Recently, it was shown that leucine-rich repeat-containing receptor 5 (LGR5)–expressing stem cells are the cellular origin of intestinal-type gastric cancer. The aim of our study was to uncover regulatory mechanisms of LGR5 expression in gastric mucosa and their implications for cancer development. Reporter assays identified an LGR5 promoter fragment, which is highly relevant for active LGR5 expression. Chromatin immunoprecipitation verified that SP1 is bound within this region, and reporter activity increased in SP1 transfected cells. Subsequently, the expression of R-spondins (RSPO1 and RSPO2), ligands of LGR5, was explored in neoplastic and nonneoplastic gastric tissue and gastric cancer cell lines. Using IHC, distinct spatial expression patterns of LGR5, RSPO1, and RSPO2 were found in nonneoplastic stomach mucosa and gastric cancer. RSPO expression was lower in gastric cancer compared with nonneoplastic mucosa on both the transcriptional (P = 0.003 for RSPO1 and P = 0.000 for RSPO2; n = 50) and the translational level. Methylation-specific PCR showed higher methylation levels of RSPO1/2 and reexpression of RSPOs in the gastric cancer cell lines MKN45 and MKN74 were induced by demethylating 5-aza-C treatment. Finally, expression patterns of LGR5 and RSPO were similar in gastric cancer.

Implications: This report identifies a regulatory mechanism of LGR5 expression in gastric carcinogenesis, with SP1 as an important component of the transcriptional complex and LGR5 activity, which is modulated by its ligands RSPO1 and RSPO2, whose expression is modulated by methylation.

Visual Overview:http://mcr.aacrjournals.org/content/15/6/776/F1.large.jpg.Mol Cancer Res; 15(6); 776–85. ©2017 AACR.

Despite a declining incidence, gastric cancer still belongs to the leading causes of cancer mortalities worldwide due to its late diagnosis at advanced stages impeding curative treatments (1–3). As reliable biomarkers for early detection and risk grouping are essentially missing, studies on the tumor-promoting cell populations mediating therapeutic resistance and recurrence of gastric cancer might raise new possibilities for clinical interventions. Cancer stem cells (CSC) are generally accepted as drivers of malignant tissue proliferation, resembling in many ways the rare tissue stem cell responsible for tissue regeneration (4). Interestingly, although CSCs are supposed to benefit from a higher chemotherapeutic resistance and higher signaling network plasticity, tumor tissues still mirror many features of cell type differentiation as well as tissue composition hierarchies, but are equipped with outstanding possibilities for de- and transdifferentiation (5). To regulate this plasticity, microenvironmental cues may preserve stem cell properties and direct lineages of differentiation to allow for tightly controlled homeostasis; in a similar manner, the tumor microenvironment is believed to support CSC populations.

In the hepato-gastrointestinal tract, several stem cell populations have been postulated, which are characterized by the expression of stem cell markers such as CD44, Bmi-1, villin, or CD133 (6, 7). With the identification of leucin-rich G-protein–coupled receptor 5 (LGR5) as a modulator of the Wnt signaling cascade, another promising biomarker was established, linking the transmembrane receptor LGR5 with functional consequences for intracellular stem cell signaling (8, 9). In lineage tracing experiments, LGR5+ cells have been shown to regenerate the whole epithelial structure of the stomach (10) as well as the intestine (11), hair follicle (12), or ovary (13). LGR5 acts as a receptor for R-spondins (RSPO), a family of secreted agonists of the Wnt signaling pathway (14, 15). LGR5 and RSPOs potently enhance an active Wnt signal by generating a ternary complex with the ubiquitin ligase Rnf43, leading to Rnf43 inactivation, thereby stabilizing Wnt receptor density on the membrane (16). Together with an orchestra of extra- and intracellular ligands known to define Wnt signaling strength (17), LGR5 is an important component of the fine-tuned interplay of signaling pathways within the stem cell compartment, allowing for a tightly controlled homeostasis by stem cell self-renewal as well as differentiation processes (18, 19).

Within the intestinal epithelium, aberrant Wnt signaling has been correlated with cancer initiation and progression (20), and its participation in gastric cancer pathogenesis has been postulated for a considerable proportion of gastric cancer cases as well (21). We and others have already shown LGR5 to be a putative molecular marker of cancer-initiating cells in gastric cancer and have shown its association with invasion and survival (22–24). For LGR5, no driver mutations are known in gastric cancer (25–27); therefore, it is tempting to speculate that changes in the LGR5 expression profile in gastric cancer are dependent on transcriptional regulation. With this report, we describe a specificity protein 1 (SP1)-mediated elevation of LGR5 expression and dysregulation of RSPO1 and RSPO2 expression partly mediated by hypermethylation in the neoplastic gastric mucosa as well as functional consequences in disease-representative cell lines.

Study cohort selection

Corresponding neoplastic and nonneoplastic tissues from 51 gastric cancer patients were retrieved from the archive of the Institute of Pathology, UKSH (Kiel, Germany); these tissues comprised formalin-fixed paraffin-embedded (FFPE) material as well as unfixed, fresh-frozen samples. All human tissues were obtained as part of a therapeutic surgery. Gastric cancer classification was evaluated according to the WHO classification (28) and the seventh edition of the Union International Contre le Cancer (29). The study was approved by the local ethics committee of the University Hospital in Kiel, Germany (ref. number D452/11 and D472/15). Survival information was obtained from the Epidemiological Cancer Registry of the state Schleswig-Holstein, Germany. Before analysis, all patient data were pseudonymized.

IHC and evaluation of immunostainings

After deparaffinization, whole-mount FFPE tissue sections were boiled in citrate buffer for antigen retrieval and subsequently washed with Tris-buffered saline. To avoid unspecific reactions, slides were treated with hydrogen peroxide block and Ultra V Block Staining (both Thermo Scientific). For chromogenic staining, slides were incubated with the primary antibody prepared in antibody diluent (ZYTOMED Systems) for 30 minutes at room temperature and overnight at 4°C in a moist chamber [LGR5, 1:1,000 from (24); RSPO1 HPA046154, 1:50; RSPO2 HPA024764, 1:100; both Sigma-Aldrich]. Immunoreactions were visualized by incubation with ImmPRESS universal-HRP-polymer for 30 minutes and application of DAB or NovaRED substrate solution for 5 minutes (all Vector Laboratories). Slides were counterstained with hematoxylin and mounted with Pertex (Medite). Immunostaining was evaluated according to the Histoscore system (30). The overall staining intensity was scored into four categories (negative, 0; low, 1; moderate, 2; high, 3) and the percentage of immunopositive tumor cells was estimated by a trained board-certified surgical pathologist. An overall Histoscore result was calculated by [%]0 × 0 + [%]1 × 1 + [%]2 × 2 + [%]3 × 3. To divide groups of high and low/negative expression, Histoscore results were split at the median.

