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Journal of Clinical Oncology, Vol 23, No 34 (December 1), 2005: pp. 8765-8773 © 2005 American Society of Clinical Oncology. DOI: 10.1200/JCO.2005.02.2871 Wnt5a Expression Is Associated With the Tumor Proliferation and the Stromal Vascular Endothelial Growth Factor—An Expression in Non–Small-Cell Lung CancerFrom the Departments of Second Surgery and Pathology and Host Defense, Faculty of Medicine, Kagawa University, Kagawa, Japan Address reprint requests to Cheng-long Huang, MD, Department of Second Surgery, Faculty of Medicine, Kagawa University, 1750-1, Miki-cho, Kita-gun, Kagawa 761-0793, Japan; e-mail: chuang{at}kms.ac.jp
PURPOSE: The Wnt gene family encodes the multifunctional signaling glycoproteins. We performed the present study to investigate the clinical significance of Wnt5a expression in non–small-cell lung cancer (NSCLC). PATIENTS AND METHODS: One hundred twenty-three patients with NSCLC who had undergone resection were investigated. Real-time quantitative reverse transcriptase polymerase chain reaction was performed to evaluate the Wnt5a gene expression. Immunohistochemistry was performed to investigate the Wnt5a protein expression, the Ki-67 proliferation index, tumor angiogenesis, and the expression of beta-catenin and vascular endothelial growth factor-A (VEGF-A). RESULTS: Wnt5a gene expression in squamous cell carcinoma was significantly higher than that in adenocarcinoma (P < .0001). There was a significant correlation between the normalized Wnt5a gene expression ratio and the intratumoral Wnt5a protein expression (r = 0.729; P < .0001). The intratumoral Wnt5a expression was significantly correlated with the Ki-67 proliferation index (r = 0.708; P < .0001). In contrast, no correlation was observed between the intratumoral Wnt5a expression and tumor angiogenesis. Furthermore, the intratumoral Wnt5a expression was significantly correlated with the stromal expression of beta-catenin (r = 0.729; P < .0001) and VEGF-A (r = 0.661; P < .0001). In addition, the stromal VEGF-A expression was also correlated with Ki-67 proliferation (r = 0.627; P < .0001). Cox regression analyses demonstrated Wnt5a status to be a significant prognostic factor for NSCLC patients (P = .0193), especially for patients with squamous cell carcinomas (P = .0491). CONCLUSION: The present study revealed that an overexpression of Wnt5a could produce more aggressive NSCLC, especially in squamous cell carcinomas, during tumor progression.
Non–small-cell lung cancer (NSCLC) is one of the most common human cancers with a poor prognosis. Surgical resections play a major role in managing patients with stage I and II NSCLCs, and surgery may also sometimes be used for patients with stage III NSCLCs.1 In addition, various concomitant treatments with chemotherapy and radiotherapy have been assessed for improving the outcome of patients with NSCLC.2 However, the 3-year survival rate is 35% to 55% in patients with stage II NSCLC and 28% in patients with stage III NSCLC.3 Therefore, it is considered important to clarify the mechanism of tumor biology to improve the clinical outcome of patients with NSCLC. Recent studies on molecular biology in human cancers have revealed that many molecules affect various biologic behaviors of malignant tumors. The activation of oncogenes or the inactivation of tumor suppressor genes could initially cause carcinogenesis.4 During the subsequent tumor progression, many molecular markers associated with angiogenesis5 or metastasis6 could produce more aggressive malignant tumors. Furthermore, recent studies have indicated that the tumor-stromal interaction also plays an important role in tumor progression.7 Among the many molecular markers associated with tumor progression, the Wnt gene family has been shown to encode the multifunctional signaling glycoproteins that are involved in the regulation of a wide variety of normal and pathologic processes, including embriogenesis, differentiation, and tumorigenesis.8-10 We recently found that the transfection of the metastatic suppressor gene MRP-1/CD9 could downregulate the Wnt5a expression in tumor cell lines.11 In fact, many previous clinical studies have demonstrated that the Wnt5a expression is frequently upregulated in various human cancers, including gastric cancers, esophageal cancers, pancreatic cancers, and breast cancers.12-15 As a result, the overexpression of Wnt5a might affect tumor biology during tumor progression. Thus understanding the biologic mechanisms of Wnt5a could lead to the development of new strategies for the treatment of cancer patients. However, the biologic functions of Wnt5a in human cancers are still unclear. Therefore, we conducted the present study to investigate the clinical significance of Wnt5a expression in NSCLC. Because Wnt5a is considered to be multifunctional, we also evaluated the tumor proliferation rate using the Ki-67 index,16 tumor angiogenesis using CD34 staining,17 and the expression of beta-catenin9 and vascular endothelial growth factor-A (VEGF-A), a potent growth factor18 and one of the target genes of the Wnt family.19
