Immunoexpression of Ezrin and CD44 in patients with osteosarcoma

CD44 In Sarcomas: A Comprehensive Review and Future Perspectives

It is widely accepted that the tumor microenvironment, particularly the extracellular matrix, plays an essential role in the development of tumors through the interaction with specific protein-membrane receptors. One of the most relevant proteins in this context is the transmembrane protein CD44. The role of CD44 in tumor progression, invasion, and metastasis has been well established in many cancers, although a comprehensive review concerning its role in sarcomas has not been published. CD44 is overexpressed in most sarcomas and several in vitro and in vivo experiments have shown a direct effect on tumor progression, dissemination, and drug resistance. Moreover, CD44 has been revealed as a useful marker for prognostic and diagnostic (CD44v6 isoform) in osteosarcoma. Besides, some innovative treatments such as HA-functionalized liposomes therapy have become an excellent CD44-mediated intracellular delivery system for osteosarcoma. Unfortunately, the reduced number of studies deciphering the prognostic/diagnostic value of CD44 in other sarcoma subgroups, neither than osteosarcoma, in addition to the low number of patients involved in those studies, have produced inconclusive results. In this review, we have gone through the information available on the role of CD44 in the development, maintenance, and progression of sarcomas, analyzing their implications at the prognostic, therapeutic, and mechanistic levels. Moreover, we illustrate how research involving the specific role of CD44 in the different sarcoma subgroups could suppose a chance to advance towards a more innovative perspective for novel therapies and future clinical trials.

The clinical prognostic significance of ezrin in patients with bone and soft tissue sarcomas: a meta-analysis

Ezrin is a member of the ezrin–radixin–moesin (ERM) protein family and has been shown to be associated with poor prognosis in patients with a variety of solid tumors. However, the clinical prognostic significance of ezrin in patients with bone and soft tissue sarcomas remains unclear. Here, we performed a systematic meta‐analysis by searching PubMed, the Cochrane Library Database, EMBASE, the Web of Science, and the CBM, WanFang Med Online and CNKI databases. In total, 19 studies with a total of 1316 bone and soft tissue sarcoma patients were included. Pooled analyses showed that ezrin overexpression was correlated with a higher rate of tumor metastasis (OR 6.59, 95% CI: 2.84–15.33, P < 0.01, P_FDR < 0.01) and recurrence (OR 3.18, 95% CI: 1.88–5.37, P < 0.01, P_FDR < 0.01) and a more advanced tumor grade (OR 3.252, 95% CI: 1.371–7.715, P = 0.01, P_FDR = 0.03). Moreover, elevated ezrin expression could predict poor OS (HR 3.02, 95% CI: 2.35–3.89, P < 0.01, P_FDR < 0.01), MFS (HR 5.22, 95% CI: 2.08–13.08, P < 0.01, P_FDR < 0.01), and EFS (HR 1.07, 95% CI: 1.03–1.11, P < 0.01, P_FDR < 0.01). Subgroup analyses revealed the underlying sources of heterogeneity. Publication bias was observed in the analysis of metastasis. Sensitivity analysis revealed that the results were robust. Our findings indicated that ezrin overexpression was significantly correlated with poor survival and more advanced tumor progression in bone and soft tissue sarcomas, which suggests that ezrin might be a valuable prognostic biomarker and a potential therapeutic target.

