Mismatch repair phenotype determines the implications of tumor grade and CDX2 expression in stage II–III colon cancer


Mismatch repair (MMR) deficiency is an indicator of good prognosis in localized colon cancer but also associated with lack of expression of caudal-type homeobox transcription factor 2 (CDX2) and high tumor grade; markers that in isolation indicate a poor prognosis. Our study aims to identify clinically relevant prognostic subgroups by combining information about tumor grade, MMR phenotype, and CDX2 expression. Immunohistochemistry for MMR proteins and CDX2 was performed in 544 patients with colon cancer stage II–III, including a cohort from a randomized trial. In patients with proficient MMR (pMMR) and CDX2 negativity, hazard ratio (HR) for cancer death was 2.93 (95% CI 1.23–6.99, p = 0.015). Cancer-specific survival for pMMR/CDX2-negative cases was 35.8 months (95% CI 23.4–48.3) versus 52.1–53.5 months (95% CI 45.6–58.6, p = 0.001) for the remaining cases (CDX2-positive tumors or deficient MMR (dMMR)/CDX2-negative tumors). In our randomized cohort, high tumor grade was predictive of response to adjuvant fluorouracil–levamisole in pMMR patients, with a significant interaction between tumor grade and treatment (p = 0.036). For pMMR patients, high tumor grade was a significant marker of poor prognosis in the surgery-only group (HR 4.60 (95% CI 1.68–12.61), p = 0.003) but not in the group receiving chemotherapy (HR 0.66 (95% CI 0.15–3.00), p = 0.587). To conclude, patients with pMMR and CDX2 negativity have a very poor prognosis. Patients with pMMR and high-graded tumors have a poor prognosis but respond well to adjuvant chemotherapy. CDX2 expression and tumor grade did not impact prognosis in patients with dMMR.

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Fig. 1: Immunohistochemical staining for CDX2.
Fig. 2: Euler diagram showing the overlap between number of patients with deficient mismatch repair, CDX2 negativity, and high tumor grade.
Fig. 3: Prognostic impact of CDX2 expression status illustrated by Kaplan–Meier curves for the whole study cohort stratified by mismatch repair (MMR) phenotype.
Fig. 4: Prognostic impact of tumor grade illustrated by Kaplan–Meier curves stratified by mismatch repair (MMR) phenotype.
Fig. 5: Predictive impact of tumor grade illustrated by separate Kaplan–Meier curves for patients randomized to surgery only versus adjuvant chemotherapy with fluorouracil–levamisole after surgery.


  1. 1.

    Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018;68:394–424.

    PubMed  PubMed Central  Google Scholar 

  2. 2.

    Labianca R, Nordlinger B, Beretta GD, Mosconi S, Mandala M, Cervantes A, et al. Early colon cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2013;24 Suppl 6:vi64–72.

    PubMed  Google Scholar 

  3. 3.

    Babcock BD, Aljehani MA, Jabo B, Choi AH, Morgan JW, Selleck MJ, et al. High-risk stage II colon cancer: not all risks are created equal. Ann Surg Oncol. 2018;25:1980–5.

    PubMed  Google Scholar 

  4. 4.

    eUpdate- Early Colon Cancer Treatment Recommendations, [Internet], ESMO Guidelines Committee, Lugano, Switzerland, 2019 [cited 2 January 2020]. Available from https://www.esmo.org/guidelines/gastrointestinal-cancers/localised-colon-cancer/eupdate-early-colon-cancer-treatment-recommendations.

  5. 5.

    Gray R, Barnwell J, McConkey C, Hills RK, Williams NS, Kerr DJ. Adjuvant chemotherapy versus observation in patients with colorectal cancer: a randomised study. Lancet. 2007;370:2020–9.

    PubMed  Google Scholar 

  6. 6.

    Guinney J, Dienstmann R, Wang X, de Reynies A, Schlicker A, Soneson C, et al. The consensus molecular subtypes of colorectal cancer. Nat Med. 2015;21:1350–6.

    CAS  PubMed  PubMed Central  Google Scholar 

  7. 7.

    Benatti P, Gafa R, Barana D, Marino M, Scarselli A, Pedroni M, et al. Microsatellite instability and colorectal cancer prognosis. Clin Cancer Res. 2005;11:8332–40.

    CAS  PubMed  Google Scholar 

  8. 8.

