiliation":[{"name":"First Propaedeutic Surgery Department, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alexandra","family":"Vasilakou","sequence":"additional","affiliation":[{"name":"First Propaedeutic Surgery Department, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9787-7391","authenticated-orcid":false,"given":"Daniel","family":"Paramythiotis","sequence":"additional","affiliation":[{"name":"First Propaedeutic Surgery Department, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Antonios","family":"Michalopoulos","sequence":"additional","affiliation":[{"name":"First Propaedeutic Surgery Department, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5662-9201","authenticated-orcid":false,"given":"Mattheos","family":"Bobos","sequence":"additional","affiliation":[{"name":"Department of Biomedical Sciences, School of Medical Sciences, International Hellenic University, Sindos, 57400 Thessaloniki, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,12,25]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"669","DOI":"10.1001\/jama.2021.0106","article-title":"Diagnosis and Treatment of Metastatic Colorectal Cancer: A Review","volume":"325","author":"Biller","year":"2021","journal-title":"JAMA"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"480","DOI":"10.1016\/j.annonc.2019.12.007","article-title":"Evaluation of the change of outcomes over a 10-year period in patients with stage III colon cancer: Pooled analysis of 6501 patients treated with fluorouracil, leucovorin, and oxaliplatin in the ACCENT database","volume":"31","author":"Salem","year":"2020","journal-title":"Ann. Oncol."},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"Orlandi, G., Roncucci, L., Carnevale, G., and Sena, P. (2023). Different Roles of Apoptosis and Autophagy in the Development of Human Colorectal Cancer. Int. J. Mol. Sci., 24.","DOI":"10.3390\/ijms241210201"},{"key":"ref_4","first-page":"233","article-title":"Colorectal cancer statistics, 2023","volume":"73","author":"Siegel","year":"2023","journal-title":"CA Cancer J. Clin."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"519","DOI":"10.1158\/0008-5472.CAN-12-2269","article-title":"Systems analysis of BCL2 protein family interactions establishes a model to predict responses to chemotherapy","volume":"73","author":"Lindner","year":"2013","journal-title":"Cancer Res."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"305","DOI":"10.1007\/s10495-020-01601-9","article-title":"BCL-2 family deregulation in colorectal cancer: Potential for BH3 mimetics in therapy","volume":"25","author":"Ramesh","year":"2020","journal-title":"Apoptosis"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"191","DOI":"10.1007\/978-1-0716-2553-8_16","article-title":"Cancer and Apoptosis","volume":"2543","author":"Chaudhry","year":"2022","journal-title":"Methods Mol. Biol."},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"Qian, S., Wei, Z., Yang, W., Huang, J., Yang, Y., and Wang, J. (2022). The role of BCL-2 family proteins in regulating apoptosis and cancer therapy. Front. Oncol., 12.","DOI":"10.3389\/fonc.2022.985363"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"20","DOI":"10.1007\/s10495-022-01780-7","article-title":"BCL-2 protein family: Attractive targets for cancer therapy","volume":"28","author":"Kaloni","year":"2023","journal-title":"Apoptosis"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1071","DOI":"10.1038\/cdd.2015.50","article-title":"The BCL-2 protein family, BH3-mimetics and cancer therapy","volume":"22","author":"Delbridge","year":"2015","journal-title":"Cell Death Differ."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"1533","DOI":"10.1158\/1535-7163.MCT-08-0140","article-title":"Reactivation of p53 by a specific MDM2 antagonist (MI-43) leads to p21-mediated cell cycle arrest and selective cell death in colon cancer","volume":"7","author":"Shangary","year":"2008","journal-title":"Mol. Cancer Ther."