Cancer Investigation, Early Online:1–7, 2015 ISSN: 0735-7907 print / 1532-4192 online C 2015 Informa Healthcare USA, Inc. Copyright DOI: 10.3109/07357907.2015.1047507
ORIGINAL ARTICLE
Cancer Stem Cell Markers Are Associated With Distant Hematogenous Liver Metastases But Not With Peritoneal Carcinomatosis in Colorectal Cancer 2 ¨ Jens Neumann,1 Lisa Lohrs, Markus Albertsmeier,2 Simone Reu,1 Markus Guba,2 Jens Werner,2 Thomas Kirchner,1,3,4 and Martin Angele2
Cancer Invest Downloaded from informahealthcare.com by Nyu Medical Center on 06/19/15 For personal use only.
1
Institute of Pathology, Ludwig-Maximilians-Universit¨at M¨unchen, Munich, Germany, 2 Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, Medical Center of the University of Munich, Munich, Germany, 3 German Cancer Consortium (DKTK), Heidelberg, Germany, 4 German Cancer Research Center (DKFZ), Heidelberg, Germany About 85% of sporadic CRC develop via the adenomacarcinoma sequence starting with either loss of APC function or oncogenic β-catenin mutations, initiating a dysregulation of Wnt/β-catenin-signalling and subsequently of Wnt/β-catenin-dependent colonic cancer stem cells (CSCs) [8–11]. Recent studies of our group could link high nuclear β-catenin in CRC with poor prognosis and progression [12]. Furthermore, the cell surface markers CD133 and CD44 have recently been associated with colonic CSCs and poor prognosis in CRC [13–16]. Based on these observations, we were able to define an immunohistochemical algorithm correlating with extremely high and extremely low risks of distant metastases in right sided colon cancer [17]. We were able to demonstrate that CRC with a mismatch-repair deficiency (MMRD) proven by loss of MLH1-protein expression were significantly associated with a very low risk of distant metastases. In contrast, MLH1-positive cases are associated with an increased risk of distant metastases to the liver, especially when combined expression of β-catenin and CD133 is present. The aim of this study is to analyze the relevance of cancer stem cell markers for different types of tumor spread, namely PC versus hematogenous liver metastasis. The results of our study provide strong evidence that the expression of cancer stem cell markers correlate only with hematogenous liver metastasis, but not with PC, and enable to distinguish carcinomas with different spreading abilities.
Although peritoneal carcinomatosis (PC) displays advanced stage in colorectal cancer (CRC), most patients present without distant metastases. To analyze the expression of cancer stem cell markers immunohistochemistry for CD133, CD44 and β-catenin was applied to CRC with exclusive PC, exclusive hepatic metastasis and CRC with combined spread. Expression of cancer stem cell markers correlated with hematogeneous metastases to the liver and was absent in patients with exclusive PC. Thus, expression of cancer stem cell markers correlates with different patterns of metastatic spread in CRC. These data indicate that CRC with exclusive PC lack stem cell features needed for distant dissemination. Keywords: Colorectal cancer, Peritoneal carcinomatosis, Liver metastasis, CD133, CD44, β-catenin
INTRODUCTION Metastatic spread is the most important life-threatening feature of malignant disease such as colorectal cancer (CRC). At time of diagnosis approximately 20% of patients with CRC have synchronous distant metastases mainly to the liver and 25% with stage II CRC and 50–60% of patients with stage III CRC relapse within 5 years, mainly due to distant spread [1]. Besides the liver, another common site of metastasis is the peritoneum. Peritoneal carcinomatosis (PC) is present in about 4–7% of CRC patients at the time of first diagnosis and in approximately 25% of patients with recurrent disease [2–5]. Of interest, PC is the only site of distant metastasis in 41–45% of metastasized CRC patients [6,7]. Thus, the question arises whether PC reflects only an advanced stage of loco-regional tumor spread or a disseminating phenotype of CRC with the ability for hematogenous distant metastases.
MATERIAL AND METHODS Tissue Selection Formalin fixed-, paraffin-embedded (FFPE) samples of CRC from 68 patients that underwent surgical tumor resection at the Ludwig-Maximilians-Universit¨at (LMU) M¨unchen
Correspondence to: Jens Neumann, M.D., Institute of Pathology, Ludwig-Maximilians-Universit¨at M¨unchen, Thalkirchner Straße 36, 80337 Munich, Germany, email: [email protected] Received 21 January 2015; accepted 29 April 2015.
J. Neumann et al.
Cancer Invest Downloaded from informahealthcare.com by Nyu Medical Center on 06/19/15 For personal use only.