    Fleming M, Ravula S, Tatishchev SF, Wang HL. Colorectal carcinoma: pathologic aspects. J Gastrointest Oncol. 2012;3:153–73.

    PubMed  PubMed Central  Google Scholar 

  9. 9.

    Boland CR, Goel A. Microsatellite instability in colorectal cancer. Gastroenterology. 2010;138:2073–87.e3.

    CAS  PubMed  PubMed Central  Google Scholar 

  10. 10.

    Wang T, Lee LH, Vyas M, Zhang L, Ganesh K, Firat C, et al. Colorectal carcinoma with double somatic mismatch repair gene inactivation: clinical and pathological characteristics and response to immune checkpoint blockade. Mod Pathol. 2019;32:1551–62.

    CAS  PubMed  PubMed Central  Google Scholar 

  11. 11.

    WHO Classification of Tumors Editorial Board. Digestive system tumors. 5th ed. Lyon: International Agency for Research on Cancer; 2019.

  12. 12.

    Sargent DJ, Marsoni S, Monges G, Thibodeau SN, Labianca R, Hamilton SR, et al. Defective mismatch repair as a predictive marker for lack of efficacy of fluorouracil-based adjuvant therapy in colon cancer. J Clin Oncol. 2010;28:3219–26.

    CAS  PubMed  PubMed Central  Google Scholar 

  13. 13.

    Koenig JL, Toesca DAS, Harris JP, Tsai CJ, Haraldsdottir S, Lin AY, et al. Microsatellite instability and adjuvant chemotherapy in stage II colon cancer. Am J Clin Oncol. 2019;42:573–80.

    CAS  PubMed  Google Scholar 

  14. 14.

    Hansen TF, Kjaer-Frifeldt S, Eriksen AC, Lindebjerg J, Jensen LH, Sorensen FB, et al. Prognostic impact of CDX2 in stage II colon cancer: results from two nationwide cohorts. Br J Cancer. 2018;119:1367–73.

    CAS  PubMed  PubMed Central  Google Scholar 

  15. 15.

    Greene FL, Stewart AK, Norton HJ. A new TNM staging strategy for node-positive (stage III) colon cancer: an analysis of 50,042 patients. Ann Surg. 2002;236:416–21.

    PubMed  PubMed Central  Google Scholar 

  16. 16.

    Dalerba P, Sahoo D, Paik S, Guo X, Yothers G, Song N, et al. CDX2 as a prognostic biomarker in stage II and stage III colon cancer. N Engl J Med. 2016;374:211–22.

    CAS  PubMed  PubMed Central  Google Scholar 

  17. 17.

    Romiti A, Roberto M, Marchetti P, Di Cerbo A, Falcone R, Campisi G, et al. Study of histopathologic parameters to define the prognosis of stage II colon cancer. Int J Colorectal Dis. 2019;34:905–13.

    PubMed  Google Scholar 

  18. 18.

    Bruun J, Sveen A, Barros R, Eide PW, Eilertsen I, Kolberg M, et al. Prognostic, predictive, and pharmacogenomic assessments of CDX2 refine stratification of colorectal cancer. Mol Oncol. 2018;12:1639–55.

    CAS  PubMed  PubMed Central  Google Scholar 

  19. 19.

    Graule J, Uth K, Fischer E, Centeno I, Galvan JA, Eichmann M, et al. CDX2 in colorectal cancer is an independent prognostic factor and regulated by promoter methylation and histone deacetylation in tumors of the serrated pathway. Clin Epigenetics. 2018;10:120.

    PubMed  PubMed Central  Google Scholar 

  20. 20.

    Suh E, Traber PG. An intestine-specific homeobox gene regulates proliferation and differentiation. Mol Cell Biol. 1996;16:619–25.

    CAS  PubMed  PubMed Central  Google Scholar 

  21. 21.

    Werling RW, Yaziji H, Bacchi CE, Gown AM. CDX2, a highly sensitive and specific marker of adenocarcinomas of intestinal origin: an immunohistochemical survey of 476 primary and metastatic carcinomas. Am J Surg Pathol. 2003;27:303–10.

    PubMed  Google Scholar 

  22. 22.

    Lugli A, Tzankov A, Zlobec I, Terracciano LM. Differential diagnostic and functional role of the multi-marker phenotype CDX2/CK20/CK7 in colorectal cancer stratified by mismatch repair status. Mod Pathol. 2008;21:1403–12.

