Invest Clin 64(2): 255 - 262, 2023 https://doi.org/10.54817/IC.v64n2a10

Corresponding author: Yi Liu. Department of Orthopedics, Wuxi People’s Hospital Affiliated to Nanjing Medical

University, Wuxi, Jiangsu Province, China. Email: liuyiwph@nau-edu.cn

Matrix metalloproteinase 2 expression

and disease-free survival of patients

with osteosarcoma: a meta-analysis.

Tianshu Gao, Zhenting Wang, and Yi Liu

Department of Orthopedics, Wuxi People’s Hospital Affiliated to Nanjing Medical

University, Wuxi, Jiangsu Province, China.

Keywords: meta-analysis; MMP-2; osteosarcoma; prognosis.

Abstract. Numerous studies indicate the influence of matrix metallopro-

teinase-2 (MMP-2) overexpression in osteosarcoma (OS) outcomes. A previous

study has systematically analyzed the correlation between MMP-2 expression

and the prognosis of OS. However, the results of subsequent studies remain in-

consistent. Therefore, a meta-analysis in terms of the prognostic value of MMP-

2 expression in OS was conducted. We employed the Newcastle-Ottawa scale

(NOS) to evaluate the quality of the studies. Five studies involving 284 patients

were included. The relative risk (RR) with a corresponding 95% confidence in-

terval (95%CI) was calculated to appraise the predictive value of MMP-2 positive

expression for OS recurrence and metastasis, and lower disease-free survival.

It was indicated by the results that MMP-2 positive individuals with OS had

higher recurrence and metastasis rates than negative individuals (RR=1.85,

95%CI:1.16-2.93, p<0.01). Sensitivity analysis showed that the combined RR

was stable. There was no significant change, independently of whichever article

was excluded.

256 Gao et al.

Investigación Clínica 64(2): 2023

Expresión de la metaloproteinasa de matriz 2 y supervivencia

libre de enfermedad de pacientes con osteosarcoma:

un metanálisis

Invest Clin 2023; 64 (2): 255 – 262

Palabras clave: metanálisis; MMP-2; osteosaroma; pronóstico.

Resumen. Numerosos estudios indican la influencia de la sobreexpresión

de la metaloproteinasa-2 de matriz (MMP-2) en los resultados del osteosarcoma

(OS). En un estudio previo se analizó sistemáticamente la correlación entre

la expresión de MMP-2 y el pronóstico del OS. Sin embargo, los resultados de

estudios posteriores siguen siendo inconsistentes. Por lo tanto, se llevó a cabo

un metanálisis en términos del valor pronóstico de la expresión de MMP-2 en el

OS. Se empleó la escala de Newcastle-Ottawa (NOS) para evaluar la calidad de

los estudios. Se incluyeron 5 estudios con 284 pacientes y se calculó el riesgo

relativo (RR) con su correspondiente intervalo de confianza del 95% (ic95%)

para evaluar el valor predictivo de la expresión positiva de MMP-2 para recidiva

de OS y metástasis, y menor supervivencia libre de enfermedad. Los resultados

indicaron que los individuos positivos para MMP-2 con OS presentaron mayor

tasa de recidiva y metástasis que los individuos negativos (RR= 1,85; ic 95%:

1,16-2,93; p<0,01). El análisis de sensibilidad mostró que el RR combinado

era estable. Cualquiera que fuera el artículo excluido, no hubo ningún cambio

significativo.

Received: 19-09-2022 Accepted: 06-11-2022

INTRODUCTION

Osteosarcoma (OS) is one of the most

common primary malignant bone tumors,

which mainly afflicts children, adolescents,

and young adults. The incidence rate of OS

worldwide is 1 to 3 per million people every

yea

1,2

. Owing to advanced surgical proce-

dures and combined chemotherapy, the sur-

vival rate of OS sufferers has improved from

under 20% to 70%

. Nevertheless, this im-

provement was limited to individuals with lo-

cal or earlier-stage OS, and the survival rate

of individuals with recurrences or metastasis

has not improved

. At present, the patho-

genesis of OS remains ambiguous

. Consid-

ering there is no suitable biomarker to esti-

mate the prognosis of OS, it is crucial to find

an appropriate biomarker to identify those

critical patients and give them individual-

ized treatment on time.