Clinical Characteristics of Patients From July 1999 to December 2002, consecutive patients with NSCLC who underwent surgery at the Second Department of Surgery of Kagawa University (Kagawa, Japan) were studied. This study was approved by the institutional review board of Kagawa University (14-7, a clinical study of biologic markers in NSCLCs). TNM staging designations were made according to the postsurgical pathologic international staging system.20 The lymph node status was pathologically evaluated using specimens resected by either thoracotomy or mediastinoscopy. In total, 123 patients with lung cancer up to stage IIIB, which included 67 patients with adenocarcinomas, 50 patients with squamous cell carcinomas, and six patients with large-cell carcinomas, were investigated (Table 1). The patients’ clinical records and histopathologic diagnoses were fully documented. This report includes follow-up data as of December 28, 2004. The median follow-up period for all patients was 41.1 ± 17.3 months.
Regarding methods of surgical resection, a pneumonectomy was performed in 13 patients with stage II to III NSCLCs. A lobectomy was performed in 101 patients: 65 patients with stage I NSCLC, 16 patients with stage II NSCLC, and 20 patients with stage III NSCLC. A segmentectomy was performed in five patients with stage I NSCLC, and a wedge resection was performed in four patients with stage I NSCLC. Systemic chemotherapy using mitomycin, vinblastine, and cisplatin was performed in all patients with stage II to III NSCLCs: neoadjuvant chemotherapy in 27 patients, and postoperative adjuvant chemotherapy in 22 patients with nodal metastases. Radiation therapy was performed in 19 patients: eight patients with T3 or T4 status and 11 patients with mediastinal lymph node metastases.
Real-Time Quantitative Reverse Transcriptase Polymerase Chain Reaction for Wnt5a Gene Expression
Immunohistochemical Assays All of the immunostained sections were reviewed by two authors (C.H. and M.U.) who had no knowledge of the patients’ clinical status. Cases with discrepancies were jointly re-evaluated, and a consensus was reached. For protein expression of Wnt5a, beta-catenin, and VEGF-A, in cases with multiple areas of low intensity that occurred during evaluation of immunostaining, five areas were selected at random and scored. Also, one random field was selected in sections where all staining appeared intense. At least 200 cells were scored per x40 field about tumor cells or stromal cells, respectively. Regarding intratumoral beta-catenin expression, we used the classification of staining patterns as reported previously21: (1) a membranous pattern, if immunoreactivity was present solely at the cell membranes; (2) a membranous-cytoplasmic pattern, if immunoreactivity was also present in the cytoplasm; (3) a cytoplasmic pattern, if immunoreactivity was chiefly present in the cytoplasm and in less than 20% of the nuclei; and (4) a cytoplasmic-nuclear pattern, if immunoreactivity was present in the cytoplasm and concomitantly in more than 20% of the nuclei. Regarding stromal beta-catenin expression, stromal cells with cytoplasmic beta-catenin expression and/or nuclear beta-catenin expression were classified as beta-catenin–positive stromal cells. The percentage of carcinoma cells with positive staining for Ki-67 in a given specimen was scored as the Ki-67 proliferation index.16 For microvessel quantification, the three most highly vascularized areas detected by CD34 immunostaining were initially selected under the x40 field, and a x200 field (0.785 mm2 per field) was used to count vessels in each of these areas. The average of three x200 field counts was recorded as the intratumoral microvessel density (IMD).17
Statistical Methods
Wnt5a Gene Expression in NSCLCs First, we studied Wnt5a gene expression in 10 noncancerous samples to evaluate the Wnt5a expression in normal lung tissues. The normalized Wnt5a gene expression ratio was low in normal lung tissues (mean, 0.1548 ± 0.0358). In contrast, the normalized Wnt5a gene expression ratio varied greatly among the 123 tumor tissues we studied (mean, 2.464 ± 3.907). Regarding tumor histology, the normalized Wnt5a gene expression ratio was 0.774 ± 0.944 in adenocarcinomas and 4.873 ± 5.153 in squamous cell carcinomas (Fig 1). Wnt5a gene expression in squamous cell carcinomas was significantly higher than that in adenocarcinomas (P < .0001).