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"84","DOI":"10.3748\/wjg.v21.i1.84","article-title":"p53 mutations in colorectal cancer- molecular pathogenesis and pharmacological reactivation","volume":"21","author":"Li","year":"2015","journal-title":"World J. Gastroenterol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"107","DOI":"10.2174\/0109298665256238231120093150","article-title":"KIF20A Promotes CRC Progression and the Warburg Effect through the C-Myc\/HIF-1\u03b1 Axis","volume":"31","author":"Wu","year":"2024","journal-title":"Protein Pept. Lett."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"43","DOI":"10.2174\/0109298665248028231122064831","article-title":"LINC01836 Promotes Colorectal Cancer Progression and Functions as ceRNA to Target SLC17A9 by Sponging miR-1226-3p","volume":"31","author":"Xu","year":"2024","journal-title":"Protein Pept. Lett."},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Richardsen, E., Andersen, S., Al-Saad, S., Rakaee, M., Nordby, Y., Pedersen, M.I., Ness, N., Grindstad, T., Movik, I., and D\u00f8nnem, T. (2017). Evaluation of the proliferation marker Ki-67 in a large prostatectomy cohort. PLoS ONE, 15.","DOI":"10.1371\/journal.pone.0186852"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1566","DOI":"10.3892\/mmr.2014.2914","article-title":"Ki67 is a promising molecular target in the diagnosis of cancer (review)","volume":"11","author":"Li","year":"2015","journal-title":"Mol. Med. Rep."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"422","DOI":"10.1111\/j.1365-2184.2007.00433.x","article-title":"Chromophore-assisted light inactivation of pKi-67 leads to inhibition of ribosomal RNA synthesis","volume":"40","author":"Rahmanzadeh","year":"2007","journal-title":"Cell Prolif."},{"key":"ref_18","first-page":"1187","article-title":"Cutoff of 25% for Ki67 expression is a good classification tool for prognosis in colorectal cancer in the AJCC-8 stratification","volume":"43","author":"Tong","year":"2020","journal-title":"Oncol. Rep."},{"key":"ref_19","doi-asserted-by":"crossref","unstructured":"Luo, Z.W., Zhu, M.G., Zhang, Z.Q., Ye, F.J., Huang, W.H., and Luo, X.Z. (2019). Increased expression of Ki-67 is a poor prognostic marker for colorectal cancer patients: A meta analysis. BMC Cancer, 19.","DOI":"10.1186\/s12885-019-5324-y"},{"key":"ref_20","doi-asserted-by":"crossref","unstructured":"Kasprzak, A. (2023). Prognostic Biomarkers of Cell Proliferation in Colorectal Cancer (CRC): From Immunohistochemistry to Molecular Biology Techniques. Cancers, 15.","DOI":"10.3390\/cancers15184570"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"1701","DOI":"10.1136\/gut.2004.052704","article-title":"Apoptosis and colorectal cancer","volume":"53","author":"Watson","year":"2004","journal-title":"Gut"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"20","DOI":"10.1016\/j.humpath.2017.07.014","article-title":"Prognostic value of programmed death ligand 1, p53, and Ki-67 in patients with advanced-stage colorectal cancer","volume":"71","author":"Wang","year":"2018","journal-title":"Hum. Pathol."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"5018","DOI":"10.3748\/wjg.v23.i27.5018","article-title":"High expression of anti-apoptotic protein Bcl-2 is a good prognostic factor in colorectal cancer: Result of a meta-analysis","volume":"23","author":"Huang","year":"2017","journal-title":"World J. Gastroenterol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"331","DOI":"10.1016\/j.otohns.2010.05.007","article-title":"A practical guide to understanding Kaplan-Meier curves","volume":"143","author":"Rich","year":"2010","journal-title":"Otolaryngol. Neck Surg."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1572","DOI":"10.1200\/JCO.2004.10.042","article-title":"Prognostic value of proliferation, apoptosis, defective DNA mismatch repair, and p53 overexpression in patients with resected Dukes\u2019 B2 or C colon cancer: A North Central Cancer Treatment Group Study","volume":"22","author":"Garrity","year":"2004","journal-title":"J. Clin. Oncol."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"436","DOI":"10.1002\/path.894","article-title":"Apoptosis and cell-cycle regulatory proteins in colorectal carcinoma: Relationship to tumour stage and patient survival","volume":"194","author":"Elkablawy","year":"2001","journal-title":"J. Pathol."