Matrix metalloproteinases-2 (MMP-2)

pertains to the family of zinc-dependent en-

dopeptidases. It is associated with diverse

cytological processes, including cell prolif-

eration, migration, apoptosis, angiogenesis,

and immunity

. Previous studies have shown

its overexpression in endometrial, oral epi-

thelial, and hepatocellular carcinoma and

generally predicted poorer prognosis

7-9

MMP-2 may also be related to the prognosis

of OS sufferers, but the conclusions remain

Matrix metalloproteinase 2 expression and osteosarcoma 257

Vol. 64(2): 255 - 262, 2023

controversial

10-14

. Therefore, we performed a

meta-analysis to systematically evaluate the

correlation between the expression of MMP-

2 and OS recurrence and metastasis.

MATERIALS AND METHODS

Search strategy

A systematic search was performed in

PubMed, Embase, Cochrane Library, Wan-

fang database and China National Knowl-

edge Internet (CNKI) for relevant articles

that were published before February 9, 2021

with no language restrictions. These terms

were included: “osteosarcoma” or “osteo-

genic sarcoma” and “matrix metalloprotein-

ase 2” or “MMP-2”. The ethics approval is in-

appropriate because meta-analysis is based

on former studies.

Inclusive and exclusive criteria

Inclusive criteria:

1. MMP-2 expression in OS tissues was

determined by immunohistochemical

staining;

2. Patients were pathologically diagnosed

with OS (gold standard);

3. Included studies had to be cohort stud-

ies;

4. Sufficient information for constructing

a 2 × 2 contingency table was available

in these studies.

Exclusive criteria:

1. No pathology was applied to confirm

the diagnosis of OS;

2. The critical value for positive versus

negative expression was not given;

3. Review articles, case reports, disserta-

tions, and articles on in vitro cell exper-

iments and animal experiments.

4. MMP-2 expression was not recorded with

dichotomous variables, or the patient

survival outcomes were unidentified.

5. Earlier and smaller sample size stud-

ies were excluded for articles with the

same patient population from the same

authors.

Data extraction

Two investigators (TG and ZW) extract-

ed the data separately from selected articles.

Two investigators (YL and TG) reached a

consensus and then crosschecked the data

extracted. The main information extracted

from the ultimately selected studies is pre-

sented below, including the first author’s

name, publication year, number of partici-

pants, and the critical value. MMP-2 expres-

sion was divided into positive and negative

groups according to the critical values pro-

vided in the articles.

Quality assessment

Newcastle-Ottawa scale (NOS)

was

employed to evaluate the quality of the stud-

ies. NOS possesses eight indicators with a to-

tal of nine stars. Studies obtaining a score of

no less than six stars were included.

Statistical analysis

The pooled risk ratio (RR) with 95%

confidence intervals (95%CI) was calculated

to evaluate the predictive value of MMP-2

expression for OS recurrence and metasta-

sis. The significance of the pooled RR was

then checked through the Z test, which was

considered significant when the P value was

<0.05. The heterogeneity between the stud-

ies was evaluated through I

statistics, which

described the proportion of total variation

in meta-analysis assessment from 0 to 100%.

The random effect model was used in this

meta-analysis. We also adopted Begg’s fun-

nel plot together with Egger’s test to evalu-

ate the probability of publication bias. The

statistical analysis was performed by The

Review Manager 5.3 (RevMan 5.3) and Stata

version 12.0 (Stata Corporation) softwares.

The 2-tailed P value under 0.05 would be

considered statistically significant.

RESULTS

Selection and study characteristics

Five cohort studies

10-14

with 284 indi-

viduals were included in the primary retriev-

258 Gao et al.

Investigación Clínica 64(2): 2023

al and ulterior evaluation of full texts (Fig.

1). Two of them were written in English, and

the other three were written in Chinese.

Among the 284 individuals, 191(67.3%)

individuals were positive for MMP-2 expres-

sion, and 93(32.7%) individuals were nega-

tive for MMP-2 expression. The other study

characteristics are shown in Table 1.

Quality assessment of studies

We evaluated the quality of the included

cohort studies through the NOS. The scores

ranged from 6 to 8 stars, with an average

score of 6.6 stars. The characteristics of the

included studies are shown in Table 1, and

the detailed scores for each study are listed

in Table 2.