Wnt5a Protein Expression in Tumor Cells and Stromal Cells We next performed immunohistochemistry to evaluate the Wnt5a protein expression in tumor cells and stromal cells, respectively. The Wnt5a protein expression appeared in the form of a cytoplasmic staining pattern (Fig 2A). Regarding the intratumoral Wnt5a protein expression, the percentage of Wnt5a-positive tumor cells varied greatly among the 123 NSCLCs (mean, 41.5% ± 29.6%). In addition, a significant correlation was seen between the normalized Wnt5a gene expression ratio and the percentage of Wnt5a-positive tumor cells evaluated by immunohistochemistry (r = 0.729; P < .0001).
In contrast, regarding the stromal Wnt5a protein expression, the percentage of Wnt5a-positive stromal cells was low (mean, 5.3% ± 4.7%). In addition, no correlation was observed between the normalized Wnt5a gene expression ratio and the percentage of Wnt5a-positive stromal cells (r = 0.095). Furthermore, the Wnt5a protein expression was also low in the normal alveolar epithelium. We used the classification of the Wnt5a status according to the intratumoral Wnt5a protein expression because this value was considered to be appropriate to evaluate the tumor-stromal interaction. Seventy-one carcinomas (57.7%) were Wnt5a-positive, and 52 carcinomas (42.3%) were Wnt5a-negative (Table 2). Regarding tumor histology, Wnt5a-positive tumors in squamous cell carcinomas were significantly more common than those in adenocarcinomas (78.0% v 41.8%; P < .0001). Regarding the clinicopathologic parameters, no significant difference in the Wnt5a status was observed in relation to tumor status, nodal status, pathologic stage, or tumor differentiation.
Tumor Proliferation and Angiogenesis of NSCLCs in Relation to Wnt5a Status To investigate the biologic function of Wnt5a in NSCLCs, we evaluated the Ki-67 proliferation index and the IMD in relation to the Wnt5a status (Fig 2B). Regarding tumor proliferation, the percentage of Wnt5a-positive tumor cells was significantly correlated with the Ki-67 proliferation index (r = 0.708; P < .0001). The Ki-67 proliferation index was significantly higher in Wnt5a-positive tumors than in Wnt5a-negative tumors (55.1% ± 15.6% v 31.7% ± 12.1%; P < .0001). However, concerning tumor angiogenesis, no correlation was observed between the percentage of Wnt5a-positive tumor cells and the IMD (r = 0.034). The IMD was 101.3 ± 31.2 in Wnt5a-negative tumors and 114.5 ± 28.8 in Wnt5a-positive tumors.
The Intratumoral Beta-Catenin Expression and the Stromal Beta-Catenin Expression in Relation to the Wnt5a Status In contrast, the stromal beta-catenin expression appeared in the form of a cytoplasmic staining pattern with varied nuclear staining (Fig 2C). The percentage of beta-catenin–positive stromal cells also varied greatly among the 123 NSCLCs (mean, 25.3% ± 25.4%). Furthermore, a significant correlation was seen between the percentage of Wnt5a-positive tumor cells and the percentage of beta-catenin–positive stromal cells (r = 0.729; P < .0001). The percentage of beta-catenin–positive stromal cells was significantly higher in Wnt5a-positive tumors than in Wnt5a-negative tumors (36.0% ± 25.7% v 10.8% ± 8.5%; P < .0001).
Intratumoral VEGF-A Expression and Stromal VEGF-A Expression in Relation to Wnt5a Status and Stromal Beta-Catenin Status However, regarding the stromal VEGF-A expression, the percentage of VEGF-A-positive stromal cells was significantly correlated with the percentage of Wnt5a-positive tumor cells (r = 0.661; P < .0001). The percentage of VEGF-A–positive stromal cells was significantly higher in Wnt5a-positive tumors than in Wnt5a-negative tumors (37.6% ± 15.6% v 22.7% ± 10.8%; P = .0005). Furthermore, the percentage of VEGF-A–positive stromal cells was also significantly correlated with the percentage of beta-catenin–positive stromal cells (r = 0.644; P < .0001).