Hyaluronated liposomes containing H2S-releasing doxorubicin are effective against P-glycoprotein-positive/doxorubicin-resistant osteosarcoma cells and xenografts

Doxorubicin (dox) is one of the first-line drug in osteosarcoma treatment but its effectiveness is limited by the efflux pump P-glycoprotein (Pgp) and by the onset of cardiotoxicity. We previously demonstrated that synthetic doxs conjugated with a H₂S-releasing moiety (Sdox) were less cardiotoxic and more effective than dox against Pgp-overexpressing osteosarcoma cells. In order to increase the active delivery to tumor cells, we produced hyaluronic acid (HA)-conjugated liposomes containing Sdox (HA-Lsdox), exploiting the abundance of the HA receptor CD44 in osteosarcoma. HA-Lsdox showed favorable drug-release profile and higher toxicity in vitro and in vivo than dox or the FDA-approved liposomal dox Caelyx^® against Pgp-overexpressing osteosarcoma, displaying the same cardiotoxicity profile of Caelyx^®. Differently from dox, HA-Lsdox delivered the drug within the endoplasmic reticulum (ER), inducing protein sulfhydration and ubiquitination, and activating a ER stress pro-apoptotic response mediated by CHOP. HA-Lsdox also sulfhydrated the nascent Pgp in the ER, reducing its activity. We propose HA-Lsdox as an innovative tool noteworthy to be tested in Pgp-overexpressing patients, who are frequently less responsive to standard treatments in which dox is one of the most important drugs.

Ezrin is Significantly Overexpressed in Luminal A, Luminal B, and HER2 Subtype Breast Cancer

Ezrin, a membrane-linking protein, has been shown to play an important role in the carcinogenesis of infiltrating breast ductal carcinoma and its strong expression has been used to predict poor prognosis in patients with breast carcinoma. In this study, we compared ezrin protein distribution pattern in benign breast disease and breast cancer molecular subtypes and evaluated their association with clinicopathologic variables. A total of 376 breast cases (142 benign and 234 malignant cases) were studied. Immunohistochemical analysis for ezrin was performed and its expression was observed in terms of its distribution, intensity, and proportion of cells reactive for ezrin. Ezrin was expressed in all benign cases and 91.7% of malignant cases. Apical staining was positively associated with benign breast disease, whereas membranous and cytoplasmic staining were more frequently observed in malignant cases, specifically of hormone receptor-positive subtypes (luminal A and luminal B). Ezrin was significantly overexpressed in luminal A, luminal B, and HER2 subtypes. Reduced ezrin expression was significantly associated with triple-negative breast cancer molecular subtype. No significant association was demonstrated between ezrin expression and Her2 gene amplification, tumor grading, or staging.

The Prognostic Role of Ezrin and HER2/neu Expression in Osteosarcoma

Osteosarcoma is the most common primary malignant bone tumor in Egypt. Ezrin is involved in cell adhesion to the extracellular matrix and in cell-cell interactions facilitating metastasis. HER2/neu is overexpressed in breast cancer and other types of cancer. This study aimed to assess the expression of ezrin and HER2/neu in 57 primary osteosarcoma cases and to correlate their expression with the available clinicopathologic parameters and the overall, metastasis-free and event-free survival. Both ezrin and HER2/neu were not expressed in the normal bone and they were upregulated in 82.5% and 71.9% of osteosarcoma, respectively. Positive ezrin expression was significantly associated with young age (below 25 y) (P=0.01), high grade (P=0.001), and short survival time (P=0.0001). Positive HER2/neu expression was significantly associated with high-grade osteosarcoma (P=0.04). Membranous HER2/neu expression was the only factor that showed significant impact on metastasis-free (P=0.002) and event-free survival (P=0.002). Ezrin was significantly correlated with HER2/neu expression (P=0.02). Advanced stage (P=0.0001), metastasis (P=0.0001), and recurrence (P=0.01) were the factors affecting the overall survival of osteosarcoma patients. Ezrin and HER2/neu are overexpressed and coexpressed in osteosarcoma with adverse prognostic features such as high grade. Membranous pattern of HER2/neu seems to be more important than the cytoplasmic pattern because of its impact on metastasis-free and event-free survival. Therefore, ezrin and HER2/neu could be potential prognostic markers and treatment targets for osteosarcoma.