Meta-analysis

The combined RR for evaluating the

correlation between positive MMP-2 expres-

sion and OS recurrence and metastasis is

(RR=1.85, 95%CI:1.16-2.93, p<0.01) (Fig.

2). This also indicated that removing any

separate study did not significantly change

our results. The Begg funnel plot and Egger’s

test assessed the publication bias. The fun-

nel plot suggested that there was no obvious

publication bias in this meta-analysis (Fig.

3), and the same outcome was obtained by

the Egger’s test (p>0.1).

DISCUSSION

OS is one kind of primary bone tumor

mainly afflicting the young generation

16,17

The survival rate of local or earlier-stage OS

patients has increased by over 70% owing

to advanced surgical techniques and com-

bined chemotherapy. Still, the prognosis of

patients with recurrence or metastasis re-

mains tragic

. Therefore, it is vital to iden-

tify high-risk patients through appropriate

biomarkers and give them individualized

treatment as soon as possible.

Belonging to the zinc-dependent en-

dopeptidase, MMP-2 hydrolyzes diverse mol-

ecules in the extracellular matrix. For exam-

ple, it participates in numerous biological

processes, including cell proliferation, dif-

ferentiation, adhesion, and migration. Its

overexpression is usually associated with

Fig. 1. Schematic representation of the study selection.

Matrix metalloproteinase 2 expression and osteosarcoma 259

Vol. 64(2): 255 - 262, 2023

Table 1

Characteristics of included studies and NOS scores.

Reference Study Year No. of

individuals

Average

age

(y)

Average

follow-up

period (m)

Critical

value

MMP-2 positive MMP-2 negative NOS score

Recurrence or

metastasis

Total Recurrence or

metastasis

Total

[10] Gong 2020 2020 73 23 42 >25% 26 40 16 33 7

[11] Guo 2004 2004 60 21.8 17.6 >5% 20 46 2 14 6

[12] Li 2006 2006 56 18 47 ≥10% 23 30 7 26 6

[13] Uchibori

2006

2006 47 25.6 43.3 >10% 15 41 2 6 8

[14] Zhou 2015 2015 48 12.4 24 >5% 8 34 1 14 6

Table 2

Detailed scores of included studies according to NOS scale.

Reference Study Representativeness

of exposed cohort

Selection

of non-

exposed

cohort

Ascertainment

of exposure

Outcome not

present at the

start of the

study

Comparability Assessment

of outcome

Follow-

up long

enough

Adequacy

of follow-

NOS

score

[10] Gong 2020 * 0 * * * * * * 7

[11] Guo 2004 * 0 * * 0 * * * 6

[12] Li 2006 0 0 * * * * * * 6

[13] Uchibori

2006

* * * * * * * * 8

[14] Zhou 2015 * 0 * * 0 * * * 6

260 Gao et al.

Investigación Clínica 64(2): 2023

the malignant phenotype of tumors

. Previ-

ous meta-analysis has suggested that MMP-2

overexpression has a close association with

poor prognosis of ovarian cancer, non-small

cell lung cancer, and gastric cancer

20-22

Therefore, we conducted a meta-analysis to

estimate the relevance between MMP-2 ex-

pression and OS recurrence or metastasis

rate.

Five published studies were finally in-

cluded (Fig. 1). Our results suggested that

the MMP-2 overexpression predicted the

higher recurrence and metastasis rate and

poorer survival of osteosarcoma patients

(RR=1.90, 95%CI:1.35-2.67, P<0.01) (Fig.

2). Considering that only five studies were

included, subgroup analysis was abandoned.

A sensitivity analysis was then conduct-

ed by removing individual studies sequen-

tially to appraise our results’ stability. The

pooled RR was stable since the elimination

of any single study had no significant influ-

ence on it. The Begg funnel plot and Egger’s

test results have shown that there was no

obvious publication bias in the research. All

the above suggested that MMP-2 could be a

potential prognostic biomarker for OS.

However, there are still some shortcom-

ings in our meta-analysis. Only 284 cases

(191 positives and 93 negative cases) were

Fig. 2. Expression of MMP-2 and recurrence and metastasis rate of OS patients.