Tumor Proliferation and Angiogenesis of NSCLCs in Relation to Stromal VEGF-A Status
Overall Survival of NSCLC Patients in Relation to Wnt5a Status
As shown in Table 3, a multivariate analysis using the Cox proportional hazards regression model demonstrated that Wnt5a status (hazard ratio, 2.451; P = .0193) and the pathologic stage (hazard ratio, 2.917; P < .0001) were significant prognostic factors for NSCLC patients. Especially, the Wnt5a status (hazard ratio, 3.514; P = .0491) and the pathologic stage (hazard ratio, 2.785; P < .0001) were also significant prognostic factors for patients with squamous cell carcinomas.
The Wnt family is a large family of homologous but distinct genes, which have been highly conserved across species in evolutions. The Wnt genes encode secreted cysteine-rich proteins with multidirectional biologic functions via autocrine or paracrine routes.9 Previous experimental studies using cell lines have demonstrated that Wnt5a is also an important regulator of many biologic functions, such as cell proliferation,22-24 differentiation,25,26 and cell motility.27 Furthermore, the Wnt5a expression is frequently upregulated in various human cancers.12-15 As a result, Wnt5a is considered to be involved in tumorigenesis. However, the clinical significance of Wnt5a expression in human cancers is still unclear and also rather controversial. Wnt5a was initially reported to belong to nontransforming members of Wnts, according to their ability to transform C57MG mammary epithelial cells.28 However, many studies have reported that Wnt5a also can induce cell proliferation in several cell lines and tissues.22-24 In addition, a recent study on breast phyllodes tumors revealed that a Wnt5a overexpression in epithelial cells induced a stromal proliferation, but not an epithelial proliferation.29 These observations support the notion that effects of Wnt signaling are cell type specific. The autocrine and paracrine use of Wnt proteins, together with expression profiles of the Frizzled (Frz) family of Wnt receptors, will ultimately determine the cellular response.23 Therefore, to clarify the clinical significance of the multifunctional Wnt5a in NSCLCs, we conducted the present study on Wnt5a expression in relation to tumor proliferation, tumor angiogenesis, and the expression of beta-catenin9 and VEGF-A, a potent growth factor and one of the target genes of the canonical Wnt/beta-catenin pathway.18,19 Regarding Wnt5a expression, both the Wnt5a gene expression evaluated by reverse transcriptase PCR and the intratumoral Wnt5a protein expression evaluated by immunohistochemistry varied greatly, and a significant correlation was observed between them. In contrast, the Wnt5a protein expression was low in both stromal cells and normal lung tissues. We conducted the present study using the classification according to the intratumoral Wnt5a protein expression evaluated by immunohistochemistry because this value was considered to be appropriate for our investigative purposes to evaluate the tumor-stromal interaction in NSCLCs. Interestingly, the present study revealed that the intratumoral Wnt5a overexpression was associated with the stromal expression of beta-catenin and VEGF-A, not with the intratumoral expression. This result suggested the existence of a tumor-stromal interaction. Previous studies also reported that Wnt5a was involved in the tumor-stromal interaction in human cancers, including breast phyllodes tumors and colorectal cancers.29,30 He et al31 demonstrated that Wnt5a may also play a role in the canonical Wnt/beta-catenin signaling pathway. The Wnt5a protein can act via Frz-5 receptor to initiate an intracellular pathway leading to the accumulation of beta-catenin. Beta-catenin is a pivotal component of the Wnt signaling pathway and E-cadherin-associated homotypic cell adhesion.32 The present study revealed the beta-catenin expression levels to differ in tumor cells and in stromal cells, respectively. The beta-catenin expression is membranous in normal epithelium. In contrast, beta-catenin demonstrated four expression patterns in tumor cells. Previous studies reported that the beta-catenin expression in the cytoplasm and/or nuclear could be considered to be an indication for its aberrant expression.21,33 The activation of the Wnt signaling pathway by the stabilization of beta-catenin has been shown to play an important role in the development of colorectal carcinoma, which is mainly caused by inactivating mutations of the adenomatous polyposis coli gene or by activating mutations of the beta-catenin gene.34 However, previous clinical studies have revealed these mutations to be rare in NSCLCs.21,35 Therefore, the