Indian Journal of Pathology and Microbiology
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ORIGINAL ARTICLE  
Year : 2022  |  Volume : 65  |  Issue : 4  |  Page : 856-859
Significance of CD47 expression in endometrial carcinoma


1 Department of Pathology, Bezmialem Vakif University, Faculty of Medicine, Istanbul, Turkey
2 Department of Pathology, Yedikule Chest Hospital, Istanbul, Turkey
3 Department of Pathology, Biruni University, Faculty of Medicine, Istanbul, Turkey
4 Department of Obstetric and Gynecology, Bezmialem Vakif University, Faculty of Medicine, Istanbul, Turkey
5 Department of Biostatistics and Medical Informatics, Bezmialem Vakif University, Faculty of Medicine; Department of Biostatistics Bursa Uludag, University Institute of Health Sciences, Bursa, Turkey

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Date of Submission28-Feb-2021
Date of Decision07-Jun-2021
Date of Acceptance13-Jun-2021
Date of Web Publication06-Jun-2022
 

   Abstract 


Objectives: CD47 is a membrane protein that belongs to the immunoglobulin superfamily and regulates macrophage phagocytosis negatively. As CD47 expression at the cancer cell membrane would inhibit the phagocytic activity of immune cells, it is connected to an unfavorable prognosis in leukemia and malignancies of various solid organs. Materials and Methods: In this study, retrospectively evaluated 72 patients who had been diagnosed with endometrial carcinoma at Pathology Department and had undergone total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH + BSO) and/or lymphadenectomy. CD47 expression was evaluated in tumorous and nontumor areas in all patients considering cytoplasmic and membranous brown staining in cells. The proportion of expression was evaluated as well as the intensity and an “h score” was obtained. This score was compared with known prognostic parameters. Results: CD47 expressions showed a statistically significant correlation with tumor grade (P < 0.05); however, no significant relationship was observed with myometrial invasion depth and lymph vascular invasion status (P = 0.923 and P = 0.754, respectively). Conclusions: As with other tumors, anti-CD47 antibody may be an alternative treatment option in patients with high-grade endometrial carcinoma.

Keywords: CD47, endometrial carcinoma, immunotherapy, monoclonal antibody

How to cite this article:
Sahin N, Coban G, Unver N, Arici DS, Kilic G, Toluk O. Significance of CD47 expression in endometrial carcinoma. Indian J Pathol Microbiol 2022;65:856-9

How to cite this URL:
Sahin N, Coban G, Unver N, Arici DS, Kilic G, Toluk O. Significance of CD47 expression in endometrial carcinoma. Indian J Pathol Microbiol [serial online] 2022 [cited 2022 Nov 30];65:856-9. Available from: https://www.ijpmonline.org/text.asp?2022/65/4/856/346691





   Introduction Top


Endometrial carcinoma (EC) is the most prevalent malignant tumor of the female genital system in developed countries.[1],[2] Its incidence increases every year according to American Cancer Statistics; 49,500 new cases were diagnosed in 2013, whereas this number reached 61,380 and 10,920 estimated deaths in 2017 in America.[1],[2] There are two types of EC. These include Type 1 EC, which is associated with estrogen, and Type 2 EC, which is independent of estrogen. The conventional treatment of both types includes total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH + BSO) ± lymph node dissection and/or chemotherapy. Prognostic parameters include the stage of the disease, histological grade of the tumor, histological subtype, state of myometrial and cervical invasion, and lymph node metastasis. Patients in developing countries have poorer prognosis. Therefore, novel markers are always needed in order to evaluate the prognosis more accurately, predict and monitor the course of metastasis, and develop specific treatments.