Fig. 3. Funnel plot for the publication bias.

Matrix metalloproteinase 2 expression and osteosarcoma 261

Vol. 64(2): 255 - 262, 2023

included in the study. A relatively small sam-

ple size will inevitably lead to random errors,

sample bias, and a decrease in the universal-

ity of our conclusion. At present, there has

been no unified critical value to delimit the

positive/negative expression of MMP-2, and

there might be some bias since only papers

written in Chinese or English were incorpo-

rated into our research. Although there is

no obvious publication bias, there may still

be potential publication bias in this meta-

analysis since studies with significant results

are more possibly to be published. In addi-

tion, a larger sample size and more studies

are needed for subgroup analysis in terms

of age, gender, tumor location, and treat-

ment methods to obtain more general and

detailed conclusions.

CONCLUSIONS

In conclusion, overexpression of MMP-

2 predicts higher recurrence and metastasis

rates and lower disease-free survival rates.

MMP-2 has the potential of a prognostic bio-

marker of osteosarcoma. Nevertheless, more

randomized studies with more samples are

necessary to obtain a more solid evaluation

of the prognostic value of MMP-2 for OS pa-

tients.

Funding

This study was financially supported

by the Science and Research Project of the

Wuxi Municipal Health Commission (No.

M202019).

Conflict of interest

None to declare.

Authors’ ORCID Number

• Tianshu Gao: 0000-0002-5524-0234

• Zhenting Wang: 0000-0001-7329-1505

• Yi Liu: 0000-0003-0350-9008

Authors contribution

TG and ZW performed this study and

drafted this manuscript. YL designed this

study and significantly revised this manu-

script. TG and ZW contributed equally to this

study and should both be considered as first

authors. All authors have approved the sub-

mission and publication of this manuscript.

REFERENCES

1. Biazzo A, De Paolis M. Multidisciplinary ap-

proach to osteosarcoma. Acta Orthop Belg

2016;82(4):690-698. PMID: 29182106.

2. Corre I, Verrecchia F, Crenn V, Redini F,

Trichet V. The osteosarcoma microenvi-

ronment: a complex but targetable ecosys-

tem. Cells 2020;9(4):976. doi: 10.3390/

cells9040976.

3. Isakoff MS, Bielack SS, Meltzer P, Gorlick

R. Osteosarcoma: current treatment and a

collaborative pathway to success. J Clin On-

col 2015;33(27):3029-3035. doi: 10.1200/

JCO.2014.59.4895.

4. Allison DC, Carney SC, Ahlmann ER, Hen-

difar A, Chawla S, Fedenko A, Angeles C,

Menendez LR. A meta-analysis of osteo-

sarcoma outcomes in the modern medi-

cal era. Sarcoma 2012;2012:704872. doi:

10.1155/2012/704872.

5. Jafari F, Javdansirat S, Sanaie S, Naseri

A, Shamekh A, Rostamzadeh D, Dolati

S. Osteosarcoma: A comprehensive review

of management and treatment strategies.

Ann Diagn Pathol 2020;49:151654. doi:

10.1016/j.anndiagpath.2020.151654.

6. Cui N, Hu M, Khalil RA. Biochemical

and biological attributes of matrix meta-

lloproteinases. Prog Mol Biol Transl Sci

2017;147:1-73. doi: 10.1016/bs.pmbts.20

17.02.005.

7. Deng W, Peng W, Wang T, Chen J, Zhu S.

Overexpression of MMPs functions as a prog-

nostic biomarker for oral cancer patients: a

systematic feview and meta-analysis. Oral

Health Prev Dent 2019;17(6):505-514. doi:

10.3290/j.ohpd.a43636.

8. Liu C, Li Y, Hu S, Chen Y, Gao L, Liu D, Guo

H, Yang Y. Clinical significance of matrix

metalloproteinase-2 in endometrial cancer:

262 Gao et al.

Investigación Clínica 64(2): 2023

A systematic review and meta-analysis. Me-

dicine (Baltimore) 2018;97(29):e10994.

doi: 10.1097/MD.0000000000010994.