    CAS  PubMed  Google Scholar 

  23. 23.

    Gill S, Loprinzi CL, Sargent DJ, Thome SD, Alberts SR, Haller DG, et al. Pooled analysis of fluorouracil-based adjuvant therapy for stage II and III colon cancer: who benefits and by how much? J Clin Oncol. 2004;22:1797–806.

    CAS  PubMed  Google Scholar 

  24. 24.

    Jessup JM, Stewart A, Greene FL, Minsky BD. Adjuvant chemotherapy for stage III colon cancer: implications of race/ethnicity, age, and differentiation. JAMA. 2005;294:2703–11.

    CAS  PubMed  Google Scholar 

  25. 25.

    Rosty C, Williamson EJ, Clendenning M, Walters RJ, Win AK, Jenkins MA, et al. Should the grading of colorectal adenocarcinoma include microsatellite instability status? Hum Pathol. 2014;45:2077–84.

    CAS  PubMed  Google Scholar 

  26. 26.

    Dahl O, Fluge O, Carlsen E, Wiig JN, Myrvold HE, Vonen B, et al. Final results of a randomised phase III study on adjuvant chemotherapy with 5 FU and levamisol in colon and rectum cancer stage II and III by the Norwegian Gastrointestinal Cancer Group. Acta Oncol. 2009;48:368–76.

    CAS  PubMed  Google Scholar 

  27. 27.

    Stanisavljevic L, Assmus J, Storli KE, Leh SM, Dahl O, Myklebust MP. CXCR4, CXCL12 and the relative CXCL12-CXCR4 expression as prognostic factors in colon cancer. Tumour Biol. 2016;37:7441–52.

    CAS  PubMed  Google Scholar 

  28. 28.

    Jacob H, Stanisavljevic L, Storli KE, Hestetun KE, Dahl O, Myklebust MP. Identification of a sixteen-microRNA signature as prognostic biomarker for stage II and III colon cancer. Oncotarget. 2017;8:87837–47.

    PubMed  PubMed Central  Google Scholar 

  29. 29.

    NordiQC: assessments and recommended protocols, [Internet], Nordic immunohistochemical Quality Control (NordiQC), Aalborg, Denmark 2016 [cited 13 June 2020]. Available from https://www.nordiqc.org/downloads/assessments/83_39.pdf.

  30. 30.

    Chen W, Frankel WL. A practical guide to biomarkers for the evaluation of colorectal cancer. Mod Pathol. 2019;32 Suppl 1:1–15.

    PubMed  Google Scholar 

  31. 31.

    Sarode VR, Robinson L. Screening for Lynch syndrome by immunohistochemistry of mismatch repair proteins: significance of indeterminate result and correlation with mutational studies. Arch Pathol Lab Med. 2019;143:1225–33.

    CAS  PubMed  Google Scholar 

  32. 32.

    Joost P, Veurink N, Holck S, Klarskov L, Bojesen A, Harbo M, et al. Heterogenous mismatch-repair status in colorectal cancer. Diagn Pathol. 2014;9:126.

    PubMed  PubMed Central  Google Scholar 

  33. 33.

    McCarthy AJ, Capo-Chichi JM, Spence T, Grenier S, Stockley T, Kamel-Reid S, et al. Heterogenous loss of mismatch repair (MMR) protein expression: a challenge for immunohistochemical interpretation and microsatellite instability (MSI) evaluation. J Pathol Clin Res. 2019;5:115–29.

    CAS  PubMed  Google Scholar 

  34. 34.

    Team RDC. R: a language and environment for statistical computing. Vienna: Team RDC; 2017.

  35. 35.

    Pilati C, Taieb J, Balogoun R, Marisa L, de Reynies A, Laurent-Puig P. CDX2 prognostic value in stage II/III resected colon cancer is related to CMS classification. Ann Oncol. 2017;28:1032–5.

    CAS  PubMed  Google Scholar 

  36. 36.

    Olsen J, Eiholm S, Kirkeby LT, Espersen ML, Jess P, Gogenur I, et al. CDX2 downregulation is associated with poor differentiation and MMR deficiency in colon cancer. Exp Mol Pathol. 2016;100:59–66.

    CAS  PubMed  Google Scholar 

  37. 37.