CD47, which is also known as integrin-associated protein (IAP), is a membrane protein that belongs to the immunoglobulin superfamily and expressed on the cell surface. It regulates macrophage phagocytosis negatively by interacting with signal-regulatory protein alpha (SIRP-α). This mechanism is involved in certain physiological processes such as the clearance of erythrocytes. In pathological conditions, CD47 expression at the cancer cell membrane is connected to an unfavorable prognosis in leukemia and malignancies of various solid organs as it would inhibit the phagocytic activity of immune cells.[3],[4] Studies have shown that CD47 was upregulated in many malignancies to evade the immune system, and its overexpression was correlated with poor prognosis.[5],[6] Moreover, blockade of CD47 and SIRPα ligation promotes the tumor cells to be phagocytized by macrophages in various malignancies.[7],[8] CD47 blockade provides potential clinical benefits for a wide variety of cancer patients.[9] Based on this, an anti-CD47 antibody was developed that targets CD47/SIRP-α interaction.[3],[4],[10] Earlier studies discussed that the anti-CD47 antibody took effect through the direct destruction of the tumor; however, recent studies suggest that anti-CD47 also increases tumor phagocytosis by preventing immune evasion.[3],[10] In addition, CD47 monoclonal antibody inhibits cancer cell proliferation and angiogenesis through the EGFR/PI3K/AKT signaling pathway and CD47 monoclonal antibody blocks the interaction between CD47 and SIRPα to activate phagocytosis of normal cells. To the best of our knowledge, the role of the CD47 expression in EC has not been studied enough in the literature. In this study, we investigated the relationship of CD47 expression with known prognostic parameters in EC and whether monoclonal CD47 antibody therapy could have a place in immunotherapy in EC.


   Materials and Methods Top


This study retrospectively evaluated 72 patients who had been diagnosed with EC at Pathology Department and had undergone TAH + BSO and/or lymphadenectomy. Demographic and clinical data of the patients were obtained from the hospital data system and recorded. Hematoxylin and Eosin (H and E)-stained slides of the cases were obtained from the pathology laboratory archives and re-evaluated, and blocks that included the non-tumor endometrial area were selected. Slices were obtained again from these blocks, transferred to glass slides, and stained with CD47 (abcam-Anti-CD47 antibody, SP 279 clone, 1/100 diluted) monoclonal antibody with the Ventana BenchMark Ultra immuno-histochemical staining device. All slides were evaluated under a Nikon Eclipse E200 light microscope. In the evaluation of CD 47, cytoplasmic and membranous brown staining in cells was considered and proportion of expression was evaluated besides its intensity to obtain an “h score.” The proportion of CD47 expression in cells was graded as 0 if no staining or it included less than 5% of epithelial cells, as 1 if staining was present in 6%–25%, as 2 if staining was present in 26%–50% and as 3 if it covered more than 51%. On the other hand, staining intensity was graded as 0 for no staining, 1 for weak staining, 2 for moderate staining, and 3 for intense staining. Then, staining intensity and staining proportion were multiplied to obtain an “h score,” and those with an h score 4 and lower were evaluated under the low CD47 expression group (CD47low exp) [Figure 1]; meanwhile, those with h score over 4 were evaluated under the high CD47 expression group (CD47high exp)[2] [Figure 2].
Figure 1: Low CD47 expression group (CD47 low exp) (a and c) FIGO Grade II endometrial carcinoma stained with H and E (x20 and x40) (b) Low CD47 expression same case in A (x40). (d) Another case with h score less than 4 (x100)

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Figure 2: High CD47 expression group (CD47 high exp) (a) FIGO Grade II endometrial carcinoma stained with H and E x40 (b) High CD47 expression same case in A (x200) (c and d) Another cases with h score more than 4 (x20 and x100)

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The study was approved by the local Clinical Trials Ethics Committee (54022451-050.05.04). Descriptive statistics were given frequencies with percentages categorical variables were compared by the Chi-Square test, Fisher's exact test, and Fisher–Freeman–Halton test. Analyses were performed using SPSS (IBM Corp. Released 2019. IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp) software. The level of significance was taken α = 0.05.


   Results Top


The mean age of the 72 cases included in our study was 61.94 ± 8.52 years. The minimum age was determined as 42 and the maximum age as 85.