Reverse transcriptase reaction and qRT-PCR

Total cellular RNA was isolated with the RNA Pure Kit (Roche) from cell culture samples. RNA from gastric tissues was prepared with the miRVana Isolation Kit, followed by DNase treatment with Turbo DNA-free Kit (both Life Technologies). Nucleic acid concentration and purity were assessed on a NanoDrop 2000 (Thermo Fisher Scientific) and reverse transcribed with Maxima First Strand cDNA Synthesis Kit (Life Technologies) according to the manufacturer's instructions. qRT-PCR was done with the QuantiTect SYBR Green PCR Kit (Qiagen) on a 1.5 LightCycler System (Roche) for cell culture experiments, and results were normalized to succinate dehydrogenase subunit A (SDHA). Expression analysis of gastric cancer tissues was performed with the LightCycler 480 Probes Master and the following probes and primer sets (RSPO1: fw-cgctgctatccagcttgtc, rev- gagaccactcgctcatttcac, probe #73; RSPO2: fw- ccatccgggtactatggaca, rev- tctttgctaaagcaagaatcaca, probe #45; additional primers are shown in Supplementary Material S1) on a LightCycler 480 Instrument II (all from Roche). Data were normalized to SDHA, calpain 2 (CAPN2), and cyclophilin C (CYCC) as housekeeping genes and normalized by logarithmic transformation to obtain approximately normally distributed data.

Methylation analysis

For methylation analysis, cell cultures were treated with 5-aza-2-deoxycytidine (5-aza-C, 1 μmol/L, BioCat) that was daily renewed over a period of 72 hours. DNA was extracted according to the protocol delivered with the QIAamp DNA Extraction Kit, and the resulting DNA was converted with the EpiTect Bisulfite Kit (both Qiagen). Samples from gastric cancer patients were prepared according to the manufacturer's specifications. For analysis of the LGR5 gene from FFPE material, the PyroMark CpG Assay Hs_LGR5_02_PM covering three potential CpG sites within the first intron was utilized and analyzed on the Pyromark Q24 (all from Qiagen). For analysis of RSPO1 and 2, methylation-specific PCR (MSP) on converted DNA from matching malignant and nonmalignant fresh-frozen tissues was established using the HotStarTaq Kit (Qiagen). The following primers were designed with MethPrimer (31) for RSPO1: tcggttagagtagggtattcgttc and ttcccaaattactcaatctacgaa for the methylated sequence; tggttagagtagggtatttgtttgg and ttcccaaattactcaatctacaaa for unmethylated RSPO1. For RSPO2, primers were adopted (also see Supplementary Material S1; ref. 32). Commercial control DNA minimally/maximally methylated (Qiagen) served as control.

Chromatin immunoprecipitation analysis

To investigate promoter regions bound by proteins, cells were cultured to subconfluency in a 10-cm dish for 3 days before crosslinking with freshly prepared paraformaldehyde solution (final concentration, 1%). The cell number was determined from a replicate dish. Chromatin was fragmented by sonication in 20 cycles (20 seconds on/40 seconds off) applied by the Sonopuls GM70 homogenizer (Bandelin), leading to fragments between 150 and 1,000 bp (Fig. 2B), and purified according to the protocol of the EZ-Magna ChIP HiSens Kit (Merck Millipore). Immunoprecipitation was carried out with a chromatin immunoprecipitation (ChIP)-validated SP1 antibody (Merck Millipore), the anti-H3K4 control antibody or an IgG negative control, and magnetic protein A/G beads. Resulting DNA fragments were quantified by qRT-PCR (primers are given in Supplement Materials S1).

Cell culture, transfection, and clonogenic assay

MKN45 were obtained from the German Collection of Microorganisms and Cell cultures (DSMZ) and cultured in RPMI1640 Medium (PAA) supplemented with 20% FCS (FCS GOLD, Invitrogen). For transfection experiments, FCS concentration was lowered to 10%. MKN74 cells were purchased from the Japanese Health Science Research Resource Bank and grown in RPMI containing 10% FCS GOLD. HEK293ebna cells (Invitrogen) were maintained in DMEM with 10% FCS GOLD, all in a humidified atmosphere. After receipt, the gastric cell lines were reauthenticated using the AmpFlSTR Identifiler PCR Amplification Kit (Thermo Fisher Scientific) and a 3500 Genetic Analyzer (Applied Biosystems). Cells were split upon subconfluency by short treatment with trypsin once or twice a week and were not cultured for longer than 20 passages. To stimulate Wnt signaling, recombinant Wnt3a (BioCat), RSPO1 (Life Technologies), or RSPO2 (antibodies-online) were added at a final concentration of 10 nmol/L each. To inhibit SP1-mediated gene expression, mithramycin A (MMA, 10 nmol/L, Biomol) was applied.

Promoter studies by luciferase reporter assay

Fragments of the human LGR5 promoter were PCR amplified from MKN45 or MKN74 genomic DNA and cloned into the pGL3prom vector using the restriction sites of KpnI and HindIII (Fig. 1B, primer sequences in Supplementary Material S1). The SV40 promoter fragment in the recipient vector was thereby removed. The religated vector without insert was named pGL3basic and served as control. Constructs were verified by sequencing using the ABI PRISM BigDye Terminator Cycle Sequencing Ready Reaction Kit (PE Applied Biosystems). Potential transcription factor–binding sites were determined using TFsearch (http://diyhpl.us/~bryan/irc/protocol-online/protocol-cache/TFSEARCH.html). The plasmid pN3-SP1 was gratefully received from Prof. Suske (Philipps University Marburg, Marburg, Germany). HEK293ebna cells were seeded at 10,000 cells/well density in white sterile 96-well plates and transfected at day 2 with Lipofectamine LTX including PLUS reagent (Invitrogen) with molar ratios of 100:20:10 (ng, promoter construct:pN3-SP1:pRenilla). Promoter activity was analyzed 24 hours later by detection of firefly and Renilla luciferase activity with the DualGlo-Assay (Promega) according to the manufacturer's protocol using the Synergy Mx luminometer (BioTek).

Figure 1.

LGR5 expression in gastric cancer is not controlled by methylation but may be affected by SP1. A, Methylation status of the LGR5 gene in stomach tissue samples. Within the first intron, three potential CpG sites were analyzed by pyrosequencing. Depicted are paired gastric cancer and nontumor samples from 48 individuals. Average methylation levels were <25 % for both nonmalignant tissue (NT) and tumor tissue (TU) samples, arguing against a regulation via methylation. B, Luciferase-based reporter gene assay to study LGR5 promoter activity. Luciferase activity under a 1.5-kb promoter fragment or shortened variants was compared with control vector when transfected into HEK293ebna cells (n = 3–5). C, Luciferase activity after MMA treatment or SP1 transfection compared with empty vector control (24 hours, n = 5–6). D, LGR5 expression level after transfection with SP1 (n = 5) or MMA treatment (n = 3) for 48 hours. Statistical analysis was performed with *, P < 0.05; **, P < 0.01; n.s., not significant.