The clinical significance of changes in ezrin expression in osteosarcoma of children and young adults

Ezrin is a protein that functions as a cross-linker between actin cytoskeleton and plasma membrane. Its clinical role in osteosarcoma is unclear. The aim of this study was to investigate, in osteosarcoma, the prognostic value of ezrin expression at biopsy and changes in expression levels after preoperative chemotherapy. Thirty-eight newly diagnosed osteosarcoma patients aged 6-23 years were included. At diagnosis, 20 patients had localized disease, the others had distant metastases. Median follow-up was 75 months (range 13-135). Ezrin expression was assessed immunohistochemically in biopsy tissue and primary tumour specimens resected after chemotherapy. The influence on survival of changes in ezrin expression after chemotherapy was analysed. Ezrin expression was significantly higher after preoperative chemotherapy and changes compared to biopsy tissue were significantly lower in patients with early progression than in patients with relapse or no further evidence of disease (p = 0.006 and p = 0.002, respectively). Similarly, ezrin expression was higher after preoperative chemotherapy and exhibited less change in expression in deceased patients compared to patients surviving more than 5 years (both p = 0.001). Ezrin expression at biopsy was significantly associated with both histopathological aggressiveness (p < 0.001) and tumour size (p = 0.037). The results of this study provide evidence that changes in overexpression of ezrin due to preoperative chemotherapy could be a useful predictive and prognostic marker in patients with osteosarcoma.

Prognostic Value of Ezrin in Various Cancers: A Systematic Review and Updated Meta-analysis

More and more studies have investigated the effects of Ezrin expression level on the prognostic role in various tumors. However, the results remain controversial rather than conclusive. Here, we performed a systematic review and meta-analysis to evaluate the correlation of Ezrin expression with the prognosis in various tumors. the pooled hazard ratios (HR) with the corresponding 95% confidence intervals (95% CI) were calculated to evaluate the degree of the association. The overall results of fifty-five studies with 6675 patients showed that elevated Ezrin expression was associated with a worse prognosis in patients with cancers, with the pooled HRs of 1.86 (95% CI: 1.51–2.31, P < 0.001) for over survival (OS), 2.55 (95% CI: 2.14–3.05, P < 0.001) for disease-specific survival (DFS) and 2.02 (95% CI: 1.13–3.63, P = 0.018) for disease-specific survival (DSS)/metastasis-free survival (MFS) by the random, fixed and random effect model respectively. Similar results were also observed in the stratified analyses by tumor types, ethnicity background and sample source. This meta-analysis suggests that Ezrin may be a potential prognostic marker in cancer patients. High Ezrin is associated with a poor prognosis in a variety of solid tumors.

Prognostic role of CD44 expression in osteosarcoma: evidence from six studies

Background

Numerous studies examining the relationship between CD44 expression and prognostic impact in patients with osteosarcoma have yielded inconclusive results. The aim of this meta-analysis was carried out to investigate the relationship between CD44 expression and the survival in patients with osteosarcoma.

Methods

We therefore conducted a meta-analysis to provide a comprehensive evaluation of the prognostic role of CD44 expression on the overall survival rate and metastasis, which compared the positive and negative expression of CD44 in patients of the available studies.

Results

A detailed search was made in MEDLINE and EMBASE for relevant original articles published in English. Finally, a total of six studies with 329 osteosarcoma patients were involved to estimate the relationship between CD44 expression and metastasis of tumor and overall survival. Positive expressions of CD44 did not predict neoplasm metastasis (RR = 1.36, 95% CI: 1.00–1.84, P = 0.50), and the results indicated that higher expression of CD44 could not predict poorer survival in osteosarcoma with the pooled HR of 0.55 (95% CI: 0.27–1.13, P = 0.47).

Conclusions

The findings from this present meta-analysis suggest that CD44 expression is not associated with overall survival rate and metastasis in osteosarcoma.

