Article | Published:

Molecular Diagnostics

LGR5 expression predicts peritoneal recurrence after curative resection of primary colon cancer

British Journal of Cancervolume 120pages9961002 (2019) | Download Citation



The aim of this study was to clarify whether a cancer stem cell marker could be an indicator of post-operative peritoneal recurrence of colon cancer.


Expression of four putative markers (CD133, CD44 variant 6, aldehyde dehydrogenase-1 and leucine-rich repeating G-protein-coupled receptor-5 (LGR5)) was evaluated immunohistochemically in primary tumour samples from 292 patients who underwent curative resection for non-metastasised pT4 colon cancer at the University of Tokyo Hospital between 1997 and 2015.


Peritoneal recurrence was significantly higher in LGR5-negative cases (5-year cumulative incidence: 27.5% vs. 14.4%, p = 0.037). Multivariable analysis confirmed that negative LGR5 expression was an independent risk factor for peritoneal recurrence (hazard ratio (HR) 2.79, p = 0.005) in addition to poor differentiation, positive lymph node metastasis, preoperative carcinoembryonic antigen > 5 ng/mL and anastomotic leakage. The addition of LGR5 significantly improved the predictive value of the multivariable model (net reclassification improvement: 0.186, p = 0.028: integrated discrimination improvement: 0.047, p = 0.008).


Negative LGR5 expression was a significant predictor of peritoneal recurrence in patients with pT4 colon cancer. Therefore, LGR5 might be a promising biomarker to identify patients at high risk of post-operative peritoneal metastasis.

Access optionsAccess options

Rent or Buy article

Get time limited or full article access on ReadCube.


All prices are NET prices.

Additional information

Publisher’s note: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.


  1. 1.

    Franko, J., Shi, Q., Meyers, J. P., Maughan, T. S., Adams, R. A., Seymour, M. T. et al. Prognosis of patients with peritoneal metastatic colorectal cancer given systemic therapy: an analysis of individual patient data from prospective randomised trials from the Analysis and Research in Cancers of the Digestive System (ARCAD) database. Lancet Oncol. 17, 1709–1719 (2016).

  2. 2.

    Elias, D., Honore, C., Dumont, F., Ducreux, M., Boige, V., Malka, D. et al. Results of systematic second-look surgery plus HIPEC in asymptomatic patients presenting a high risk of developing colorectal peritoneal carcinomatosis. Ann. Surg. 254, 289–293 (2011).

  3. 3.

    Sugarbaker, P. H. Update on the prevention of local recurrence and peritoneal metastases in patients with colorectal cancer. World J. Gastroenterol. 20, 9286–9291 (2014).

  4. 4.

    Clarke, M. F., Dick, J. E., Dirks, P. B., Eaves, C. J., Jamieson, C. H., Jones, D. L. et al. Cancer stem cells--perspectives on current status and future directions: AACR Workshop on cancer stem cells. Cancer Res. 66, 9339–9344 (2006).

  5. 5.

    Vermeulen, L., de Sousa e Melo, F., Richel, D. J. & Medema, J. P. The developing cancer stem-cell model: clinical challenges and opportunities. Lancet Oncol. 13, e83–e89 (2012).

  6. 6.

    Nagata, H., Ishihara, S., Hata, K., Murono, K., Kaneko, M., Yasuda, K. et al. Survival and prognostic factors for metachronous peritoneal metastasis in patients with colon cancer. Ann. Surg. Oncol. 24, 1269–1280 (2017).

  7. 7.

    Brierley, J. D., Gospodarowicz, M. K., Wittekind, C. (eds). TNM Classification of Malignant Tumours. 8th edn (Wiley-Blackwell, West Sussex, UK, 2017).

  8. 8.

    Watanabe, T., Muro, K., Ajioka, Y., Hashiguchi, Y., Ito, Y., Saito, Y. et al. Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines 2016 for the treatment of colorectal cancer. Int. J. Clin. Oncol. 23, 1–34 (2018).

  9. 9.

    Nagata, H., Ishihara, S., Kishikawa, J., Sonoda, H., Murono, K., Emoto, S. et al. CD133 expression predicts post-operative recurrence in patients with colon cancer with peritoneal metastasis. Int. J. Oncol. 52, 721–732 (2018).

  10. 10.

    Maeda, S., Shinchi, H., Kurahara, H., Mataki, Y., Maemura, K., Sato, M. et al. CD133 expression is correlated with lymph node metastasis and vascular endothelial growth factor-C expression in pancreatic cancer. Br. J. Cancer 98, 1389–1397 (2008).

  11. 11.