Five (6.94%) of 72 cases were Type II (serous carcinoma) tumors and high CD47 expression was observed in all of them (100%). High CD47 expression was found in only 34 (50.75%) of 67 Type I tumors. Forty-six cases (63.9%) were of FIGO Grade 2, 14 (19.4%) of Grade 1, and 12 (16.7%) of Grade 3 or serous carcinoma.

Again, 47 cases (65.3%) showed less than ½ myometrial invasion, whereas 25 (34.7%) showed equal or more than ½ myometrial invasion. Fifty cases (69.4%) had no lymphovascular invasion, whereas 22 cases (30.6%) had lymphovascular invasion. Metastasis was observed in 5 (11.36%) of 44 patients who underwent lymph node dissection. High CD47 expression was observed in 3 (60%) of these cases, and low CD47 expression was observed in 2 (40%) of them. Low CD47 expression was observed in 21 (61.8%) of 39 patients without lymph node metastasis. Meanwhile, 28 of our cases had not undergone lymph node dissection 34 cases (47.2%) manifested low CD47 expression and 38 (52.8%) manifested high CD47 expression. In Grade I total cases 14 so Low CD47 seen in 11 (78.6% cases) and high CD47 seen in 3 (21.4%), Grade II total cases 46 so Low CD47 seen in 20 (43.5% cases), and high CD47 seen in 26 (56.5%), and in Grade III total cases 12 so Low CD47 seen in 3 (25% cases), and high CD47 seen in 9 (75%). CD47 expressions were showed that statistically significant correlation with tumor grade (P < 0.05); however, no significant relationship was found with myometrial invasion depth and lymphovascular invasion status (P = 0.923 and P = 0.754, respectively) [Table 1]. And no differences were determined with h score of CD47 expression in tumorous and non-tumor areas (P = 0.830).
Table 1: Summary of Variables and Analysis Results Regarding Tumour Expression

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   Discussion Top


EC prognosis is dependent on many factors such as histological type, FIGO grade, depth of myometrial invasion, lymphovascular invasion, age at diagnosis, and tumor stage.[11] Reaching an early diagnosis and formulating an early treatment plan is easier in the case of symptomatic patients, whereas novel predictive parameters need to be discovered in order to predict the course of the disease, recurrence, and metastasis in the case of asymptomatic patients with delayed diagnosis and advanced disease. In this study, we investigated the role of integrin-associated protein (IAP/CD47), of which the prognostic marker effect has been shown in relation to hematological malignancies and various solid organ tumors, in the prognosis of EC.

In this study, among the prognostic parameters in EC, only a significant relationship was found between tumor grade and CD47 expression (P < 0.05). Thus, as the grade increases, increased CD47 expression also indicates a poor prognosis. It should be noted that histological grade is not an independent prognosticator and correlates with other prognostic factors, including age, stage, and depth of myometrial invasion. Also, as suggested by Lax et al.[12] even for patients with advanced-stage disease, histological grade carries prognostic value. Many studies have shown elevated CD47 expression in various malignancies in the literature. Overexpression was shown to be related to an unfavorable prognosis in esophagus squamous cell carcinomas and in colon carcinomas.[13],[14] On the other hand, further studies are required for immunohistochemistry of this molecule to determine the best cut-off of overexpression.

Another prognostic parameter in EC is lymph node metastasis. In our study, no significant relationship was found between lymph node metastasis and CD47 overexpression (P > 0.05) But the presence of overexpression in 60% of metastatic cases should be taken into account and so CD47 overexpression evaluation should be performed in wider EC series with lymph node metastases in order to discuss this issue more clearly. Moreover, many studies have showed that elevated expression contributes to the escape of cancer cells from phagocytosis[15],[16] and cancer cells encouraged tumorigenesis and metastasis in this way.[5] And also tumor cell phagocytosis was elevated and tumor growth was inhibited by anti-CD47 therapy in cancer cell series.[17] Currently, there are two therapeutic approaches targeting CD47 in clinical trials for hematologic and solid malignancies: (1) Hu5F9-G4 in colorectal cancer, non-Hodgkin's lymphoma, and acute myeloid leukemia (NCT02953782), an anti-CD47 antibody tested and 2) TTI-621, a fusion protein combining CD47 (NCT02663518)[18] Phase I and phase II studies of these drugs have been completed, but have not yet entered the NCCN guidelines. Similarly, CD47 could be a predictive biomarker in oral precancerous and cancer progression as shown in fewer studies.[19] In contradiction to all of these studies, Sudo et al.[20] reported no relationship between elevated tumor CD47 mRNA expression and an unfavorable prognosis in patients with gastric tumors. They suggested that this could be connected to post-transcriptional differences such as disturbances in protein degradation or transportation.

