Reader TTS

ABSTRACT Although all carcinoids are potentially malignant, their biologic behavior is quite variable. Currently there are no reliable morphological criteria to predict metastatic potential.

Cell adhesion molecules, such as CD44 and E-cadherin, are considered important in regulating invasion and metastasis of tumors. Also, angiogenesis has been shown to be associated with tumor

growth and progression. In this study, we examined 51 carcinoids, including 13 carcinoids with known lymph node and/or visceral metastasis, for expression of CD44s (the standard form of

CD44) and E-cadherin by immunohistochemistry. We found that 55% and 37% of carcinoids were negative for CD44s and E-cadherin, respectively. Carcinoids with lymph node and/or visceral

metastasis were significantly more frequently negative for CD44s than were those without demonstrated metastasis (_P_ =.030). Ten of 11 tumors with lymph node metastasis lacked CD44s (_P_

=.022), whereas E-cadherin was negative in only 3 (_P_ =.975). Additionally, we analyzed microvessel density to evaluate the role of tumor angiogenesis in the tumor behavior. Carcinoid

tumors in general demonstrated high microvessel density (160 ± 82/five 200 × fields), irrespective of location and with and without metastasis. These results suggest that loss of CD44s, but

not E-cadherin, may be a useful predictor of metastatic potential of carcinoid tumors. SIMILAR CONTENT BEING VIEWED BY OTHERS PCDH17 INDUCES COLORECTAL CANCER METASTASIS BY DESTROYING THE

VASCULAR ENDOTHELIAL BARRIER Article Open access 21 January 2025 LOSS OF VIMENTIN EXPRESSION IN PREOPERATIVE BIOPSIES INDEPENDENTLY PREDICTS POOR PROGNOSIS, LYMPH NODE METASTASIS AND

RECURRENCE IN ENDOMETRIAL CANCER Article Open access 18 October 2024 VASCULAR HETEROGENEITY OF TIGHT JUNCTION CLAUDINS GUIDES ORGANOTROPIC METASTASIS Article 17 September 2024 INTRODUCTION

Although most carcinoid tumors exhibit benign behavior, a significant proportion of them act in a malignant fashion and are difficult to manage (1, 2). Evaluation of the malignant potential

of a carcinoid tumor remains problematic. Primary tumor site, tumor size, level of urinary 5-hydroxyindoleacetic acid, and specific histologic growth patterns have been touted as useful

prognostic factors. However, information regarding the utility of these data in predicting behavior is controversial (3, 4). Recently, several other tumor markers such as Ki-67, Bcl-2, and

p53; cell adhesion molecules; and tumor angiogenesis have been explored as possible prognostic markers (5, 6, 7, 8, 9, 10). Cell adhesion molecules play a critical role in a variety of

processes such as embryonic development, extracellular matrix binding, hematopoiesis, lymphocyte homing, cell migration, and tumor metastasis (11, 12, 13, 14). CD44 and E-cadherin (ECAD) are

two important adhesion molecules that have been extensively studied. CD44 is a large family of cell surface transmembrane glycoproteins whose members differ in their extracellular domains

as a result of alternative splicing (12, 15). The data regarding the role of CD44 in neoplasia are controversial in regard to whether CD44 acts as a growth/invasion- promoting molecule or a

tumor suppression cofactor (16, 17). The standard or hematopoietic form of CD44 (CD44s) is a receptor for hyaluronan and is highly expressed on human lymphocytes. Expression of CD44s has

been shown to be associated with good prognosis in patients with bronchial carcinoids (8, 9). ECAD is a calcium-dependent transmembrane protein. Decreased expression of ECAD has been

correlated with regional lymph node metastasis in squamous cell carcinomas (18) and with poor prognosis in gastric and colorectal cancers (19, 20, 21). Expression of ECAD in carcinoid tumors

has not been reported previously. In this study, we have investigated the relationship of CD44s expression, ECAD expression, and microvessel density to the biological behavior of carcinoid

tumors. MATERIALS AND METHODS Archival materials of 51 carcinoid tumors from the lung (_n_ = 20), large bowel (_n_ = 11), appendix (_n_ = 7), small bowel (_n_ = 6), stomach (_n_ = 5), ovary