    Miller, T. J., McCoy, M. J., Hemmings, C., Bulsara, M. K., Iacopetta, B. & Platell, C. F. Objective analysis of cancer stem cell marker expression using immunohistochemistry. Pathology 49, 24–29 (2017).

  12. 12.

    Yu, J., Li, X., Zhong, C., Li, D., Zhai, X., Hu, W. et al. High-throughput proteomics integrated with gene microarray for discovery of colorectal cancer potential biomarkers. Oncotarget 7, 75279–75292 (2016).

  13. 13.

    Takeda, K., Kinoshita, I., Shimizu, Y., Matsuno, Y., Shichinohe, T. & Dosaka-Akita, H. Expression of LGR5, an intestinal stem cell marker, during each stage of colorectal tumorigenesis. Anticancer Res. 31, 263–270 (2011).

  14. 14.

    Hessman, C. J., Bubbers, E. J., Billingsley, K. G., Herzig, D. O. & Wong, M. H. Loss of expression of the cancer stem cell marker aldehyde dehydrogenase 1 correlates with advanced-stage colorectal cancer. Am. J. Surg. 203, 649–653 (2012).

  15. 15.

    Saito, S., Okabe, H., Watanabe, M., Ishimoto, T., Iwatsuki, M., Baba, Y. et al. CD44v6 expression is related to mesenchymal phenotype and poor prognosis in patients with colorectal cancer. Oncol. Rep. 29, 1570–1578 (2013).

  16. 16.

    Zhang, Z. Y., Luo, Q. F., Yin, X. W., Dai, Z. L., Basnet, S. & Ge, H. Y. Nomograms to predict survival after colorectal cancer resection without preoperative therapy. Bmc. Cancer 16, 658 (2016).

  17. 17.

    Harrell, F. E. Jr., Lee, K. L. & Mark, D. B. Multivariable prognostic models: issues in developing models, evaluating assumptions and adequacy, and measuring and reducing errors. Stat. Med. 15, 361–387 (1996).

  18. 18.

    Cook, N. R. & Paynter, N. P. Performance of reclassification statistics in comparing risk prediction models. Biom. J. 53, 237–258 (2011).

  19. 19.

    Hirsch, D., Barker, N., McNeil, N., Hu, Y., Camps, J., McKinnon, K. et al. LGR5 positivity defines stem-like cells in colorectal cancer. Carcinogenesis 35, 849–858 (2014).

  20. 20.

    Barker, N., van Es, J. H., Kuipers, J., Kujala, P., van den Born, M., Cozijnsen, M. et al. Identification of stem cells in small intestine and colon by marker gene Lgr5. Nature 449, 1003–1007 (2007).

  21. 21.

    de Lau, W., Barker, N., Low, T. Y., Koo, B. K., Li, V. S., Teunissen, H. et al. Lgr5 homologues associate with Wnt receptors and mediate R-spondin signalling. Nature 476, 293–297 (2011).

  22. 22.

    Wu, C., Qiu, S., Lu, L., Zou, J., Li, W. F., Wang, O. et al. RSPO2-LGR5 signaling has tumour-suppressive activity in colorectal cancer. Nat. Commun. 5, 3149 (2014).

  23. 23.

    Morgan, R. G., Mortensson, E. & Williams, A. C. Targeting LGR5 in colorectal cancer: therapeutic gold or too plastic? Br. J. Cancer 118, 1410–1418 (2018).

  24. 24.

    Hsu, H. C., Liu, Y. S., Tseng, K. C., Hsu, C. L., Liang, Y., Yang, T. S. et al. Overexpression of Lgr5 correlates with resistance to 5-FU-based chemotherapy in colorectal cancer. Int. J. Colorectal Dis. 28, 1535–1546 (2013).

  25. 25.

    Barker, N., Ridgway, R. A., van Es, J. H., van de Wetering, M., Begthel, H., van den Born, M. et al. Crypt stem cells as the cells-of-origin of intestinal cancer. Nature 457, 608–611 (2009).

  26. 26.

    McClanahan, T., Koseoglu, S., Smith, K., Grein, J., Gustafson, E., Black, S. et al. Identification of overexpression of orphan G protein-coupled receptor GPR49 in human colon and ovarian primary tumors. Cancer Biol. Ther. 5, 419–426 (2006).

  27. 27.

    Powell, A. E., Wang, Y., Li, Y., Poulin, E. J., Means, A. L., Washington, M. K. et al. The pan-ErbB negative regulator Lrig1 is an intestinal stem cell marker that functions as a tumor suppressor. Cell 149, 146–158 (2012).

  28. 28.