Virtual Slides

The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1373995521295618

Prognostic role of cytovillin expression in patients with osteosarcoma: a meta-analysis

Cytovillin plays structural and regulatory roles in the assembly and stabilization of specialized plasma membrane domains and in the tumor angiogenesis. Cytovillin expression has been proposed to be an effective biomarker of prognosis in patients with osteosarcoma, and many studies have been performed to assess the prognostic role of cytovillin expression in patients with osteosarcoma. We performed this meta-analysis to provide a comprehensive evaluation of the role of cytovillin expression on the overall survival rate by calculating the pooled risk ratio (RR) with corresponding 95% confidence interval (95% CI). Finally, eight studies with a total of 415 patients with osteosarcoma were included into the meta-analysis. Meta-analysis of total eight studies showed that cytovillin expression was obviously associated with lower overall survival rate in patients with osteosarcoma (RR = 0.41, 95% CI 0.28–0.58, P < 0.001). Meta-analysis of five studies with large sample still showed that cytovillin expression was obviously associated with lower overall survival rate (RR = 0.48, 95% CI 0.38–0.60, P < 0.001). In conclusion, the meta-analysis shows that cytovillin expression is obviously associated with lower overall survival rate in patients with osteosarcoma, and it is an effective biomarker of prognosis.

Role of ezrin in osteosarcoma metastasis

The cause of death for the vast majority of cancer patients is the development of metastases at sites distant from that of the primary tumor. For most pediatric sarcoma patients such as those with osteosarcoma (OS), despite successful management of the primary tumor through multimodality approaches, the development of metastases, commonly to the lungs, is the cause of death. Significant improvements in long-term outcome for these patients have not been seen in more than 30 years. Furthermore, the long-term outcome for patients who present with metastatic disease is grave [1-5]. New treatment options are needed.Opportunities to improve outcomes for patients who present with metastases and those at-risk for progression and metastasis require an improved understanding of cancer progression and metastasis. With this goal in mind we and others have identified ezrin as a metastasis-associated protein that associated with OS and other cancers. Ezrin is the prototypical ERM (Ezrin/Radixin/Moesin) protein family member. ERMs function as linker proteins connecting the actin cytoskeleton and the plasma membrane. Since our initial identification of ezrin in pediatric sarcoma, an increasing understanding the role of ezrin in metastasis has emerged. Briefly, ezrin appears to allow metastatic cells to overcome a number of stresses experienced during the metastatic cascade, most notably the stress experienced as cells interact with the microenvironment of the secondary site. Cells must rapidly adapt to this environment in order to survive. Evidence now suggests a connection between ezrin expression and a variety of mechanisms linked to this important cellular adaptation including the ability of metastatic cells to initiate the translation of new proteins and to allow the efficient generation of ATP through a variety of sources. This understanding of the role of ezrin in the biology of metastasis is now sufficient to consider ezrin as an important therapeutic target in osteosarcoma patients. This chapter reviews our understanding of ezrin and the related ERM proteins in normal tissues and physiology, summarizes the expression of ezrin in human cancers and associations with clinical parameters of disease progression, reviews reports that detail a biological understanding of ezrin's role in metastatic progression, and concludes with a rationale that may be considered to target ezrin and ezrin biology in osteosarcoma.

The prognostic value of elevated ezrin in patients with osteosarcoma

Published studies researching the prognostic significance of ezrin expression in patients with osteosarcoma are inconclusive and heterogeneous. We conducted a meta-analysis to assess its prognostic value more precisely. The hazard ratios with corresponding 95 % confidence intervals were calculated to evaluate the effects. Five studies with 318 osteosarcoma patients were included to estimate the relationship between ezrin and disease-free survival, and ezrin and overall survival. Compared with osteosarcoma patients with low or negative ezrin expression, patients with high ezrin expression tended to be associated with lower disease-free survival, but the difference was not significant. However, patients with high ezrin expression were obviously associated with lower overall survival. Therefore, the findings from this systematic review suggest that ezrin expression is an effective biomarker of prognosis in patients with osteosarcoma.