    Lundberg IV, Edin S, Eklof V, Oberg A, Palmqvist R, Wikberg ML. SOX2 expression is associated with a cancer stem cell state and down-regulation of CDX2 in colorectal cancer. BMC Cancer. 2016;16:471.

    PubMed  PubMed Central  Google Scholar 

  38. 38.

    Bae JM, Lee TH, Cho NY, Kim TY, Kang GH. Loss of CDX2 expression is associated with poor prognosis in colorectal cancer patients. World J Gastroenterol. 2015;21:1457–67.

    CAS  PubMed  PubMed Central  Google Scholar 

  39. 39.

    Slik K, Turkki R, Carpen O, Kurki S, Korkeila E, Sundstrom J, et al. CDX2 loss with microsatellite stable phenotype predicts poor clinical outcome in stage II colorectal carcinoma. Am J Surg Pathol. 2019;43:1473–82.

    PubMed  Google Scholar 

  40. 40.

    Kim JH, Rhee YY, Bae JM, Cho NY, Kang GH. Loss of CDX2/CK20 expression is associated with poorly differentiated carcinoma, the CpG island methylator phenotype, and adverse prognosis in microsatellite-unstable colorectal cancer. Am J Surg Pathol. 2013;37:1532–41.

    PubMed  Google Scholar 

  41. 41.

    Baba Y, Nosho K, Shima K, Freed E, Irahara N, Philips J, et al. Relationship of CDX2 loss with molecular features and prognosis in colorectal cancer. Clin Cancer Res. 2009;15:4665–73.

    CAS  PubMed  PubMed Central  Google Scholar 

  42. 42.

    Ma C, Olevian D, Miller C, Herbst C, Jayachandran P, Kozak MM, et al. SATB2 and CDX2 are prognostic biomarkers in DNA mismatch repair protein deficient colon cancer. Mod Pathol. 2019;32:1217–31.

    CAS  PubMed  Google Scholar 

  43. 43.

    Knosel T, Chen Y, Hotovy S, Settmacher U, Altendorf-Hofmann A, Petersen I. Loss of desmocollin 1-3 and homeobox genes PITX1 and CDX2 are associated with tumor progression and survival in colorectal carcinoma. Int J Colorectal Dis. 2012;27:1391–9.

    PubMed  Google Scholar 

  44. 44.

    Ryan EJ, Creavin B, Khaw YL, Kelly ME, Mohan HM, Geraghty R, et al. Effects of CDX2 on prognosis and chemotherapy responsiveness in mismatch repair-deficient colorectal cancer. BJS Open. 2018;2:456–63.

    CAS  PubMed  PubMed Central  Google Scholar 

  45. 45.

    Liu Q, Luo D, An H, Zhang S, Cai S, Li Q, et al. Survival benefit of adjuvant chemotherapy for patients with poorly differentiated stage IIA colon cancer. J Cancer. 2019;10:1209–15.

    CAS  PubMed  PubMed Central  Google Scholar 

  46. 46.

    Andre T, Boni C, Navarro M, Tabernero J, Hickish T, Topham C, et al. Improved overall survival with oxaliplatin, fluorouracil, and leucovorin as adjuvant treatment in stage II or III colon cancer in the MOSAIC trial. J Clin Oncol. 2009;27:3109–16.

    CAS  PubMed  Google Scholar 

  47. 47.

    Fluge Ø, Gravdal K, Carlsen E, Vonen B, Kjellevold K, Refsum S, et al. Expression of EZH2 and Ki-67 in colorectal cancer and associations with treatment response and prognosis. Br J Cancer. 2009;101:1282–9.

    CAS  PubMed  PubMed Central  Google Scholar 

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We thank the Department of Pathology Ålesund for performing MMR protein staining, the Department of Pathology, Haukeland University Hospital for performing CDX2 staining and the Mohn Laboratory for Cancer Research for excellent facilities. We want to give a special acknowledgement to Ole Johnny Steffensen for invaluable technical support.

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Correspondence to Kjersti Elvestad Hestetun.

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The Regional Committee for Medical Research Ethics of Western Norway and the Data Inspectorate for National Registries approved the study protocols. All patients signed informed consents.

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Hestetun, K.E., Aasebø, K., Rosenlund, N.B. et al. Mismatch repair phenotype determines the implications of tumor grade and CDX2 expression in stage II–III colon cancer. Mod Pathol (2020). https://doi.org/10.1038/s41379-020-0634-9

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