Figure 1.

LGR5 expression in gastric cancer is not controlled by methylation but may be affected by SP1. A, Methylation status of the LGR5 gene in stomach tissue samples. Within the first intron, three potential CpG sites were analyzed by pyrosequencing. Depicted are paired gastric cancer and nontumor samples from 48 individuals. Average methylation levels were <25 % for both nonmalignant tissue (NT) and tumor tissue (TU) samples, arguing against a regulation via methylation. B, Luciferase-based reporter gene assay to study LGR5 promoter activity. Luciferase activity under a 1.5-kb promoter fragment or shortened variants was compared with control vector when transfected into HEK293ebna cells (n = 3–5). C, Luciferase activity after MMA treatment or SP1 transfection compared with empty vector control (24 hours, n = 5–6). D, LGR5 expression level after transfection with SP1 (n = 5) or MMA treatment (n = 3) for 48 hours. Statistical analysis was performed with *, P < 0.05; **, P < 0.01; n.s., not significant.

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Statistical analyses

Statistical analyses were done with the PASW 20.0 statistical software (IBM SPSS Statistics) and Prism4 software (GraphPad Software Inc.). Cell culture data were analyzed by the paired t test (Fig. 1, 5) or the Mann–Whitney U test (Fig. 6), whereas histochemical data were evaluated using the two-sided Fisher exact test for nominal variables or Kendall tau rank-order correlation for trends within a group. Effects of multiple testing were accounted for by applying the explorative Simes (Benjamini–Hochberg) procedure (33). The median overall survival was determined by the Kaplan–Meier method, and significance was assessed by the log-rank test. The results were considered significant with P < 0.05.

Role for SP1 in LGR5 expression

Dysregulation of promoter methylation is a common feature in carcinogenesis. We therefore investigated a possible epigenetic regulation of LGR5 expression by analyzing the first intronic region of the LGR5 gene from 48 gastric cancer patients (Table 1; three missing values) with bisulfite sequencing. Comparing tumor regions against the matching nonmalignant controls, we were unable to detect significant changes in the methylation pattern of the LGR5 gene (Fig. 1A). Similarly, treatment of gastric cancer cell lines with 5-aza-C for demethylation did not lead to differential expression of LGR5 (see Fig. 6C), arguing against direct or indirect effects of methylation in regulating LGR5 expression under these conditions.

Table 1.

Correlation of RSPO1+2 expression with clinicopathologic characteristics in gastric cancer patients analyzed with the two-sided Fisher exact test, for trends with the Kendall tau testa and significance after multiple testing as indicatedb

RSPO1RSPO2
NegativePositivePNegativePositiveP
Age   0.782   0.154 
 <68 years 12 (46.2) 14 (53.8)  8 (32.0) 17 (68.0)  
 ≥68 13 (52.0) 12 (48.0)  14 (56.0) 11 (44.0)  
Gender   0.776   0.018 
 Female 9 (45.0) 11 (55.0)  4 (21.1) 15 (78.9)  
 Male 16 (51.6) 15 (48.4)  18 (58.1) 13 (41.9)  
Lauren   0.006b   0.02 
 Intestinal 10 (33.3) 20 (66.7)  8 (26.7) 22 (73.3)  
 Diffuse 15 (75.0) 5 (25.0)  14 (73.7) 5 (26.3)  
 Mixed 0 (0.0) 1 (100)  0 (0.0) 1 (100)  
  0.673a   0.189a 
 T1a/b 2 (66.7) 1 (33.3)  1 (33.3) 2 (66.7)  
 T2 3 (33.3) 6 (66.7)  2 (22.2) 7 (77.8)  
 T3 10 (50.0) 10 (50.0)  9 (47.4) 10 (52.6)  
 T4a/b 10 (52.6) 9 (47.4)  10 (52.6) 9 (47.4)  
  0.856a   0.999a 
 N0 7 (43.8) 9 (56.2)  6 (37.5) 10 (62.5)  
 N1 5 (62.5) 3 (37.5)  5 (71.4) 2 (28.6)  
 N2 5 (62.5) 3 (37.5)  3 (37.5) 5 (62.5)  
 N3 a/b 8 (42.1) 11 (57.9)  8 (42.1) 11 (57.9)  
Stage   0.572a   0.577a 
 I A/B 5 (62.5) 3 (37.5)  3 (37.5) 5 (62.5)  
 II A/B 3 (27.3) 8 (72.7)  4 (36.4) 7 (63.6)  
 III A/B/C 11 (50.0) 11 (50.0)  11 (50.0) 11 (50.0)  
 IV 6 (6.0) 4 (40.0)  4 (44.4) 5 (55.6)  
  0.439   1.000 
 M0 19 (46.3) 22 (53.7)  18 (43.9) 23 (56.1)  
 M1 6 (60) 4 (40)  4 (44.4) 5 (55.6)  
  0.401   0.367 
 G1/G2 6 (40.0) 9 (60.0)  5 (33.3) 10 (66.7)  
 G3/G4 19 (52.8) 17 (47.2)  17 (48.6) 18 (51.4)  
RSPO1RSPO2
NegativePositivePNegativePositiveP
Age   0.782   0.154 
 <68 years 12 (46.2) 14 (53.8)  8 (32.0) 17 (68.0)  
 ≥68 13 (52.0) 12 (48.0)  14 (56.0) 11 (44.0)  
Gender   0.776   0.018 
 Female 9 (45.0) 11 (55.0)  4 (21.1) 15 (78.9)  
 Male 16 (51.6) 15 (48.4)  18 (58.1) 13 (41.9)  
Lauren   0.006b   0.02 
 Intestinal 10 (33.3) 20 (66.7)  8 (26.7) 22 (73.3)  
 Diffuse 15 (75.0) 5 (25.0)  14 (73.7) 5 (26.3)  
 Mixed 0 (0.0) 1 (100)  0 (0.0) 1 (100)  
  0.673a   0.189a 
 T1a/b 2 (66.7) 1 (33.3)  1 (33.3) 2 (66.7)  
 T2 3 (33.3) 6 (66.7)  2 (22.2) 7 (77.8)  
 T3 10 (50.0) 10 (50.0)  9 (47.4) 10 (52.6)  
 T4a/b 10 (52.6) 9 (47.4)  10 (52.6) 9 (47.4)  
  0.856a   0.999a 
 N0 7 (43.8) 9 (56.2)  6 (37.5) 10 (62.5)  
 N1 5 (62.5) 3 (37.5)  5 (71.4) 2 (28.6)  
 N2 5 (62.5) 3 (37.5)  3 (37.5) 5 (62.5)  
 N3 a/b 8 (42.1) 11 (57.9)  8 (42.1) 11 (57.9)  
Stage   0.572a   0.577a 
 I A/B 5 (62.5) 3 (37.5)  3 (37.5) 5 (62.5)  
 II A/B 3 (27.3) 8 (72.7)  4 (36.4) 7 (63.6)  
 III A/B/C 11 (50.0) 11 (50.0)  11 (50.0) 11 (50.0)  
 IV 6 (6.0) 4 (40.0)  4 (44.4) 5 (55.6)  
  0.439   1.000 
 M0 19 (46.3) 22 (53.7)  18 (43.9) 23 (56.1)  
 M1 6 (60) 4 (40)  4 (44.4) 5 (55.6)  
  0.401   0.367 
 G1/G2 6 (40.0) 9 (60.0)  5 (33.3) 10 (66.7)  
 G3/G4 19 (52.8) 17 (47.2)  17 (48.6) 18 (51.4)  