Clinical implications of Ezrin and CD44 co‑expression in breast cancer

The aim of the present study was to investigate the expression status and clinical implications of the stem cell genes Ezrin and CD44 in breast cancers. Expression of the Ezrin protein in CD44+/CD24-/low tumor cells (CSCs) was detected by western blotting. The resulting expression status and the relationship between Ezrin and CD44 were determined in 726 breast cancers using immunohistochemistry staining and immunofluorescence double staining. Subsequently, the relationship between Ezrin and CD44 protein co-expression and clinicopathological parameters and prognosis was determined. The Ezrin protein was expressed at a higher level in CSCs when compared to that in the control cells and was related to the resistance of CSCs to chemotherapy. The Ezrin and CD44 proteins were co-expressed in the co-immunoprecipitation (Co-IP) test. Ezrin and CD44 co-expression was observed in 235 (32.37%) of the 726 cases examined. After universal analysis and multivariate analysis, histological type, lymph node metastasis, triple-negative breast cancer, TNM stage and distant metastasis were verified as related to Ezrin and CD44 co-expression (P=0.011, 0.006, 0.001, 0.011 and 0.001, respectively). A survival analysis revealed that Ezrin and CD44 co-expression was associated with a poorer prognosis (36.91 vs. 81.54%, P=0.001). After running Cox regression, the factors of age, tumor size, lymph node metastasis, triple-negative tumor status, TNM stage, distant metastasis and Ezrin and CD44 co-expression were shown to be independent prognostic factors of breast cancer. The co-expression of Ezrin and CD44 may be a new biomarker for evaluating the progression and chemotherapy sensitivity of breast cancer.

The Prognostic Role of Ezrin Immunoexpression in Osteosarcoma: A Meta-Analysis of Published Data

Background

The significance of ezrin immunoexpression and prognosis for osteosarcoma is still controversial. The aim was to provide a meta-analysis for ezrin immunoexpression and prognostic features of osteosarcoma patients.

Methods

A detailed search was made in MEDLINE, EMBASE and the Web of Knowledge for relevant original articles published in English; methodological quality of the included studies was also assessed. Two reviewers extracted data independently. Studies were pooled and summary hazard ratios (HRs) and odds ratio (ORs) with corresponding confidence intervals (CIs) were calculated.

Results

Final analysis of 318 patients from 5 eligible studies was performed. Combined HR of ezrin immunohistochemical staining suggested that positive immunoexpression had an unfavorable impact on osteosarcoma patients' overall survival (n = 223 in 4 studies; HR = 4.79; 95% CI: 1.50–15.30; P = 0.008) but not on event-free survival (n = 202 in 3 studies; HR = 1.59; 95% CI: 0.61–4.15; P = 0. 0.342). Combined OR of ezrin immunohistochemical staining indicated that positive immunoexpression was associated with recurrence (n = 134 in 2 studies; OR = 3.79; 95% CI: 1.49–9.64; P = 0.005) but not with serum ALP level (n = 160 in 2 studies; OR = 2.16; 95% CI: 0.09–52.50; P = 0.637) and histological response to neoadjuvant chemotherapy(n = 260 in 4 studies; OR = 0.87; 95% CI: 0.37–2.03; P = 0.740).

Conclusions

The results of this meta-analysis suggest that ezrin positive immunoexpression confers a higher risk of recurrence and a worse survival in osteosarcoma patients. Large prospective studies are needed to provide solid data to investigate the precise prognostic significance of ezrin.