aberrant expression of beta-catenin in the cytoplasm and/or the nucleus among NSCLCs might be functional.21 The present study found that intratumoral Wnt5a expression was not associated with the intratumoral beta-catenin expression. This result might be due to the fact that tumor cells do not have a Frz receptor for Wnt5a, as suggested previously.29 Thus the intratumoral aberrant expression of beta-catenin among NSCLCs might be caused by other mechanisms, such as the overexpression of other members of the Wnt family or a reduced E-cadherin expression.21,36 In contrast, the stromal beta-catenin expression appeared in the form of a cytoplasmic staining pattern with varied nuclear staining. The present study revealed that the intratumoral Wnt5a expression was significantly correlated with the stromal beta-catenin expression. Furthermore, the intratumoral Wnt5a expression was also significantly correlated with the stromal VEGF-A expression. Although an immunohistochemistry assay does not precisely represent the source of VEGF-A, a known secreted protein, a significant correlation was seen between the stromal beta-catenin expression and the stromal VEGF-A expression in the present study. This result suggested that stromal cells with a positive beta-catenin expression could produce the VEGF-A expression. Therefore, the Wnt5a protein secreted by tumor cells could activate the canonical Wnt/beta-catenin pathway in stromal cells with a receptor for Wnt5a, thereby inducing the stromal VEGF-A expression. Subsequently, the stromal VEGF-A expression could affect tumor growth via the VEGF-receptor of tumor cells. Further studies including the Frz receptor and the VEGF-receptor should be performed to clarify this mechanism. Concerning the regulation of Wnt5a expression, both gene amplification and gene rearrangement have been reported to occur infrequently in human cancers.37 In contrast, experimental studies using cell lines demonstrated the Wnt5a expression to be regulated by various molecules, including hepatocyte growth factor, protein kinase C activity, and MRP-1/CD9.11,38,39 Our pilot study found that there was no significant association between a reduced expression of MRP-1/CD9 and Wnt5a overexpression in NSCLCs (data not shown). Therefore, the Wnt5a expression might be secondarily regulated in response to a range of changes in these many biologic molecules during tumor progression. Consequently, the present study revealed that Wnt5a expression in squamous cell carcinomas was significantly higher than that in adenocarcinomas. Regarding tumor biology, an overexpression of Wnt5a was associated with the Ki-67 proliferation index. Although the Ki-67 proliferation index was relatively high in the present study, this result might be due to epidermiologic difference. In addition, an overexpression of Wnt5a was associated with a poor prognosis in NSCLC patients, especially in stage II to III (locally advanced) NSCLCs. Our recent study has also shown that biologic markers associated with tumor cell proliferation could be prognostic factors in stage II to III NSCLCs.40 Furthermore, an overexpression of Wnt5a was associated with a poor prognosis, especially in squamous cell carcinomas. To our knowledge, the present study is the first clinical report demonstrating the clinical significance of intratumoral Wnt5a expression in NSCLCs. In particular, an overexpression of Wnt5a could affect the progression of squamous cell carcinoma of the lung. In conclusion, the present study demonstrated that an overexpression of Wnt5a was associated with the tumor cell proliferation in NSCLCs. Furthermore, the intratumoral Wnt5a overexpression was also found to be associated with expression of beta-catenin and VEGF-A in stromal cells, which suggests the existence of a tumor-stromal interaction. In addition, the overexpression of Wnt5a is considered to be a significant prognostic factor for poor prognosis in NSCLC patients, especially in squamous cell carcinomas. Therefore, new strategies, such as the RNA inhibition of Wnt5a, secreted Frizzled-related proteins, and bevacizumab (Avastin; Genentech, Inc, South San Francisco, CA), may be potentially effective treatments for patients with Wnt5a-positive NSCLCs.41-43
The authors indicated no potential conflicts of interest.
Authors' disclosures of potential conflicts of interest are found at the end of this article.
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Copyright © 2005 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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ABSTRACT
INTRODUCTION
in MKN45 cells and up-regulation of Wnt5B by beta-estradiol in MCF-7 cells. Int J Mol Med 10:345-349, 2002
