Thrombomodulin expression regulates tumorigenesis in bladder cancer
© Wu et al.; licensee BioMed Central Ltd. 2014
Received: 22 February 2014
Accepted: 22 May 2014
Published: 28 May 2014
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© Wu et al.; licensee BioMed Central Ltd. 2014
Received: 22 February 2014
Accepted: 22 May 2014
Published: 28 May 2014
The identification of potential tumor markers will help improve therapeutic planning and patient management. Thrombomodulin (TM) is a sensitive urothelial marker. TM was reported to be one of the endogenous anti-metastatic factors and has diagnostic and prognostic values for the progression of carcinoma. In the present study, we examine the role of TM in bladder cancer.
We studied the role of TM in tumor behavior and related signaling pathways in vitro using the human bladder cancer cell lines HT1376, HT1197, J82 and T24, and in vivo using animal models. We also selected clinical specimens from 100 patients with bladder cancer for immunohistochemical staining to evaluate the predictive capacity of TM in tumor invasiveness.
The data revealed that positive immunoreactivity for TM was inversely correlated with clinical stage and DNA methyltransferase 1 immunoreactivity. Decreased TM expression could predict the aggressive tumor growth and advanced clinical stage in bladder cancer. When TM was inhibited, tumor growth rate and invasion ability were augmented in vitro and in vivo. The underlying changes included increased cell proliferation, enhanced epithelial-mesenchymal transition (EMT) and angiogenesis. Moreover, inhibition of NF-κB activation significantly increased TM expression and attenuated tumor aggressiveness in bladder cancer.
TM plays an important role in bladder cancer tumor aggressiveness in vitro and in vivo and is a clinically significant predictor that may represent a suitable therapeutic target for bladder cancer.
Urinary bladder cancer represents a spectrum of neoplasms, including non-muscle invasive, muscle invasive, and metastatic lesions. Approximately 70% of patients present with non-muscle invasive tumors, while the remaining 30% present with muscle-invasive bladder cancers. Despite good prognosis for patients with superficial disease, superficial bladder cancer has a very high rate of recurrence after treatment . Of these recurrent tumors, 10–30% show progression in grade and stage . Unlike other urological cancers, bladder cancer lacks clinically useful biomarkers for predicting disease stage and clinical outcome . Therefore, molecular markers that can be used to stratify and identify the true malignant potential of a tumor and its response to specific therapies are required.
Thrombomodulin (TM), a type 1 transmembrane glycoprotein, is an anticoagulant factor [4, 5] that mediates hemostatic function and regulates multiple functions important in inflammation and tumor promotion [6–9]. A potential role for TM in tumor biology was further suggested by studies showing that TM expression in tumor tissues correlated with a less advanced stage at diagnosis and a better prognosis for multiple cancers [6, 10–12]. Anticoagulation, anti-inflammation, adhesion and proliferation have all been suggested as mechanisms mediating the effects of TM in tumors. Although TM expression in tumor cells has been suggested to limit the invasive potential and proliferation of tumor cells in certain types of cancers, its role in bladder cancer remains to be elucidated.
Chronic inflammation often precedes or accompanies a substantial number of cancers [13, 14], and data from animal and human studies strongly support the hypothesis that chronic inflammation plays a role in bladder carcinogenesis [15, 16]. TM has been considered as a sensitive, but nonspecific, marker of urothelial carcinoma [17, 18]. Moreover, the anti-inflammatory role of TM has been clearly demonstrated in vivo[9, 19, 20], in which it modified the inflammatory response, maintained the integrity of cell-cell interactions, and reduced matrix degradation. Thus, TM might play a role in bladder cancer, even though the mechanisms underlying TM’s role remain unclear. Several factors are implicated in regulation of TM expression including DNA methylation and nuclear factor-Kappa B (NF-κB) [21, 22]. We have previously reported that DNA methyltransferase1 (DNMT1) indicates more aggressive tumor growth and resistance to treatment in bladder cancer , and the activation of DNMT1 is enhanced by inflammatory cytokines . Moreover, NF-κB is widely-recognized as a key regulator of the inflammatory responses, and plays an important role in various types of human cancers including bladder cancer [25–27]. Therefore, we proposed the inhibition of TM by NF-κB activation and DNMT1 might mediate in part the aggressive bladder tumor behavior.
Herein it is shown that decreased TM expression could predict the aggressive tumor growth and advanced clinical stage in bladder cancer. In addition, the link between TM signaling, the activation of NF-κB and DNMT1 in bladder cancer was demonstrated. The study highlight a potential role for TM as a molecular predictor and therapeutic target for bladder urothelial carcinoma.