(_n_ = 1), and kidney (_n_ = 1) that were accessioned in the surgical pathology files at our institution from 1996 to 2000 were used in this study. In 26 cases, regional lymph nodes were

available for evaluation. Immunohistochemical studies were performed on formalin-fixed, paraffin-embedded tissue with monoclonal antibodies directed against the standard form of CD44 (CD44s,

DAKO), ECAD (Zymed), and CD34 (Immunotech) using a standard avidin-biotin-peroxidase method (22). Briefly, 4-μm-thick paraffin sections were dewaxed and treated with 1% H2O2 in methanol for

30 minutes to block endogenous peroxidase activity. Antigen retrieval was performed in a microwave oven (pressure cooker) with Antigen Retrieval Citra microwave solution (BioGenex). The

sections were incubated for 30 minutes with normal nonimmune serum to eliminate nonspecific staining. The antibody (1:200 dilution for anti-CD44s and 1:500 dilution for anti-ECAD) was then

applied for 2 hours at room temperature. For anti-CD34, manufacturer-prediluted antibody solution was used and reaction was carried out in a Ventana machine (Tucson, AZ) for 32 minutes at

37° C. Antigen was detected with a biotin-labeled secondary antibody and avidin-biotin peroxidase technique using 3′,3′-diaminobenzidine as the chromogen. Sections were counterstained with

hematoxylin. Negative controls were performed by omitting the primary antibodies. For CD44s and ECAD, immunohistochemical reactions were graded as positive or negative based on the staining

intensity of the membrane as well as on the number of cells stained (23). Tumors with no reactivity, weak reactivity, or moderate to strong reactivity in <10% of tumor cells were graded

as negative, whereas those with a moderate to strong degree of reactivity in ≥10% tumor cells were considered positive. For microvessel density, microvessels highlighted by anti-CD34 were

counted in each case from the five most vascular, nonoverlapping fields (20 × objective and 10 × ocular, Nikon, 0.74 mm2 per field as measured with an ocular micrometer) in a section. The

averages of the five counts were used for statistical analyses. For statistical analyses, χ2 and Fisher exact tests using the Prophet 5.0 statistics program (BBN System & Technology)

were applied, and a _P_ value of <.05 was considered significant. RESULTS Fifty-one carcinoid tumors included in this study were obtained from 30 females and 21 males, ranging in age from

17 to 80 years (median, 53 y). Except for two carcinoids, all the other tumors were located either in the lung or gastrointestinal tract (Table 1). Of the 20 pulmonary carcinoids, 18 were

typical and the other 2 were classified as atypical carcinoids according to the WHO classification (24). Of the 29 carcinoids from gastrointestinal tract, 25 were classified as classical

type, showing trabecular and insular morphological features, and the other 4 (from appendix) were classified as goblet cell type. A total of 13 cases demonstrated either lymph node (10

patients) or visceral (2 patients) or both lymph node and visceral (1 patient) metastasis (Tables 2 and 3). No difference in the morphological features of carcinoids with and without

metastasis was observed. CD44s and ECAD expression were detected in 45% (23/51) and 63% (32/51) of carcinoid tumors, respectively (Table 1). Coexpression of the two adhesion molecules was

seen in 19 tumors, and both markers were negative in 15 tumors, with only 4 tumors expressing only CD44s, and 13 tumors, only ECAD (_P_ =.01). There was no significant difference in the

expression of CD44s or ECAD in carcinoids derived from different sites. However, 85% of carcinoids (11 of 13) with known metastasis lacked CD44s expression compared with 45% of tumors (17 of