Therefore, we aimed to identify promoter regions responsible for active LGR5 expression. A 1.5-kb fragment of the human LGR5 promoter was cloned into the regulatory space of the pGL3 vector coding for firefly luciferase, and serial deletions were made to detect critical binding regions. Interestingly, omission of the T-cell factor/lymphoid enhancer factor (TCF/LEF)–containing fragment appeared to be scarcely relevant for transcriptional activity under these conditions, whereas the region +638 to +349 was shown to be crucial for transcription of LGR5 (Fig. 1B). Within this region, one SP1-binding site was predicted. By cotransfection, SP1 proved relevant for LGR5 expression, although inhibition of SP1-mediated gene expression by MMA did not significantly decrease the luciferase signal (Fig. 1C). This result was further substantiated by cell culture experiments, in which SP1 overexpression in HEK293ebna cells led to increased LGR5 mRNA levels (Fig. 1D).

To rule out any indirect effect, binding of SP1 to the LGR5 promoter was verified by ChIP assays. With an antibody directed against SP1, DNA promoter fragments from ultrasound fragmented chromatin preparations (Fig. 2B) were precipitated and analyzed by qRT-PCR. As positive control, the SP1-binding domains of the ADAM17 promoter (Szalad 2009/2012) were used (Fig. 2D). In both MKN45 and HEK293ebna chromatin preparations, the SP1-binding fragment of the LGR5 promoter was specifically enriched by this method (Fig. 2E and F), with superior enrichment in HEK293ebna, consistent with the higher LGR5 expression level in this line (Fig. 2A). These results suggest SP1 as an important component of the regulatory transcriptional complex for LGR5 expression.

Figure 2.

Binding of SP1 directly to the LGR5 promoter verified by ChIP. A, Expression level of LGR5 and ADAM17 in gastric cancer cell lines or HEK293ebna cells (n = 2) compared with nonneoplastic stomach mucosa (n = 3). B, Chromatin preparation from HEK293ebna cells was sheared by ultrasound pulses resulting in 150- to 1,000-bp fragments when separated in a 2% agarose gel. C, Validation of the ChIP assay with an antibody directed against trimethylated histone 3 (anti-H3K4) or an IgG control in two independent experiments. ADAM17 and LGR5 promoter fragments are enriched according to the positive control GAPDH. The negative control locus within the K-ras gene was not specifically bound. D, Graphic presentation of primer-binding sites along both promoters used for ChIP analysis. E and F, Both SP1-binding sites of the ADAM17 and LGR5 promoter are specifically enriched with the SP1-directed antibody. K-ras does not contain any SP1-binding site and was only unspecifically precipitated. According to the expression levels (A), isolation of the LGR5 fragment was superior from HEK293 cells (E, n = 4) compared with MKN45 (F, n = 2).

Figure 2.

Binding of SP1 directly to the LGR5 promoter verified by ChIP. A, Expression level of LGR5 and ADAM17 in gastric cancer cell lines or HEK293ebna cells (n = 2) compared with nonneoplastic stomach mucosa (n = 3). B, Chromatin preparation from HEK293ebna cells was sheared by ultrasound pulses resulting in 150- to 1,000-bp fragments when separated in a 2% agarose gel. C, Validation of the ChIP assay with an antibody directed against trimethylated histone 3 (anti-H3K4) or an IgG control in two independent experiments. ADAM17 and LGR5 promoter fragments are enriched according to the positive control GAPDH. The negative control locus within the K-ras gene was not specifically bound. D, Graphic presentation of primer-binding sites along both promoters used for ChIP analysis. E and F, Both SP1-binding sites of the ADAM17 and LGR5 promoter are specifically enriched with the SP1-directed antibody. K-ras does not contain any SP1-binding site and was only unspecifically precipitated. According to the expression levels (A), isolation of the LGR5 fragment was superior from HEK293 cells (E, n = 4) compared with MKN45 (F, n = 2).

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Expression of RSPOs in the gastric mucosa

LGR5 function is regulated by RSPOs, which allow the formation of a complex with the ubiquitin-ligase Rnf43 or its close relative Znrf3. Internalization of the ternary complex LGR5–RSPO–Rnf43 abrogates the inhibitory effect on Wnt receptors, thereby stabilizing a robust Wnt signal (16). To investigate the availability of RSPOs in the gastric epithelium, we performed IHC stainings on whole-mount nonneoplastic stomach sections from sleeve gastrectomy specimens. Expression of both RSPO1 and 2 was readily detected in epithelial cells of the gastric neck and gland (Fig. 3) with contrasting intensities. RSPO1 showed a cytoplasmic staining with a gradual increase of staining intensity from negative luminal areas to the immunopositive gland base and scattered strongly expressing cells mostly residing in the lower gland section (Fig. 3A and 3A2). In contrast, RSPO2 staining identified distinct immunopositive cells within the isthmus and neck region, again omitting the foveola (Fig. 3B and 3B2). This arrangement of RSPO1 and 2 expression, together covering the proposed stem cell regions (Fig. 3C), led us to speculate about a possible role for RSPOs in defining the stem cell compartment and influencing differentiation directions within the corpus epithelium.

Figure 3.

RSPO 1 and 2 are differentially expressed in the stomach corpus mucosa enclosing the stem cell compartment. A and B, IHC staining of sleeve gastrectomy sections with RSPO1 (A) and RSPO2 (B). The RSPOs appear in opposing trends both omitting luminal areas (*). In the neck region, RSPO2 is more frequently expressed, whereas RSPO1 dominates in the gland base. Original magnification: ×90 (A and B) or ×250 (A2 and B2). C, Schematic correlation of RSPO 1 and 2 expression within the gastric mucosa to the proposed localization of LGR5+ cells as well as differentiation directions.

Figure 3.

RSPO 1 and 2 are differentially expressed in the stomach corpus mucosa enclosing the stem cell compartment. A and B, IHC staining of sleeve gastrectomy sections with RSPO1 (A) and RSPO2 (B). The RSPOs appear in opposing trends both omitting luminal areas (*). In the neck region, RSPO2 is more frequently expressed, whereas RSPO1 dominates in the gland base. Original magnification: ×90 (A and B) or ×250 (A2 and B2). C, Schematic correlation of RSPO 1 and 2 expression within the gastric mucosa to the proposed localization of LGR5+ cells as well as differentiation directions.