Although studies in the literature have investigated the effects of CD47 expression on the prognoses of many solid tumors such as those of the lung, mesothelium, liver, pancreas, breast, skin, bladder, and ovaries,[21],[22],[23] studies that have investigated CD47 expression in EC are limited.[1],[2]


   Conclusions Top


In Our study, CD47 overexpression increases with a higher grade of ECs and is associated with poor prognosis in other malignancies such as Acute Myeloid Leukemia (AML) and colon carcinoma. Therefore, an anti CD47 antibody may be a targeted treatment option in patients with high-grade EC. However, more in vivo and in vitro studies are needed on this subject.

Financial support and sponsorship

Scientific Project Support Fund of Bezmialem Vakif University.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Sun Y, Yoshida T, Okabe M, Zhou K, Wang F, Soko C, et al. Isolation of stem-like cancer cells in primary endometrial cancer using cell surface markers CD133 and CXCR4. Transl Oncol 2017;10:976-87.  Back to cited text no. 1
    
2.
Gu S, Ni T, Wang J, Liu Y, Fan Q, Wang Y, et al. CD47 blockade inhibits tumour progression through promoting phagocytosis of tumour cells by M2 polarized macrophages in endometrial cancer. J Immunol Res 2018;2018:6156757. doi: 10.1155/2018/6156757.  Back to cited text no. 2
    
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Liu R, Wei H, Gao P, Yu H, Wang K, Fu Z, et al. CD47 promotes ovarian cancer progression by inhibiting macrophage phagocytosis. Oncotarget 2017;8:39021-32.  Back to cited text no. 3
    
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Zeng D, Sun Q, Chen A, Fan J, Yang X, Xu L, et al. A fully human anti-CD47 blocking antibody with therapeutic potential for cancer. Oncotarget 2016;7:83040-50.  Back to cited text no. 4
    
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Majeti R, Chao MP, Alizadeh AA, Pang WW, Jaiswal S, Gibbs KD Jr, et al. CD47 is an adverse prognostic factor and therapeutic antibody target on human acute myeloid leukaemia stem cells. Cell 2009;138:286-99.  Back to cited text no. 5
    
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Yoshida K, Tsujimoto H, Matsumura K, Kinoshita M, Takahata R, Matsumoto Y, et al. CD47 is an adverse prognostic factor and a therapeutic target in gastric cancer. Cancer Med 2015;4:1322-33.  Back to cited text no. 6
    
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Chao MP, Alizadeh AA, Tang C, Jan M, Weissman-Tsukamoto R, Zhao F, et al. Therapeutic antibody targeting of CD47 eliminates human acute lymphoblastic leukaemia. Cancer Res 2011;71:1374-84.  Back to cited text no. 7
    
8.
Kim D, Wang J, Willingham SB, Martin R, Wernig G, Weissman IL. Anti-CD47 antibodies promote phagocytosis and inhibit the growth of human myeloma cells. Leukaemia 2012;26:2538-45.  Back to cited text no. 8
    
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Ridong F, Hai Z, Jianguo X, Shen C. CD47: The next checkpoint target for cancer immunotherapy. Crit Rev Oncol Haematol 2020;152:103014.  Back to cited text no. 9
    
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Liu X, Kwon H, Li Z, Fu Y-X. Is CD47 an innate immune checkpoint for tumour evasion? J Hematol Oncol 2017;10:12.  Back to cited text no. 10
    