38) without demonstrated metastasis (_P_ =.030; Table 2). Similarly, in the subgroup of patients who had lymph nodes available for evaluation, CD44s negativity was more frequently observed

in tumors with lymph node metastasis (10/11) than in those with negative lymph nodes (6/15; _P_ =.022; Table 3 and Fig. 1A–1D). No difference was observed with ECAD expression in tumors with

and without metastasis. Furthermore, no significant difference in the expression of the two adhesion molecules was observed between tumors of different sizes or with respect to age of the

patients (Table 2). All four goblet cell carcinoid tumors were positive for ECAD, but only two were positive for CD44s. Carcinoid tumors in general demonstrated a high microvessel density

(mean 160 ± 82; Table 4 and Fig. 1E). Microvessel density of carcinoid tumors of the lung (190 ± 106) was higher than that of tumors from other sites (142 ± 59), although the difference was

not statistically significant. The goblet cell carcinoids were histologically less cellular and had a more myxoid background. These tumors had lower microvessel density than did other

carcinoids (_P_ =.0195; Fig. 1F). Microvessel density was not significantly different in tumors with or without metastasis, whether they were compared in the whole series or in the subgroup

with lymph node dissection. DISCUSSION The biological behavior of carcinoids, in general, is unpredictable, although size, location, and morphological features may provide some clues

regarding behavior. Recently, various other parameters have been evaluated as potential prognostic indicators for carcinoid tumors. Some parameters, such as proliferative activity and

expression of growth factors have proved somewhat useful (6). Because cell adhesion molecules are considered important in tumor growth, invasion, and metastasis, we evaluated the prognostic

value of these molecules in carcinoids arising from different sites and carcinoids with known metastasis. In this study, we found reduced expression of CD44s in tumors with metastasis. In

contrast, the expression of ECAD showed no correlation with metastatic spread. Similarly, microvessel density also failed to distinguish carcinoid tumors by site or potential for metastatic

spread. Although our clinical follow-up interval of 2 to 6 years is relatively short, outcome for our patients was good with 47 of the 51 patients alive and only 2 succumbing to the disease.

Longer follow-up is required to more firmly establish the correlation between clinical outcome and the expression of the cell adhesion molecules and the effect of angiogenesis. The role of

CD44s and its various isoforms in tumorigenesis and tumor progression is very controversial. For example, loss of CD44s expression was reported to be associated with unfavorable outcome in

patients with neuroblastoma (25), prostate carcinoma (26), transitional cell carcinoma of the bladder (27) and differentiated thyroid carcinoma (28). However, opposite results have been

reported in primary lung adenocarcinoma (29), colorectal cancer (30), and pancreatic endocrine tumors (5). The complexity of the biological function of the molecule, the small sample size in

some studies, and the methods used to evaluate significance of these molecules may have all contributed to this controversy. Reports on CD44 expression in carcinoid tumors are limited.

Coppola and coworkers (6) showed decreased expression of CD44s and CD44v6 in atypical carcinoids and small cell carcinomas of the lung compared with the case of typical carcinoids. These

investigators suggested that loss of CD44 expression correlated with more aggressive phenotypes. More recently, Granberg and coworkers (8, 9) demonstrated that expression of CD44s as well as

CD44v7–8 and v9 was associated with decreased risk for distant metastases and with a more favorable outcome in patients who had typical carcinoids of the lung. In our series, we included

not only carcinoid tumors from the lung but also those from other organs such as gastrointestinal tract. Our results showed that CD44s expression was more frequently negative in tumors with

lymph node and/or visceral metastasis than in those without demonstrated metastasis (_P_ =.030). A statistically significant difference was also noted in the subgroup of 26 patients whose

lymph node status was known (_P_ =.022). These findings further support the concept that loss of the adhesion molecule plays a crucial role in tumor progression and metastases in carcinoids.