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"545","DOI":"10.1002\/(SICI)1097-0215(19991222)84:6<545::AID-IJC1>3.0.CO;2-2","article-title":"Evaluation of multiple bio-pathological factors in colorectal adenocarcinomas: Independent prognostic role of p53 and bcl-2","volume":"84","author":"Buglioni","year":"1999","journal-title":"Int. J. Cancer"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"S71","DOI":"10.1038\/onc.2009.45","article-title":"PUMA, a potent killer with or without p53","volume":"27","author":"Yu","year":"2008","journal-title":"Oncogene"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"6579","DOI":"10.1007\/s13277-015-3353-y","article-title":"Genetic dissimilarity between primary colorectal carcinomas and their lymph node metastases: Ploidy, p53, bcl-2, and c-myc expression\u2014A pilot study","volume":"36","author":"Zalata","year":"2015","journal-title":"Tumor Biol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"2751","DOI":"10.1007\/s10620-007-9799-z","article-title":"Pro-apoptotic PUMA and anti-apoptotic phospho-BAD are highly expressed in colorectal carcinomas","volume":"52","author":"Kim","year":"2007","journal-title":"Dig. Dis. Sci."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1292","DOI":"10.1007\/s00268-023-06918-5","article-title":"Prognostic Impact of Main Lymph Node Metastasis in Patients with Colon Cancer","volume":"47","author":"Sugiura","year":"2023","journal-title":"World J. Surg."},{"key":"ref_32","doi-asserted-by":"crossref","unstructured":"Zhang, M., Zhao, F., Wu, A., Du, X., Zhou, L., Mei, S., Wei, F., Hu, S., Liu, X., and Yang, H. (2025). Metastatic Patterns of Apical Lymph Node and Prognostic Analysis in Rectal and Sigmoid Colon Cancer-A Multicenter Retrospective Cohort Study of 2809 Cases. Cancers, 17.","DOI":"10.3390\/cancers17142389"},{"key":"ref_33","doi-asserted-by":"crossref","unstructured":"Mroczkowski, P., Kim, S., Otto, R., Lippert, H., Zajdel, R., Zajdel, K., and Merecz-Sadowska, A. (2024). Prognostic Value of Metastatic Lymph Node Ratio and Identification of Factors Influencing the Lymph Node Yield in Patients Undergoing Curative Colon Cancer Resection. Cancers, 16.","DOI":"10.3390\/cancers16010218"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"294","DOI":"10.1016\/S0140-6736(24)00360-X","article-title":"Colorectal cancer","volume":"404","author":"Eng","year":"2024","journal-title":"Lancet"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"181","DOI":"10.1097\/DCR.0000000000001258","article-title":"Lymphovascular Invasion and Perineural Invasion Negatively Impact Overall Survival for Stage II Adenocarcinoma of the Colon","volume":"62","author":"Skancke","year":"2019","journal-title":"Dis. Colon Rectum"},{"key":"ref_36","first-page":"2965","article-title":"Prognostic impact of lymphatic invasion of colorectal cancer: A single-center analysis of 1616 patients over 24 years","volume":"33","author":"Akagi","year":"2013","journal-title":"Anticancer Res."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"212","DOI":"10.1038\/bjc.2015.211","article-title":"Prognostic value of lymph node ratio and extramural vascular invasion on survival for patients undergoing curative colon cancer resection","volume":"113","author":"Parnaby","year":"2015","journal-title":"Br. J. Cancer"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"e17256","DOI":"10.1111\/codi.17256","article-title":"Association between lymphovascular invasion and lymph node metastases in colon cancer: A National Cancer Database analysis","volume":"27","author":"Emile","year":"2025","journal-title":"Color. Dis."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"753","DOI":"10.1093\/jjco\/hyae035","article-title":"Prognostic impact of primary tumour location after curative resection in Stage I-III colorectal cancer: A single-centre retrospective study","volume":"54","author":"Inoue","year":"2024","journal-title":"Jpn. J. Clin. Oncol."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"917","DOI":"10.1097\/SLA.0000000000002206","article-title":"Impact of Primary Tumor Location on Postoperative Recurrence and Subsequent Prognosis in Nonmetastatic Colon Cancers: A Multicenter Retrospective Study Using a Propensity Score Analysis","volume":"267","author":"Ishihara","year":"2018","journal-title":"Ann. Surg."