    Walker, F., Zhang, H. H., Odorizzi, A. & Burgess, A. W. LGR5 is a negative regulator of tumourigenicity, antagonizes Wnt signalling and regulates cell adhesion in colorectal cancer cell lines. PLoS One 6, e22733 (2011).

  29. 29.

    de Sousa, E. M. F., Colak, S., Buikhuisen, J., Koster, J., Cameron, K., de Jong, J. H. et al. Methylation of cancer-stem-cell-associated Wnt target genes predicts poor prognosis in colorectal cancer patients. Cell. Stem. Cell. 9, 476–485 (2011).

  30. 30.

    Zhou, X., Geng, L., Wang, D., Yi, H., Talmon, G. & Wang, J. R-Spondin1/LGR5 activates TGFbeta signaling and suppresses colon cancer metastasis. Cancer Res. 77, 6589–6602 (2017).

  31. 31.

    Carmon, K. S., Gong, X., Yi, J., Wu, L., Thomas, A., Moore, C. M. et al. LGR5 receptor promotes cell-cell adhesion in stem cells and colon cancer cells via the IQGAP1-Rac1 pathway. J. Biol. Chem. 292, 14989–15001 (2017).

  32. 32.

    Osawa, H., Takahashi, H., Nishimura, J., Ohta, K., Haraguchi, N., Hata, T. et al. Full-length LGR5-positive cells have chemoresistant characteristics in colorectal cancer. Br. J. Cancer 114, 1251–1260 (2016).

  33. 33.

    Marin, D., Catalano, C., Baski, M., Di Martino, M., Geiger, D., Di Giorgio, A. et al. 64-Section multi-detector row CT in the preoperative diagnosis of peritoneal carcinomatosis: correlation with histopathological findings. Abdom. Imaging 35, 694–700 (2010).

  34. 34.

    de Bree, E., Koops, W., Kroger, R., van Ruth, S., Witkamp, A. J. & Zoetmulder, F. A. Peritoneal carcinomatosis from colorectal or appendiceal origin: correlation of preoperative CT with intraoperative findings and evaluation of interobserver agreement. J. Surg. Oncol. 86, 64–73 (2004).

  35. 35.

    Jacquet, P., Jelinek, J. S., Steves, M. A. & Sugarbaker, P. H. Evaluation of computed tomography in patients with peritoneal carcinomatosis. Cancer 72, 1631–1636 (1993).

Download references


This research is supported by Grants-in-Aid for Scientific Research from Japan Society for the promotion of Science [grant numbers: 16K07143, 16K07161, 17K10620, 17K10621 and 17K10623], and the Project for Cancer Research and Therapeutic Evolution from the Japan Agency for Medical Research and Development [grant number: JP17cm0106502].

Author contributions

Hiroshi Nagata and S.I. made substantial contributions to conception and design of the study, as well as analysis and interpretation of data and drafting of the article; H.A., T.U. and J.K. significantly contributed to the pathological evaluation of specimens and revision of the paper; T.T., K.H. and K.K. participated in the interpretation of data and drafting of the article; M.F. and Hiroaki Nozawa contributed to conception of the study and critically revised the paper.

Author information


  1. Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan

    • Hiroshi Nagata
    • , Soichiro Ishihara
    • , Junko Kishikawa
    • , Toshiaki Tanaka
    • , Keisuke Hata
    • , Kazushige Kawai
    •  & Hiroaki Nozawa
  2. Department of Pathology, The University of Tokyo, Tokyo, Japan

    • Hiroyuki Abe
    • , Tetsuo Ushiku
    •  & Masashi Fukayama


  1. Search for Hiroshi Nagata in:

  2. Search for Soichiro Ishihara in:

  3. Search for Hiroyuki Abe in:

  4. Search for Tetsuo Ushiku in:

  5. Search for Junko Kishikawa in:

  6. Search for Toshiaki Tanaka in:

  7. Search for Keisuke Hata in:

  8. Search for Kazushige Kawai in:

  9. Search for Masashi Fukayama in:

  10. Search for Hiroaki Nozawa in:

Competing interests

The authors declare no competing interests.

Ethics approval and consent to participate

The study protocol was approved by the research ethics committee at the Graduate School of Medicine, the University of Tokyo (3252-(7)). The need for written consent was waved by the Board because of the retrospective nature of the study. The research was conducted in accordance with the 1964 Declaration of Helsinki and its later amendments.

Data availability

The datasets generated and analysed during the current study are available from the corresponding author on reasonable request.


This work is published under the standard license to publish agreement. After 12 months the work will become freely available and the license terms will switch to a Creative Commons Attribution 4.0 International (CC BY 4.0).

Corresponding author

Correspondence to Hiroshi Nagata.

Supplementary information

About this article

Publication history





Issue Date