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Role of RSPOs in gastric cancer

In gastric cancer specimens, RSPO expression was found more homogenously distributed among tumor cells with often lower staining intensities compared with nonmalignant tissues (Fig. 4). Although the Histoscore analysis detected no difference between gastric cancer and normal tissue (Fig. 5A and B; Table 1), RSPO expression levels evaluated by qRT-PCR were clearly decreased (Fig. 5C and D). To decipher the role of RSPOs in gastric cancer, we analyzed Histoscore parameters separately revealing two opposing trends: whereas the number of immunopositive cells was increased in gastric cancer (Fig. 5H), staining intensities decreased concomitantly (Fig. 5I), accounting for the overall unchanged Histoscore result. This finding raised the question whether a silenced RSPO expression in gastric cancer acted possibly tumor suppressing but was counterbalanced by an increased number of RSPO-expressing cells. To test this hypothesis, we performed LGR5 immunostainings on serial sections and found a basic correlation between the localization of RSPO+ cells and LGR5+ cells (Fig. 5E–G), which are of prognostic relevance for gastric cancer (24). Along this line of evidence, the change in LGR5+ cells positively correlated with the change in RSPO-expressing cells (Fig. 5K). Therefore, we believe that similar to the healthy stomach stem cell niche, RSPOs might contribute to the expansion of cancer stem cells by defining regions where LGR5+ cell properties can be maintained.

Figure 4.

Expression profile of RSPO1 and 2 in gastric cancer. During tumorigenesis, expression of RSPO1 (A–D) and RSPO2 (E–H) is found more homogenously, with strong (A and E), but also moderate (B and F) to low (C and G) staining as well as immunonegative tumors. Most of the diffuse type gastric cancers (D and H) were classified low or negative for RSPO staining.

Figure 4.

Expression profile of RSPO1 and 2 in gastric cancer. During tumorigenesis, expression of RSPO1 (A–D) and RSPO2 (E–H) is found more homogenously, with strong (A and E), but also moderate (B and F) to low (C and G) staining as well as immunonegative tumors. Most of the diffuse type gastric cancers (D and H) were classified low or negative for RSPO staining.

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Figure 5.

Correlation of RSPO expression to LGR5 expansion in gastric cancer. A and B, The Histoscore result for RSPO1 and 2 staining is not changed in tumor tissue (TU) compared with nonmalignant tissue (NT). Individual changes in the score result are shown below (n = 52). C and D, Total RSPO1 and 2 mRNA levels are significantly decreased in gastric cancer patients compared with their matched control tissue. Bar plot depicts the expression value difference for each case (n = 50). E–G, IHC staining of LGR5 (E), RSPO1 (F), and RSPO2 (G) on serial sections of an intestinal-type gastric cancer (×250 magnification). Brownish staining reveals concomitant expression of LGR5 and its ligands in close proximity. H and I, Splitting up the Histoscore result, the overall number of RSPO1/2+ cells significantly increases in gastric cancer patients (H). Nevertheless, intensity scores are negatively affected compared with nonmalignant tissue (I). K, Changes in the percentage of immunostained RSPO1 or 2 and LGR5 cells are correlated.

Figure 5.

Correlation of RSPO expression to LGR5 expansion in gastric cancer. A and B, The Histoscore result for RSPO1 and 2 staining is not changed in tumor tissue (TU) compared with nonmalignant tissue (NT). Individual changes in the score result are shown below (n = 52). C and D, Total RSPO1 and 2 mRNA levels are significantly decreased in gastric cancer patients compared with their matched control tissue. Bar plot depicts the expression value difference for each case (n = 50). E–G, IHC staining of LGR5 (E), RSPO1 (F), and RSPO2 (G) on serial sections of an intestinal-type gastric cancer (×250 magnification). Brownish staining reveals concomitant expression of LGR5 and its ligands in close proximity. H and I, Splitting up the Histoscore result, the overall number of RSPO1/2+ cells significantly increases in gastric cancer patients (H). Nevertheless, intensity scores are negatively affected compared with nonmalignant tissue (I). K, Changes in the percentage of immunostained RSPO1 or 2 and LGR5 cells are correlated.

Close modal

Methylation controls the expression of RSPOs

The overall decrease in RSPO staining intensities in gastric cancer prompted us to check the methylation state of RSPO1 and 2. We therefore established MSP (Fig. 6A) and compared the results of MSP (Fig. 6B) to qRT-PCR expression values for three different cell lines. Whereas HEK293ebna cells showed distinct expression of RSPO1 and RSPO2 (Fig. 6C), RSPO expression in the gastric cell lines MKN45 and MKN74 was hardly detectable. Accordingly, MSP analysis showed no methylation at either locus in HEK293ebna cells. In contrast, in MKN45 and MKN74, the RSPO2 locus was highly methylated; for RSPO1, both PCR products were detected (Fig. 6B).

Figure 6.

RSPO expression is regulated via methylation. A, MSP as semiquantitative analysis for RSPO1 and 2 promoter methylation. B, In both gastric cancer cell lines MKN45 and MKN74, methylation within the RSPO promoter is detected, but not in HEK293ebna cells. Inhibition of methylation with 5-aza-C (1 μmol/L for 3 days) slightly changes MSP analysis. C, qRT-PCR analysis determined only low or nondetectable expression levels of RSPO1 and 2 in MKN45 and MKN74. After 5-aza-C treatment, expression of both RSPO1+2 was induced, whereas LGR5 expression remained unchanged. D, Methylation state of the RSPO1 and 2 promoter in the gastric mucosa of tumor-free (NT) and cancerous tissue (TU) samples from five representative gastric cancer patients. E, Bright-light microscopy image of MKN45 cultured in the absence or presence of Wnt3a and RSPO1 and 2 (all 10 nmol/L) for 3 days. F, Functionally, both RSPO1 and 2 are able to induce the expression of vimentin, whereas E-cadherin expression is unchanged (n = 3).

Figure 6.

RSPO expression is regulated via methylation. A, MSP as semiquantitative analysis for RSPO1 and 2 promoter methylation. B, In both gastric cancer cell lines MKN45 and MKN74, methylation within the RSPO promoter is detected, but not in HEK293ebna cells. Inhibition of methylation with 5-aza-C (1 μmol/L for 3 days) slightly changes MSP analysis. C, qRT-PCR analysis determined only low or nondetectable expression levels of RSPO1 and 2 in MKN45 and MKN74. After 5-aza-C treatment, expression of both RSPO1+2 was induced, whereas LGR5 expression remained unchanged. D, Methylation state of the RSPO1 and 2 promoter in the gastric mucosa of tumor-free (NT) and cancerous tissue (TU) samples from five representative gastric cancer patients. E, Bright-light microscopy image of MKN45 cultured in the absence or presence of Wnt3a and RSPO1 and 2 (all 10 nmol/L) for 3 days. F, Functionally, both RSPO1 and 2 are able to induce the expression of vimentin, whereas E-cadherin expression is unchanged (n = 3).