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"2444","DOI":"10.7150\/jca.85695","article-title":"Differences in Colorectal Cancer Survival Based on Primary Tumor Location: Retrospective Study from a Single Institution","volume":"14","author":"Ortega","year":"2023","journal-title":"J. Cancer"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"oyaf317","DOI":"10.1093\/oncolo\/oyaf317","article-title":"Prognosis in stage II colorectal cancer: The effect of the primary tumour location and biomarkers\u2014A retrospective cohort study","volume":"30","author":"Colebunders","year":"2025","journal-title":"Oncologist"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"620","DOI":"10.1002\/gcc.20774","article-title":"MDM2 gene amplification in colorectal cancer is associated with disease progression at the primary site, but inversely correlated with distant metastasis","volume":"49","author":"Sugano","year":"2010","journal-title":"Genes Chromosom. Cancer"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"562","DOI":"10.1093\/carcin\/bgad040","article-title":"The ubiquitin E3 ligase MDM2 induces chemoresistance in colorectal cancer by degradation of ING3","volume":"44","author":"Zhang","year":"2023","journal-title":"Carcinogenesis"},{"key":"ref_45","first-page":"7825","article-title":"Expression and clinical significance of ATM and PUMA gene in patients with colorectal cancer","volume":"14","author":"Xiong","year":"2017","journal-title":"Oncol. Lett."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"811","DOI":"10.1080\/14737159.2022.2125802","article-title":"The prognostic and clinical value of p53 upregulated modulator of apoptosis expression in solid tumors: A meta-analysis and TCGA data review","volume":"22","author":"Gao","year":"2022","journal-title":"Expert Rev. Mol. Diagn."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"5810","DOI":"10.1158\/1078-0432.CCR-07-5202","article-title":"Prognostic impact of bim, puma, and noxa expression in human colon carcinomas","volume":"14","author":"Sinicrope","year":"2008","journal-title":"Clin. Cancer Res."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"1540","DOI":"10.1016\/j.bcp.2006.02.011","article-title":"The BH3-only protein, PUMA, is involved in oxaliplatin-induced apoptosis in colon cancer cells","volume":"71","author":"Wang","year":"2006","journal-title":"Biochem. Pharmacol."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"499","DOI":"10.1186\/s12964-025-02112-3","article-title":"The multifaceted role of PUMA in cell death pathways: Its therapeutic potential across cancer types","volume":"23","author":"Tat","year":"2025","journal-title":"Cell Commun. Signal."},{"key":"ref_50","first-page":"3965","article-title":"Expression of p53 and Ki-67 as prognostic factors for survival of men with colorectal cancer","volume":"32","author":"Lumachi","year":"2012","journal-title":"Anticancer. Res."},{"key":"ref_51","first-page":"657","article-title":"Abstracts presented at the 13th European Colorectal Congress (#ECCStGallen), 1-5.12.2019, St. Gallen, Switzerland","volume":"24","author":"Adamina","year":"2020","journal-title":"Tech. Coloproctol."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"e89","DOI":"10.1016\/j.jamcollsurg.2019.08.955","article-title":"Combined High Expression of PUMA and Ki-67 with Low Expression of p53 Are Independent Unfavourable Prognostic Indicators for Both the Overall Survival (OS) and Cancer Specific Survival (CSS) in Resectable Colorectal Adenocarcinomas","volume":"229","author":"Mekras","year":"2019","journal-title":"J. Am. Coll. Surg."}],"container-title":["Cancers"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2072-6694\/18\/1\/72\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,12,26]],"date-time":"2025-12-26T02:17:54Z","timestamp":1766715474000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2072-6694\/18\/1\/72"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,12,25]]},"references-count":52,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2026,1]]}},"alternative-id":["cancers18010072"],"URL":"https:\/\/doi.org\/10.3390\/cancers18010072","relation":{},"ISSN":["2072-6694"],"issn-type":[{"value":"2072-6694","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,12,25]]}}}