Table 1. Correlation of Clinico-Pathological Variables of Colorectal Cancer Patients at Time of Surgery (According to TNM Classification of Malignant Tumors 7th edition 2009) with Patterns of Metastatic Spread All patients Age years
ORIGINAL ARTICLE
Cancer Stem Cell Markers Are Associated With Distant Hematogenous Liver Metastases But Not With Peritoneal Carcinomatosis in Colorectal Cancer 2 ¨ Jens Neumann,1 Lisa Lohrs, Markus Albertsmeier,2 Simone Reu,1 Markus Guba,2 Jens Werner,2 Thomas Kirchner,1,3,4 and Martin Angele2
Cancer Invest Downloaded from informahealthcare.com by Nyu Medical Center on 06/19/15 For personal use only.
1
Institute of Pathology, Ludwig-Maximilians-Universit¨at M¨unchen, Munich, Germany, 2 Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, Medical Center of the University of Munich, Munich, Germany, 3 German Cancer Consortium (DKTK), Heidelberg, Germany, 4 German Cancer Research Center (DKFZ), Heidelberg, Germany About 85% of sporadic CRC develop via the adenomacarcinoma sequence starting with either loss of APC function or oncogenic β-catenin mutations, initiating a dysregulation of Wnt/β-catenin-signalling and subsequently of Wnt/β-catenin-dependent colonic cancer stem cells (CSCs) [8–11]. Recent studies of our group could link high nuclear β-catenin in CRC with poor prognosis and progression [12]. Furthermore, the cell surface markers CD133 and CD44 have recently been associated with colonic CSCs and poor prognosis in CRC [13–16]. Based on these observations, we were able to define an immunohistochemical algorithm correlating with extremely high and extremely low risks of distant metastases in right sided colon cancer [17]. We were able to demonstrate that CRC with a mismatch-repair deficiency (MMRD) proven by loss of MLH1-protein expression were significantly associated with a very low risk of distant metastases. In contrast, MLH1-positive cases are associated with an increased risk of distant metastases to the liver, especially when combined expression of β-catenin and CD133 is present. The aim of this study is to analyze the relevance of cancer stem cell markers for different types of tumor spread, namely PC versus hematogenous liver metastasis. The results of our study provide strong evidence that the expression of cancer stem cell markers correlate only with hematogenous liver metastasis, but not with PC, and enable to distinguish carcinomas with different spreading abilities.
Although peritoneal carcinomatosis (PC) displays advanced stage in colorectal cancer (CRC), most patients present without distant metastases. To analyze the expression of cancer stem cell markers immunohistochemistry for CD133, CD44 and β-catenin was applied to CRC with exclusive PC, exclusive hepatic metastasis and CRC with combined spread. Expression of cancer stem cell markers correlated with hematogeneous metastases to the liver and was absent in patients with exclusive PC. Thus, expression of cancer stem cell markers correlates with different patterns of metastatic spread in CRC. These data indicate that CRC with exclusive PC lack stem cell features needed for distant dissemination. Keywords: Colorectal cancer, Peritoneal carcinomatosis, Liver metastasis, CD133, CD44, β-catenin
INTRODUCTION Metastatic spread is the most important life-threatening feature of malignant disease such as colorectal cancer (CRC). At time of diagnosis approximately 20% of patients with CRC have synchronous distant metastases mainly to the liver and 25% with stage II CRC and 50–60% of patients with stage III CRC relapse within 5 years, mainly due to distant spread [1]. Besides the liver, another common site of metastasis is the peritoneum. Peritoneal carcinomatosis (PC) is present in about 4–7% of CRC patients at the time of first diagnosis and in approximately 25% of patients with recurrent disease [2–5]. Of interest, PC is the only site of distant metastasis in 41–45% of metastasized CRC patients [6,7]. Thus, the question arises whether PC reflects only an advanced stage of loco-regional tumor spread or a disseminating phenotype of CRC with the ability for hematogenous distant metastases.
MATERIAL AND METHODS Tissue Selection Formalin fixed-, paraffin-embedded (FFPE) samples of CRC from 68 patients that underwent surgical tumor resection at the Ludwig-Maximilians-Universit¨at (LMU) M¨unchen
Correspondence to: Jens Neumann, M.D., Institute of Pathology, Ludwig-Maximilians-Universit¨at M¨unchen, Thalkirchner Straße 36, 80337 Munich, Germany, email: [email protected] Received 21 January 2015; accepted 29 April 2015.
J. Neumann et al.
Cancer Invest Downloaded from informahealthcare.com by Nyu Medical Center on 06/19/15 For personal use only.
Table 1. Correlation of Clinico-Pathological Variables of Colorectal Cancer Patients at Time of Surgery (According to TNM Classification of Malignant Tumors 7th edition 2009) with Patterns of Metastatic Spread All patients Age years