11.
Robboy SJ, editor. Robboy's Pathology of the Female Reproductive Tract. Elsevier Health Sciences; 2009.  Back to cited text no. 11
    
12.
Lax SF, Kurman RJ, Pizer ES, Wu L, Ronnett BM. A binary architectural grading system for uterine endometrial endometrioid carcinoma has superior reproducibility compared with FIGO grading and identifies subsets of advanced-stage tumours with favourable and unfavourable prognosis. Am J Surg Pathol 2000;24:1201-8.  Back to cited text no. 12
    
13.
Chao, MP, Weissman IL, Majeti R. The CD47–SIRPα pathway in cancer immune evasion and potential therapeutic implications. Curr Opin Immunol 2012;24:225-32.  Back to cited text no. 13
    
14.
Lascorz J, Bevier M, Schönfels WV, Kalthoff H, Aselmann H, Beckmann J, et al. Association study identifying polymorphisms in CD47 and other extracellular matrix pathway genes as putative prognostic markers for colorectal cancer. Int J Colorectal Dis 2013;28:173-81.  Back to cited text no. 14
    
15.
Horrigan SK; Reproducibility Project: Cancer Biology. Replication study: The CD47-signal regulatory protein alpha (SIRPa) interaction is a therapeutic target for human solid tumours. Elife 2017;6:e18173.  Back to cited text no. 15
    
16.
Jaiswal S, Jamieson CHM, Pang WW, Park CY, Chao MP, Majeti R, et al. CD47 is up regulated on circulating hematopoietic stem cells and leukaemia cells to avoid phagocytosis. Cell 2009;138:271-85.  Back to cited text no. 16
    
17.
Edris B, Weiskopf K, Volkmer AK, Volkmer J-P, Willingham SB, Contreras-Trujillo H, et al. Antibody therapy targeting the CD47 protein is effective in a model of aggressive metastatic leiomyosarcoma. Proc Natl Acad Sci U S A 2012;109:6656-61.  Back to cited text no. 17
    
18.
Arrieta O, Aviles-Salas A, Orozco-Morales M, Hernández-Pedro N, Cardona AF, Cabrera-Miranda L, et al. Association between CD47 expression, clinical characteristics and prognosis in patients with advanced non-small cell lung cancer. Cancer Med 2020;9:2390-402.  Back to cited text no. 18
    
19.
Ye X, Wang X, Lu R, Zhang J, Chen X, Zhou G, et al. CD47 as a potential prognostic marker for oral leukoplakia and oral squamous cell carcinoma. Oncol Lett 2018;15:9075-80.  Back to cited text no. 19
    
20.
Sudo T, Takahashi Y, Sawada G, Uchi R, Mimori K, Akagi Y. Significance of CD47 expression in gastric cancer. Oncol Lett 2017;14:801-9.  Back to cited text no. 20
    
21.
Olcucuoglu E, Sirin ME, Aydog G, Gazel E, Tastemur S, Odabas O. Relationship between immunohistochemical staining extent of CD47 and histopathologic features of bladder tumour. Cent European J Urol 2017;70:349-55.  Back to cited text no. 21
    
22.
Li Y, Lu S, Xu Y, Qiu C, Jin C, Wang Y, et al. Overexpression of CD47 predicts poor prognosis and promotes cancer cell invasion in high-grade serous ovarian carcinoma. Am J Transl Res 2017;9:2901-10.  Back to cited text no. 22
    
23.
Schürch CM, Forster S, Brühl F, Yang SH, Felley-Bosco E, Hewer E. The “don't eat me” signal CD47 is a novel diagnostic biomarker and potential therapeutic target for diffuse malignant mesothelioma. Oncoimmunology 2018;7:e1373235.  Back to cited text no. 23
    

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Correspondence Address:
Nurhan Sahin
Adnan Menderes Boulevard P.C. 34093 Fatih, Istanbul
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpm.ijpm_223_21

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