ECAD and the associated catenin complex play an integral role in epithelial cell adhesion. Reduced expression of ECAD has been associated with lymph node metastasis in various carcinomas

(18, 21). In our series, ECAD expression correlated with CD44s expression, although more tumors were positive for ECAD than for CD44s. Unlike CD44s, ECAD expression was not significantly

different in lymph node–positive and –negative groups. Although a larger series is needed to confirm this finding, different cell adhesion molecules may be involved in the regulation of

metastatic spread of different tumors. Clinical and experimental studies have shown that angiogenesis is a prerequisite for tumor growth and progression and has been correlated with

metastasis in breast, prostate, and bladder carcinomas and in melanomas (31, 32, 33). Previous studies, however, failed to demonstrate correlation of angiogenesis with the metastatic

potential of pulmonary carcinoid tumors (10). Our data also showed no statistically significant difference in MVD between tumor groups with or without lymph node metastasis or among tumors

of various origins. Although the reason for this lack of correlation in carcinoid tumors is not known, factors other than MVD, which is normally high in carcinoid tumors, may be more

important in controlling the metastatic process. REFERENCES * Caplin ME, Buscombe JR, Hilson AJ, Jones AL, Watkinson AF, Burroughs AK . Carcinoid tumour. _Lancet_ 1998; 352: 799–805. Article

  CAS  Google Scholar  * Kulke MH, Mayer RJ . Carcinoid tumors. _N Engl J Med_ 1999; 340: 858–868. Article  CAS  Google Scholar  * Bukowski RM, Johnson KG, Peterson RF, Stephens RL, Rivkin

SE, Neilan B, _et al_. A phase II trial of combination chemotherapy in patients with metastatic carcinoid tumors. A Southwest Oncology Group Study. _Cancer_ 1987; 60: 2891–2895. Article  CAS

  Google Scholar  * Engstrom PF, Lavin PT, Moertel CG, Folsch E, Douglass HO Jr . Streptocin plus fluorouracil versus doxorubicin therapy for metastatic carcinoid tumor. _J Clin Oncol_ 1984;

2: 1255–1259. Article  CAS  Google Scholar  * Chaudhry A, Gobl A, Eriksson B, Skogseid B, Oberg K . Different splice variants of CD44 are expressed in gastrinomas but not in other subtypes

of endocrine pancreatic tumors. _Cancer Res_ 1994; 54: 981–986. CAS  PubMed  Google Scholar  * Coppola D, Clarke M, Landreneau R, Weyant RJ, Cooper D, Yousem SA . Bcl-2, p53, CD44, and

CD44v6 isoform expression in neuroendocrine tumors of the lung. _Mod Pathol_ 1996; 9: 484–490. CAS  PubMed  Google Scholar  * Fasano M, Sabatini MT, Wieczorek R, Sidhu G, Goswami S, Jagirdar

J . CD44 and its v6 spliced variant in lung tumors: a role in histogenesis? _Cancer_ 1997; 80: 34–41. Article  CAS  Google Scholar  * Granberg D, Wilander E, Oberg K, Skogseid B .

Prognostic markers in patients with typical bronchial carcinoid tumors. _J Clin Endocrinol Metab_ 2000; 85: 3425–3430. CAS  Google Scholar  * Granberg D, Wilander E, Oberg K, Skogseid B .

Decreased survival in patients with CD44-negative typical bronchial carcinoid tumors. _Int J Cancer_ 1999; 84: 484–488. Article  CAS  Google Scholar  * Slodkowska J, Sikora J, Androsiuk W,

Rudzinski P, Radomyski A . Lung carcinoids. Tumor angiogenesis in relation to clinicopathologic characteristics. _Anal Quant Cytol Histol_ 1999; 21: 267–272. CAS  Google Scholar  * Sherman

L, Sleeman J, Dall P, Hekele A, Moll J, Ponta H, _et al_. The CD44 proteins in embryonic development and in cancer. _Curr Top Microbiol Immunol_ 1996; 213: 249–269. CAS  PubMed  Google

Scholar  * Gunthert U, Hofmann M, Rudy W, _et al_. A new variant of glycoprotein CD44 confers metastatic potential to rat carcinoma cells. _Cell_ 1991; 65: 13–24. Article  CAS  Google

Scholar  * Sherman L, Sleeman J, Herrlich P, Ponta H . Hyaluronate receptors: key players in growth, differentiation, migration and tumor progression. _Curr Opin Cell Biol_ 1994; 6: 726–733.