Close modal

We then subjected the gastric cancer cell lines to treatment with 5-aza-C, having determined that 1 μmol/L 5-aza-C was the optimal dose to inhibit methylation without toxic effects in a dose–response analysis (data not shown). After 3 days, a shift to the unmethylated PCR product was detected by MSP (Fig. 6B), correlating with reliable induction of RSPO1 expression in both cell lines. The effect for RSPO2 was even greater in MKN45, whereas in MKN74, expression was only partially restored (Fig. 6C). These results suggest methylation within the promoter regions responsible for the decreased RSPO1/2 expression. Indeed, we observed distinct methylation patterns within the gastric mucosa of nonneoplastic and tumor tissues of gastric cancer patients. In a small random selection from our gastric cancer cohort, methylation of RSPO1 and RSPO2 was detected in all five samples (Fig. 6D). For 3 patients, methylation was elevated in tumors, compared with their normal tissue. The other 2 patients showed higher methylation levels already in the normal tissue, possibly arguing for an early onset of epigenetic changes during gastric tumorigenesis. Therefore, methylation seems to be an important mechanism to regulate gastric RSPO expression.

To clarify the surprising results regarding higher number of expressing cells in gastric cancer versus repression by methylation, we performed cell culture experiments with recombinant RSPO proteins. Incubation of MKN45 with Wnt3a and RSPOs, which increased Wnt target gene expression as already shown (34), also induced morphologic changes in the semiadherent culture favoring the flattened cell type (Fig. 6E). By qRT-PCR analysis, an increase in vimentin expression was detected, whereas no significant change in E-cadherin expression occurred (Fig. 6F), suggesting a stimulating effect of RSPOs for epithelial–mesenchymal transition in this culture system.

In summary, we provide evidence for a possible role of SP1 in elevating LGR5 expression and the dysregulation of RSPO expression by methylation in the diseased stomach mucosa. Positivity for RSPO1+2 correlated with LGR5 positivity, and these changes were associated with morphologic changes in gastric cancer cell culture.

The importance of LGR5+ cells in regenerating gastrointestinal epithelia has been supported in many recent studies (35). In the intestine, LGR5+ cells are localized at the base of the glands in close relation to Paneth cells, which provide Wnt and EGFR ligands (36). In the murine stomach, LGR5+ cells mainly reside in the pyloric glands (10). As lineage tracing studies are not available in humans, LGR5 expression has been confirmed by in situ hybridization, RNAscope, or antibodies with controversial results regarding the localization of LGR5+ cells (37–39). With our recently established highly specific LGR5 antibody, we were able to confirm the localization of immunopositive cells in not only the distal but also the neck region of human gastric glands (Fig. 3; 24). This particular localization raises the question of the underlying regulatory and restricting mechanisms maintaining stem cell functions and tissue homeostasis.

As target gene of the Wnt signal pathway, the LGR5 promoter contains two typical TCF/LEF-binding domains. Furthermore, the involvement of GATA-6 was proven for LGR5 expression in the colon (40), and a role for Ascl2 was identified in the murine intestine (41). Here, we provide evidence for a relevant impact of SP1 in the regulation of LGR5 expression. By rational promoter analysis, we identified a promoter region from +638 to +349 (similar to the region identified by Tsuji and colleagues; ref. 40) containing one binding site for SP1 and providing first evidence for its biological function. SP1 belongs to the family of SP/KLF transcription factors and interacts by its zinc finger motif directly with GC-rich promoter elements. Thereby, SP1 is involved in important biological processes like cell growth and differentiation, immune responses, or chromatin remodeling (42). Aberrant expression of SP1 was positively correlated with tumorigenesis of the stomach (43). Using ChIP experiments, we found a direct interaction of SP1 with the LGR5 promoter. SP1-mediated expression has also been established for other stem cell markers, such as ABCG2, a transporter characterizing the so-called side population and accounting for elevated multi drug resistance (44). As SP1 is hypoxia induced (45), a stimulatory influence of ischemic conditions within the tumor milieu is conceivable, and increased SP1-mediated expression of LGR5 and other proteins accounting for stem cell properties could exert synergistic effects and additionally fuel the cancer stem cell phenotype.

Recently, RSPOs have been introduced as potentiators of LGR5-stimulated Wnt signaling. In vivo, overexpression of RSPO1 increases crypt cell proliferation in the small intestine and colon (46). Furthermore, RSPO1 supply is essential for the maturation of miniguts in organoid cultures (10), implying a fundamental role for RSPOs in the maintenance of LGR5 stem cell function as driver for tissue regeneration. Nevertheless, in colorectal cancer, RSPO2 has been shown to suppress tumor growth, and RSPO2 promoter methylation was reasoned to allow unrestricted tumor growth (32). Our investigations of RSPO1 and RSPO2 expression in the stomach mucosa likewise showed an epigenetic regulation for both spondins. We found a restored RSPO expression in gastric cancer cell culture after 5-aza-C treatment as well as promoter methylation in gastric cancer patients. To determine whether elevated methylation is based on an active methylation process or due to the expansion of a certain cell population, carrying the methylated sequences will necessitate further investigations.

These data fit well with the observation of a decreased RSPO staining intensity in gastric cancer. Aberrant DNA methylation is a common feature of carcinogenesis arising in early stages, accounting for fundamental gain- or loss of function of the affected genes and presumably driving tumor progression. One prominent example is E-cadherin, a tumor suppressor that is silenced in various cancers, including gastric cancer. In contrast, neither in gastric cancer cell cultures nor in patient samples did we find evidence for an epigenetic control of LGR5 expression, supporting the hypothesis that mainly the ligands and regulators of the Wnt signaling cascade are controlled by methylation within diverse human cancer entities (47).

We already reported the relevance of specific LGR5+ cell localization for the prognostic prediction of gastric cancer patients (24). Although in the nonneoplastic mucosa, only few single LGR5+ cells could be detected, in gastric cancer patients, patches of LGR5 tumor cells were detected, including also luminal areas and showing strong staining intensities at the invasive front. These observations might indicate a change in the stem cell compartment, which allows for unorganized growth and aberrant differentiation behavior. With the observation of differential RSPO expression within the stomach epithelium, such mechanism could be identified. It is intriguing to speculate about RSPOs as critical factors determining and restricting the Wnt-dependent stem cell niche and affecting migration direction or differentiation. Which R-spondin is relevant for the preservation of stem cell properties, or whether a combination of both is needed, still needs further investigations. In gastric cancer cell culture, both RSPOs enhanced the mesenchymal phenotype and induced Wnt target gene expression as already shown in HEK293 (8, 9). In contrast to the suggested action of RSPO2 as tumor suppressor in the colon, our results of a concomitant expansion of LGR5+ cells in relation to RSPO expression imply a positive stimulation of the Wnt active stem cells by RSPOs in the stomach epithelium (visual overview).