9. Scheau C, Badarau IA, Costache R, Carun-

tu C, Mihai GL, Didilescu AC, Constantin

C, Neagu M. The role of matrix metallo-

proteinases in the epithelial-mesenchymal

transition of hepatocellular carcinoma. Anal

Cell Pathol (Amst) 2019;2019:9423907.

doi: 10.1155/2019/9423907.

10. Gong C, Sun K, Xiong HH, Sneh T, Zhang

J, Zhou X, Yan P, Wang JH. Expression of

CXCR4 and MMP-2 is associated with poor

prognosis in patients with osteosarcoma.

Histol Histopathol 2020;35(8):863-870.

doi: 10.14670/HH-18-219.

11. Yamahana H, Komiya Y, Takino T, Endo Y,

Yamada H, Asada C, Uto Y. Structure-ac-

tivity relationships of UTX-121 derivatives

for the development of novel matrix meta-

lloproteinase-2/9 inhibitors. Chem Pharm

Bull (Tokyo) 2021;69(10):1017-1028. doi:

10.1248/cpb.c21-00549.

12. Gieger TL, Nettifee-Osborne J, Hallman

B, Johannes C, Clarke D, Nolan MW, Wi-

lliams LE. The impact of carboplatin and

toceranib phosphate on serum vascular

endothelial growth factor (VEGF) and me-

talloproteinase-9 (MMP-9) levels and survi-

val in canine osteosarcoma. Can J Vet Res

2017;81(3):199-205. PMID: 28725110.

13. Uchibori M, Nishida Y, Nagasaka T, Yama-

da Y, Nakanishi K, Ishiguro N. Increased

expression of membrane-type matrix meta-

lloproteinase-1 is correlated with poor prog-

nosis in patients with osteosarcoma. Int J

Oncol 2006;28(1):33-42. PMID: 16327977.

14. Kunz P, Sähr H, Lehner B, Fischer C,

Seebach E, Fellenberg J. Elevated ratio

of MMP2/MMP9 activity is associated with

poor response to chemotherapy in osteo-

sarcoma. BMC Cancer 2016;16:223. doi:

10.1186/s12885-016-2266-5.

15. Wells GA, Shea B, O’Connell D, Peterson

J, Welch V, Losos M, Tugwell P. The New-

castle-Ottawa Scale (NOS) for assessing the

quality if nonrandomized studies in meta-

analyses. Available at: http://www.ohri.ca/

programs/clinical_epidemiology/oxford.

htm

16. Benjamin RS, Patel SR. Pediatric and adult

osteosarcoma: comparisons and contrasts

in presentation and therapy. Cancer Treat

Res 2009;152:355-363. doi: 10.1007/978-

1-4419-0284-9_19.

17. Simpson E, Brown HL. Understanding os-

teosarcomas. JAAPA 2018;31(8):15-19. doi:

10.1097/01.JAA.0000541477.24116.8d

18. Kager L, Tamamyan G, Bielack S. No-

vel insights and therapeutic interventions

for pediatric osteosarcoma. Future Oncol

2017;13(4):357-368. doi: 10.2217/fon-

2016-0261.

19. Henriet P, Emonard H. Matrix metallo-

proteinase-2: Not (just) a “hero” of the

past. Biochimie 2019;166:223-232. doi:

10.1016/j.biochi.2019.07.019.

20. Fu Z, Xu S, Xu Y, Ma J, Li J, Xu P. The ex-

pression of tumor-derived and stromal-deri-

ved matrix metalloproteinase 2 predicted

prognosis of ovarian cancer. Int J Gynecol

Cancer 2015;25(3):356-362. doi: 10.1097/

IGC.0000000000000386.

21. Qian Q, Wang Q, Zhan P, Peng L, Wei

SZ, Shi Y, Song Y. The role of matrix me-

talloproteinase 2 on the survival of pa-

tients with non-small cell lung cancer:

a systematic review with meta-analysis.

Cancer Invest 2010;28(6):661-669. doi:

10.3109/07357901003735634.

22. Shen W, Xi H, Wei B, Chen L. The prog-

nostic role of matrix metalloproteinase

2 in gastric cancer: a systematic review

with meta-analysis. J Cancer Res Clin On-

col 2014;140(6):1003-1009. doi: 10.1007/

s00432-014-1630-6.