Article  CAS  Google Scholar  * Lesley J, Hyman R, Kincade PW . CD44 and its interaction with extracellular matrix. _Adv Immunol_ 1993; 54: 271–335. Article  CAS  Google Scholar  *

Stamenkovic I, Amiot M, Pesando JM, Seed B . A lymphocyte molecule implicated in lymph node homing is a member of the cartilage link protein family. _Cell_ 1989; 56: 1057–1062. Article  CAS

  Google Scholar  * Sneath RJ, Mangham DC . The normal structure and function of CD44 and its role in neoplasia. _Mol Pathol_ 1998; 51: 191–200. Article  CAS  Google Scholar  * Herrlich P,

Morrison H, Sleeman J, Orian-Rousseau V, Konig H, Weg-Remers S, _et al_. CD44 acts both as a growth- and invasiveness-promoting molecule and as a tumor-suppressing cofactor. _Ann NY Acad

Sci_ 2000; 910: 106–120. Article  CAS  Google Scholar  * Koseki S, Aoki T, Ansai S, Hozumi Y, Mitsuhashi Y, Kondo S . An immunohistochemical study of E-cadherin expression in human squamous

cell carcinoma of the skin: relationship between decreased expression of E-cadherin in the primary lesion and regional lymph node metastasis. _J Dermatol_ 1999; 26: 416–422. Article  CAS 

Google Scholar  * Ramesh S, Nash J, McCulloch PG . Reduction in membranous expression of beta- catenin and increased cytoplasmic E-cadherin expression predict poor survival in gastric

cancer. _Br J Cancer_ 1999; 81: 1392–1397. Article  CAS  Google Scholar  * Kimura T, Tanaka S, Haruma K, Sumii K, Kajiyama G, Shimamot F, _et al_. Clinical significance of MUC1 and

E-cadherin expression, cellular proliferation, and angiogenesis at the deepest invasive portion of colorectal cancer. _Int J Oncol_ 2000; 16: 55–64. CAS  PubMed  Google Scholar  * Kawanishi

K, Doki Y, Shiozaki H, Yano M, Inoue M, Fukuchi N, _et al_. Correlation between loss of E-cadherin expression and overexpression of autocrine motility factor receptor in association with

progression of human gastric cancers. _Am J Clin Pathol_ 2000; 113: 266–274. Article  CAS  Google Scholar  * Hsu SM, Raine L, Fanger H . Use of avidin-biotin-peroxidase complex (ABC) in

immunoperoxidase techniques: a comparison between ABC and unlabeled antibody (PAP) procedures. _J Histochem Cytochem_ 1981; 29: 577–580. Article  CAS  Google Scholar  * Mikami T, Mitomi H,

Hara A, Yanagisawa N, Yoshida T, Tsuruta O, _et al_. Decreased expression of CD44, alpha-catenin, and deleted colon carcinoma and altered expression of beta-catenin in ulcerative

colitis-associated dysplasia and carcinoma, as compared with sporadic colon neoplasms. _Cancer_ 2000; 89: 733–740. Article  CAS  Google Scholar  * Travis WD, Colby TV, Corrin B, Shimosato Y,

Brambilla E . _WHO histological typing of lung and pleural tumors_. 3rd ed. Geneva: World Health Organization; 1999. Book  Google Scholar  * Christiansen H, Sahin K, Berthold F, Hero B,

Terpe HJ, Lampert F . Comparison of DNA aneuploidy, chromosome 1 abnormalities, MYCN amplification and CD44 expression as prognostic factors in neuroblastoma. _Eur J Cancer_ 1995; 31A:

541–544. Article  CAS  Google Scholar  * Aaltomaa S, Lipponen P, Viitanen J, Kankkunen JP, Ala-Opas M, Kosma VM . Prognostic value of CD44 standard, variant isoforms 3 and 6 and -catenin

expression in local prostate cancer treated by radical prostatectomy. _Eur Urol_ 2000; 38: 555–562. Article  CAS  Google Scholar  * Masuda M, Takano Y, Iki M, Makiyama K, Noguchi S, Hosaka M