Collectively, our data and recent deep sequencing data provide evidence of a complex and diverse mechanism, by which the WNT signaling pathway and gastric stem cells can be deregulated, for example, mutations of the APC, CDH1, and RNF43 genes or methylation of CTNNB, RSPO1, and RSPO2 (visual overview). As mediators of RSPO-induced effects, LGR5+ cells acquired a central position in the diagnosis of Wnt-driven gastric cancer and are of value as predictive markers. In this study, we demonstrated evidence for an SP1-driven expression of LGR5 and RSPOs as positive niche-shaping factors in the stomach, being regulated by methylation.

No potential conflicts of interest were disclosed.

Conception and design: F. Wilhelm, C. Röcken

Development of methodology: E. Simon, S. Krüger, C. Röcken

Acquisition of data (provided animals, acquired and managed patients, provided facilities, etc.): F. Wilhelm, C. Böger, C. Röcken

Analysis and interpretation of data (e.g., statistical analysis, biostatistics, computational analysis): F. Wilhelm, C. Böger, H.-M. Behrens, C. Röcken

Writing, review, and/or revision of the manuscript: F. Wilhelm, C. Böger, H.-M. Behrens, S. Krüger, C. Röcken

Administrative, technical, or material support (i.e., reporting or organizing data, constructing databases): H.-M. Behrens, S. Krüger, C. Röcken

Study supervision: F. Wilhelm, C. Röcken

Other (primary grant applicant): C. Röcken

The authors thank Denisa Hajzeri and Marten Rönckendorf for excellent technical support.

This work was supported by a grant of the German Research Foundation (DFG) to C. Röcken (Ro-1173/12-1).

The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked advertisement in accordance with 18 U.S.C. Section 1734 solely to indicate this fact.