The Institutional Review Board of our Hospital approved the present study. Informed written consent was obtained from patients for the acquisition and storage of medical information and tissue specimens. A total of 100 patients with bladder TCC, 60 with muscle-invasive tumors and 40 with non-muscle-invasive tumors, were enrolled in the study. Formalin-fixed, paraffin-embedded tissues obtained by transurethral resection in the diagnosis were cut into 5-μm sections and mounted on slides for IHC staining. For histological evaluation of TM immunoreactivity, the staining was scored independently by two observers blinded to the clinical outcome; discordant scores were reviewed, and a consensus was reached. Positive IHC scoring was defined as > 10% positive tumor cells.
Four human bladder cancer cell lines, HT1376, HT1197, T24 and J82, were obtained from the American Type Culture Collection (ATCC). We maintained the bladder cancer cell lines in Dulbecco’s modified Eagle’s medium supplemented with 10% fetal bovine serum. The TM silencing vector (the TM shRNA lentiviral transduction particles with puromycin resistance) and control vector (consisting of a non-effective scrambled shRNA cassette) were purchased from Santa Cruz Biotechnologies (Santa Cruz, CA, USA). Stable TM-silenced cancer cells were generated by transfecting bladder cancer cells with the TM silencing vector and selected by culturing in medium containing puromycin for 4 weeks. The DNA methyltransferase (DMNT) inhibitor 5-aza-2′-deoxycytidine (5-AZDC) and caffeic acid phenethyl ester (CAPE), a specific inhibitor of NF-κB, were obtained from Sigma (St. Louis, MO, USA).
This study was carried out in strict accordance with the recommendations in the Guide for the Care and Use of Laboratory Animals as promulgated by the Institutes of Laboratory Animal Resources, National Research Council, U.S.A. The protocol was approved by the Committee on the Ethics of Animal Experiments of our Hospital. Eight-week-old female athymic nude mice were used as the xenograft tumor implantation model. In the ectopic tumor implantation model, 1 × 106 tumor cells were subcutaneously implanted by injection into the dorsal gluteal region (five animals/group). Tumor size was measured every 3 days after implantation (day 0). The tumor volume was calculated assuming an ellipsoid shape. In the orthotopic tumor implantation model, we performed intravesicular instillation of cancer cells as described previously (five animals/group). The extent of orthotopic tumor invasion was measured after implantation at the indicated times. The effect of CAPE treatment was also investigated in vivo. In the treatment group, mice received intraperitoneal injection of 4 mg/kg CAPE solubilized in a saline vehicle solution containing 20% dimethylsulfoxide (DMSO) 3 times per week for 2 weeks starting on day 3. CAPE-treated mice were compared with the control group mice, which were treated with vehicle only.
Cell invasion capacity was determined using the Cell Invasion Assay (Trevigen, Gaithersburg, MD, USA). The top chambers were pre-coated with basement membrane extract derived from the Engelbreth-Holm-Swarm (EHS) tumor provided in the kit. After incubation for 24 h, the number of cells in the bottom chamber was determined by measuring the fluorescent anion calcein released from the intracellular calcein acetoxymethylester. To validate experiments on cell migration, scratch assays were performed by drawing a 2-mm wide scratch across each cell layer using a pipette tip. The plates were photographed at the times indicated.
Cells were seeded onto glass coverslips at 5 × 104 cells/ml in 6-well plates for IF staining with or without treatment. After treatment at the specified times, cells were fixed with 2% paraformaldehyde for 5 min and washed in phosphate buffered saline (PBS) with Tween-20 (PBST). The slides were incubated for 1 h at room temperature with antibodies against TM, E-cadherin and cleaved caspase 3, followed by incubation with a FITC-conjugated secondary antibody for 1 h and counterstained with DAPI to visualize nuclei.
Real-time RT-PCR was performed on RNA extracted from cell cultures. The primer sequences were as follows: (forward and reverse, respectively) 5′-TAACGAAGACACAGACTGCGA TT-3′ and 5′-CTAGCCCACGAGGTCAAGGT-3′ for TM. A β-actin primer set was used as a loading control. The optimized PCR was performed on an iCycler iQ Multicolor Real-Time PCR detection system. Significant fluorescent PCR signals from carcinoma tissue were normalized relative to the mean value of signals obtained from control samples.
Data were presented as means ± standard error of the mean (SEM) in triplicate for each experiment, and the entire set of experiments was replicated at least twice. Significant differences between groups were assessed using the log-rank test. Significant differences between samples were determined using the Student’s t-test. All statistical tests were two-sided, with P < 0.05 indicating significance.