. Expression and prognostic value of CD44 isoforms in transitional cell carcinoma of renal pelvis and ureter. _J Urol_ 1999; 161: 805–808;discussion 808–809. Article  CAS  Google Scholar  *

Bohm JP, Niskanen LK, Pirinen RT, Kiraly K, Kellokoski JK, Moisio KI, _et al_. Reduced CD44 standard expression is associated with tumour recurrence and unfavourable outcome in

differentiated thyroid carcinoma. _J Pathol_ 2000; 192: 321–327. Article  CAS  Google Scholar  * Takanami I, Takeuchi K, Naruke M . Expression and prognostic value of the standard CD44

protein in pulmonary adenocarcinoma. _Oncol Rep_ 2000; 7: 1065–1067. CAS  PubMed  Google Scholar  * Sumiyoshi Y, Yamashita Y, Maekawa T, Sakai N, Shirakusa T, Kikuchi M . Expression of CD44,

vascular endothelial growth factor, and proliferating cell nuclear antigen in severe venous invasional colorectal cancer and its relationship to liver metastasis. _Surg Today_ 2000; 30:

323–327. Article  CAS  Google Scholar  * Carmeliet P, Jain RK . Angiogenesis in cancer and other diseases. _Nature_ 2000; 407: 249–257. Article  CAS  Google Scholar  * Gimbrone MA Jr, Cotran

RS, Leapman SB, Folkman J . Tumor growth and neovascularization: an experimental model using the rabbit cornea. _J Natl Cancer Inst_ 1974; 52: 413–427. Article  Google Scholar  * Gimbrone

MA Jr, Leapman SB, Cotran RS, Folkman J . Tumor dormancy _in vivo_ by prevention of neovascularization. _J Exp Med_ 1972; 136: 261–276. Article  Google Scholar  Download references

ACKNOWLEDGEMENTS We thank Dr. W. B. Laskin for his comments on the manuscript and Carol Kiely for her assistance in immunohistochemical staining. AUTHOR INFORMATION AUTHORS AND AFFILIATIONS

* Department of Pathology, Northwestern University Medical School, Chicago, Illinois Xiaoping Sun M.D., Ph.D., Yun Gong M.D. & M Sambasiva Rao M.D. * Department of Surgery, Northwestern

University Medical School, Chicago, Illinois Mark S Talamonti M.D. Authors * Xiaoping Sun M.D., Ph.D. View author publications You can also search for this author inPubMed Google Scholar *

Yun Gong M.D. View author publications You can also search for this author inPubMed Google Scholar * Mark S Talamonti M.D. View author publications You can also search for this author

inPubMed Google Scholar * M Sambasiva Rao M.D. View author publications You can also search for this author inPubMed Google Scholar CORRESPONDING AUTHOR Correspondence to M Sambasiva Rao

M.D.. RIGHTS AND PERMISSIONS Reprints and permissions ABOUT THIS ARTICLE CITE THIS ARTICLE Sun, X., Gong, Y., Talamonti, M. _et al._ Expression of Cell Adhesion Molecules, CD44s and

E-Cadherin, and Microvessel Density in Carcinoid Tumors. _Mod Pathol_ 15, 1333–1338 (2002). https://doi.org/10.1097/01.MP.0000038464.44522.90 Download citation * Accepted: 07 August 2002 *

Published: 01 December 2002 * Issue Date: 01 December 2002 * DOI: https://doi.org/10.1097/01.MP.0000038464.44522.90 SHARE THIS ARTICLE Anyone you share the following link with will be able

to read this content: Get shareable link Sorry, a shareable link is not currently available for this article. Copy to clipboard Provided by the Springer Nature SharedIt content-sharing

initiative KEYWORDS * Angiogenesis * Carcinoid tumor * CD44 * Cell adhesion molecules * E-cadherin * Metastasis * Microvessel density