1.
Colquhoun
A
,
Arnold
M
,
Ferlay
J
,
Goodman
KJ
,
Forman
D
,
Soerjomataram
I
. 
Global patterns of cardia and non-cardia gastric cancer incidence in 2012
.
Gut
2015
;
64
:
1881
8
.
2.
Ferlay
J
,
Soerjomataram
I
,
Dikshit
R
,
Eser
S
,
Mathers
C
,
Rebelo
M
, et al
Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012
.
Int J Cancer
2015
;
136
:
E359
86
.
3.
Röcken
C
. 
[Ways to personalized medicine for gastric cancer]
.
Pathologe
2013
;
34
:
403
12
.
4.
Stojnev
S
,
Krstic
M
,
Ristic-Petrovic
A
,
Stefanovic
V
,
Hattori
T
. 
Gastric cancer stem cells: therapeutic targets
.
Gastric Cancer
2014
;
17
:
13
25
.
5.
Tetteh
PW
,
Farin
HF
,
Clevers
H
. 
Plasticity within stem cell hierarchies in mammalian epithelia
.
Trends Cell Biol
2015
;
25
:
100
8
.
6.
Qiao
XT
,
Gumucio
DL
. 
Current molecular markers for gastric progenitor cells and gastric cancer stem cells
.
J Gastroenterol
2011
;
46
:
855
65
.
7.
Barker
N
. 
Adult intestinal stem cells: critical drivers of epithelial homeostasis and regeneration
.
Nat Rev Mol Cell Biol
2014
;
15
:
19
33
.
8.
Carmon
KS
,
Gong
X
,
Lin
Q
,
Thomas
A
,
Liu
Q
. 
R-spondins function as ligands of the orphan receptors LGR4 and LGR5 to regulate Wnt/beta-catenin signaling
.
Proc Natl Acad Sci USA
2011
;
108
:
11452
7
.
9.
de Lau
W
,
Barker
N
,
Low
TY
,
Koo
BK
,
Li
VS
,
Teunissen
H
, et al
Lgr5 homologues associate with Wnt receptors and mediate R-spondin signalling
.
Nature
2011
;
476
:
293
7
.
10.
Barker
N
,
Huch
M
,
Kujala
P
,
van de Wetering
M
,
Snippert
HJ
,
van Es
JH
, et al
Lgr5(+ve) stem cells drive self-renewal in the stomach and build long-lived gastric units in vitro
.
Cell Stem Cell
2010
;
6
:
25
36
.
11.
Barker
N
,
van Es
JH
,
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
2007
;
449
:
1003
7
.
12.
Jaks
V
,
Barker
N
,
Kasper
M
,
van Es
JH
,
Snippert
HJ
,
Clevers
H
, et al
Lgr5 marks cycling, yet long-lived, hair follicle stem cells
.
Nat Genet
2008
;
40
:
1291
9
.
13.
Ng
A
,
Tan
S
,
Singh
G
,
Rizk
P
,
Swathi
Y
,
Tan
TZ
, et al
Lgr5 marks stem/progenitor cells in ovary and tubal epithelia
.
Nat Cell Biol
2014
;
16
:
745
57
.
14.
Kazanskaya
O
,
Glinka
A
,
del Barco Barrantes
I
,
Stannek
P
,
Niehrs
C
,
Wu
W
. 
R-Spondin2 is a secreted activator of Wnt/beta-catenin signaling and is required for Xenopus myogenesis
.
Dev Cell
2004
;
7
:
525
34
.
15.
de Lau
WB
,
Snel
B
,
Clevers
HC
. 
The R-spondin protein family
.
Genome Biol
2012
;
13
:
242
.
16.
de Lau
W
,
Peng
WC
,
Gros
P
,
Clevers
H
. 
The R-spondin/Lgr5/Rnf43 module: regulator of Wnt signal strength
.
Genes Dev
2014
;
28
:
305
16
.
17.
Malinauskas
T
,
Jones
EY
. 
Extracellular modulators of Wnt signalling
.
Curr Opin Struct Biol
2014
;
29
:
77
84
.
18.
Tan
S
,
Barker
N
. 
Epithelial stem cells and intestinal cancer
.
Semin Cancer Biol
2015
;
32
:
40
53
.
19.
Clevers
H
. 
An integral program for tissue renewal and regeneration: Wnt signaling and stem cell control
.
Science
2014
;
346
:
1248012
.
20.
Ong
BA
,
Vega
KJ
,
Houchen
CW
. 
Intestinal stem cells and the colorectal cancer microenvironment
.
World J Gastroenterol
2014
;
20
:
1898
909
.
21.
Chiurillo
MA
. 
Role of the Wnt/β-catenin pathway in gastric cancer: An in-depth literature review
.
World J Exp Med
2015
;
5
:
84
102
.
22.
Xi
HQ
,
Cai
AZ
,
Wu
XS
,
Cui
JX
,
Shen
WS
,
Bian
SB
, et al
Leucine-rich repeat-containing G-protein-coupled receptor 5 is associated with invasion, metastasis, and could be a potential therapeutic target in human gastric cancer
.
Br J Cancer
2014
;
110
:
2011
20
.
23.
Li
XB
,
Yang
G
,
Zhu
L
,
Tang
YL
,
Zhang
C
,
Ju
Z
, et al
Gastric Lgr5 stem cells are the cellular origin of invasive intestinal-type gastric cancer in mice
.
Cell Res
2016
;
26
:
838
49
.
24.
Simon
E
,
Petke
D
,
Boger
C
,
Behrens
HM
,
Warneke
V
,
Ebert
M
, et al
The spatial distribution of LGR5+ cells correlates with gastric cancer progression
.
PLoS One
2012
;
7
:
e35486
.
25.
The Cancer Genome Atlas Research Network
. 
Comprehensive molecular characterization of gastric adenocarcinoma
.
Nature
2014
;
513
:
202
9
.
26.
Cristescu
R
,
Lee
J
,
Nebozhyn
M
,
Kim
KM
,
Ting
JC
,
Wong
SS
, et al
Molecular analysis of gastric cancer identifies subtypes associated with distinct clinical outcomes
.
Nat Med
2015
;
21
:
449
56
.
27.
Li
S
,
Zhu
X
,
Liu
B
,
Wang
G
,
Ao
P
. 
Endogenous molecular network reveals two mechanisms of heterogeneity within gastric cancer
.
Oncotarget
2015
;
6
:
13607
27
.
28.
Fenoglio-Preiser
C
,
Carneiro
F
,
Correa
P
,
Guilford
P
,
Lambert
R
. 
Gastric carcinoma
. In:
Hamilton
SR
,
Aaltonen
LA
,
eds.
Pathology and genetics of tumours of the digestive system. WHO classification of tumours
.
Lyon
,
France
:
IARC
; 
2000
.
29.
Sobin
LH
,
Compton
CC
. 
TNM seventh edition: what's new, what's changed: communication from the International Union Against Cancer and the American Joint Committee on Cancer
.
Cancer
2010
;
116
:
5336
9
.
30.
McCarty
KS
 Jr
,
Miller
LS
,
Cox
EB
,
Konrath
J
,
McCarty
KS
 Sr
. 
Estrogen receptor analyses. Correlation of biochemical and immunohistochemical methods using monoclonal antireceptor antibodies
.
Arch Pathol Lab Med
1985
;
109
:
716
21
.
31.
Li
LC
,
Dahiya
R
. 
MethPrimer: designing primers for methylation PCRs
.
Bioinformatics
2002
;
18
:
1427
31
.
32.
Wu
C
,
Qiu
S
,
Lu
L
,
Zou
J
,
Li
WF
,
Wang
O
, et al
RSPO2-LGR5 signaling has tumour-suppressive activity in colorectal cancer
.
Nat Commun
2014
;
5
:
3149
.
33.
Benjamini
Y
. 
Discovering the false discovery rate
.
J Royal Stat Soc
2010
;
72
:
405
16
.
34.
Wilhelm
F
,
Böger
C
,
Krüger
S
,
Behrens
HM
,
Röcken
C
. 
Troy is expressed in human stomach mucosa and a novel putative prognostic marker of intestinal type gastric cancer
.
Oncotarget
2016 Jul 8
.
doi: 10.18632/oncotarget.10672. [Epub ahead of print]
.
35.
Koo
BK
,
Clevers
H
. 
Stem cells marked by the R-spondin receptor LGR5
.
Gastroenterology
2014
;
147
:
289
302
.
36.
Sato
T
,
van Es
JH
,
Snippert
HJ
,
Stange
DE
,
Vries
RG
,
van den Born
M
, et al
Paneth cells constitute the niche for Lgr5 stem cells in intestinal crypts
.
Nature
2011
;
469
:
415
8
.
37.
Ziskin
JL
,
Dunlap
D
,
Yaylaoglu
M
,
Fodor
IK
,
Forrest
WF
,
Patel
R
, et al
In situ validation of an intestinal stem cell signature in colorectal cancer
.
Gut
2013
;
62
:
1012
23
.
38.
Jang
BG
,
Lee
BL
,
Kim
WH
. 
Distribution of LGR5+ cells and associated implications during the early stage of gastric tumorigenesis
.
PLoS One
2013
;
8
:
e82390
.
39.
Wang
T
,
Yeoh
KG
,
Salto-Tellez
M
. 
Lgr5 expression is absent in human premalignant lesions of the stomach
.
Gut
2012
;
61
:
1777
8
.
40.
Tsuji
S
,
Kawasaki
Y
,
Furukawa
S
,
Taniue
K
,
Hayashi
T
,
Okuno
M
, et al
The miR-363-GATA6-Lgr5 pathway is critical for colorectal tumourigenesis
.
Nat Commun
2014
;
5
:
3150
.
41.
Schuijers
J
,
Junker Jan
P
,
Mokry
M
,
Hatzis
P
,
Koo
B-K
,
Sasselli
V
, et al
Ascl2 acts as an R-spondin/Wnt-responsive switch to control stemness in intestinal crypts
.
Cell Stem Cell
2015
;
16
:
158
70
.
42.
Li
L
,
Davie
JR
. 
The role of Sp1 and Sp3 in normal and cancer cell biology
.
Ann Anat
2010
;
192
:
275
83
.
43.
Wang
L
,
Wei
D
,
Huang
S
,
Peng
Z
,
Le
X
,
Wu
TT
, et al
Transcription factor Sp1 expression is a significant predictor of survival in human gastric cancer
.
Clin Cancer Res
2003
;
9
:
6371
80
.
44.
Yang
WJ
,
Song
MJ
,
Park
EY
,
Lee
JJ
,
Park
JH
,
Park
K
, et al
Transcription factors Sp1 and Sp3 regulate expression of human ABCG2 gene and chemoresistance phenotype
.
Mol Cells
2013
;
36
:
368
75
.
45.
Szalad
A
,
Katakowski
M
,
Zheng
X
,
Jiang
F
,
Chopp
M
. 
Transcription factor Sp1 induces ADAM17 and contributes to tumor cell invasiveness under hypoxia
.
J Exp Clin Cancer Res
2009
;
28
:
129
.
46.
Kim
KA
,
Kakitani
M
,
Zhao
J
,
Oshima
T
,
Tang
T
,
Binnerts
M
, et al
Mitogenic influence of human R-spondin1 on the intestinal epithelium
.
Science
2005
;
309
:
1256
9
.
47.
Ying
Y
,
Tao
Q
. 
Epigenetic disruption of the WNT/beta-catenin signaling pathway in human cancers
.
Epigenetics
2009
;
4
:
307
12
.

Supplementary data