TM, an endothelial thrombin receptor, is a sensitive urothelial marker expressed in 48–90% of urothelial carcinomas [17, 18]. Although TM has been suggested possessing prognostic value in some cancers [6, 10–12], the predictive role of TM in bladder cancer requires further investigation. Therefore, we evaluated tumor suppression role of TM in bladder cancer in the present study. The data obtained from cellular experiments using bladder cancer cell lines revealed that the expression of TM was inversely correlated with the invasive ability. To investigate whether TM was responsible for the less aggressive behavior of bladder TCC, TM was suppressed in bladder cancer cells by stable transfection with a silencing vector. We found that the TM silencing vector significantly augmented the invasive ability of cells detected in cellular invasion assays and mouse orthotopic models. The molecular and phenotypic changes involved in EMT appear to be functionally relevant to the invasive characteristics of epithelial tumors including bladder cancer [31, 32]. At the molecular level, EMT is characterized by loss of E-cadherin, a hallmark of EMT, and increased expression of invasion-related factors . This loss of E-cadherin was consistently observed at sites of EMT in different human cancers and with increased tumor cell invasiveness. We demonstrated that silencing TM expression abolished the expression of E-cadherin, associated with increased Snail, VEGF and MMP-9 expressions. Snail has been reported to represses transcription from the E-cadherin promoter and promotes tumor cell metastasis [34, 35]. In addition, increased VEGF and MMP-9 expression correlated with EMT changes and poor prognosis of bladder cancer [36, 37]. Angiogenesis is one of the mechanisms that promote tumor progression, and it involves CD31-mediated endothelial cell-cell interactions . Our in vivo data revealed that TM silencing augmented tumor invasiveness, which was associated with increased MMP-9, CD31 and VEGF expression in tumors. On the basis of these findings, changes in EMT might be responsible for reduced invasiveness in TM-positive urothelial cancers.
In addition to EMT changes, we demonstrated that TM silencing resulted in increased bladder tumor growth in vitro and in vivo. Our in vitro experiments demonstrated that inhibition of several types of cell death, including apoptosis and cellular autophagy, were responsible for the aggressive tumor growth induced by inhibiting TM. Decreased cell death induced by the TM silencing vector was associated with increased anti-apoptotic Bcl-1 expression and decreased p53 expression.
Identification of potential molecular markers has important implications for the development and selection of molecular targeting in cancer therapy. Our in vitro and in vivo data revealed that loss of TM was associated with more aggressive tumor growth. Accordingly, we proposed that this loss of TM might be a clinically relevant characteristic linked to disease progression in bladder cancer. To test this hypothesis, we examined the expression of TM in bladder cancer tissue using IHC and found that it was expressed in 54% of these bladder cancer specimens. Positive staining for TM was preferentially associated with lower cancer stages relative to muscle-invasive bladder TCC (40% of T2–T4 bladder cancer tissues vs. 75% in Ta–T1). Our study established that the expression of TM in muscle-invasive human bladder cancer is down-regulated in comparison with superficial bladder cancer.
TM is reported to be expressed at the cell surface in normal cells of epithelial origin, while TM staining was not found in cells undergoing transformation into a malignant phenotype . Silencing of the TM gene promoter has been implicated in the down-regulation of TM synthesis, . Aberrant DNA methylation plays a key role in carcinogenesis, leading to the epigenetic silencing of the expression of tumor-suppressor genes. Moreover, the expression of TM was restored after treatment with DNMT inhibitor in certain types of cancer cells [22, 41]. We previously reported  that DNMT1 could be a significant clinical predictor of bladder cancer. Accordingly, we further investigate the link between TM expression and DNMT1 in the present study. A negative correlation between TM-positive samples and nuclear staining for DNMT1 was found using IHC. We further examined the relationship between TM and DNMT1 by regulating DNMT1 expression. The mRNA and protein levels revealed that inhibition of DNMT1 suppressed TM expression. We therefore suggest that inhibition of TM expression might be responsible for aggressive tumors in DNMT1-positive bladder cancer.
Our in vitro and in vivo data indicate that TM plays an important role in bladder cancer tumor aggressiveness. Moreover, TM is a clinically significant predictor that might be partially responsible for aggressive tumors in DNMT1-positive bladder cancer. CAPE could be a promising therapeutic agent for bladder cancer that inhibits NF-κB activation and reverses the response induced by TM inhibition. Our study has established a foundation for future studies on the role of TM in bladder cancer progression and the therapeutic potential of TM in bladder cancer treatment.
The work was support by National Science Council, Taiwan. Grant 101-2314-B-182A-018-MY3, and Chang Gung Memorial Hospital, Taiwan, grant OMRPG6C0011.
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