Silencing of CD44 gene expression in human 143-B osteosarcoma cells promotes metastasis of intratibial tumors in SCID mice

Osteosarcoma (OS) is the most frequent primary malignant bone cancer in children and adolescents with a high propensity for lung metastasis. Therefore, it is of great importance to identify molecular markers leading to increased metastatic potential in order to devise more effective therapeutic strategies that suppress metastasis, the major cause of death in OS. CD44, the principal receptor for the extracellular matrix component hyaluronan (HA), is frequently found overexpressed in tumor cells and has been implicated in metastatic spread in various cancer types. Here, we investigated the effects of stable shRNA-mediated silencing of CD44 gene products on in vitro and in vivo metastatic properties of the highly metastatic human 143-B OS cell line. In vitro, CD44 knockdown resulted in a 73% decrease in the adhesion to HA, a 57% decrease in the migration rate in a trans-filter migration assay, and a 28% decrease in the cells' capacity for anchorage-independent growth in soft agar compared to the control cells, implicating that CD44 expression contributes to the metastatic activity of 143-B cells. However, making use of an orthotopic xenograft OS mouse model, we demonstrated that reduced CD44 expression facilitated primary tumor growth and formation of pulmonary metastases. The enhanced malignant phenotype was associated with decreased adhesion to HA and reduced expression of the tumor suppressor merlin in vivo. In conclusion, our study identified CD44 as a metastasis suppressor in this particular experimental OS model.

CD44 enhances tumor formation and lung metastasis in experimental osteosarcoma and is an additional predictor for poor patient outcome

Formation of metastases in the lungs is the major cause of death in patients suffering from osteosarcoma (OS). Metastases at presentation and poor response to preoperative chemotherapy are strong predictors for poor patient outcome. The elucidation of molecular markers that promote metastasis formation and/or chemoresistance is therefore of importance. CD44 is a plasma membrane glycoprotein that binds to the extracellular matrix component hyaluronan (HA) and has been shown to be involved in metastasis formation in a variety of other tumors. Here we investigated the role of CD44 expression on OS tumor formation and metastasis. High CD44 expression, evaluated with a tissue microarray including samples from 53 OS patients and stained with a pan-CD44 antibody (Hermes3), showed a tendency (p < 0.08) to shortened overall survival. However, nonresponders and patients with lung metastases and high CD44 expression had significantly poorer prognosis than patients with low CD44 expression. Overexpression of the standard CD44 isoform (CD44s) and its HA-binding defective mutant R41A in osteoblastic SaOS-2 cells resulted in HA-independent higher migration rates and increased chemoresistance, partially dependent on HA. In an orthotopic mouse model of OS, overexpression of CD44s in SaOS-2 cells resulted in an HA-dependent increased primary tumor formation and increased numbers of micrometastases and macrometastases in the lungs. In conclusion, although CD44 failed to be an independent predictor for patient outcome in this limited cohort of OS patients, increased CD44 expression was associated with even worse survival in patients with chemoresistance and with lung metastases. CD44-associated chemoresistance was also observed in vitro, and increased formation of lung metastases was found in vivo in SCID mice.

Sphingosine 1-phosphate induces filopodia formation through S1PR2 activation of ERM proteins

Previously we demonstrated that the sphingolipids ceramide and S1P (sphingosine 1-phosphate) regulate phosphorylation of the ERM (ezrin/radixin/moesin) family of cytoskeletal proteins [Canals, Jenkins, Roddy, Hernande-Corbacho, Obeid and Hannun (2010) J. Biol. Chem. 285, 32476-3285]. In the present article, we show that exogenously applied or endogenously generated S1P (in a sphingosine kinase-dependent manner) results in significant increases in phosphorylation of ERM proteins as well as filopodia formation. Using phosphomimetic and non-phosphorylatable ezrin mutants, we show that the S1P-induced cytoskeletal protrusions are dependent on ERM phosphorylation. Employing various pharmacological S1PR (S1P receptor) agonists and antagonists, along with siRNA (small interfering RNA) techniques and genetic knockout approaches, we identify the S1PR2 as the specific and necessary receptor to induce phosphorylation of ERM proteins and subsequent filopodia formation. Taken together, the results demonstrate a novel mechanism by which S1P regulates cellular architecture that requires S1PR2 and subsequent phosphorylation of ERM proteins.