Pediatric sarcomas.

Sarcomas arise from primitive mesenchymal cells, which are classified, into two main groups: Bone and soft tissue sarcomas. We have searched all-important electronic databases including Google scholar and PubMed for the collection of latest literature pertaining to pediatric sarcomas. Latest literature confirmed that these tumors are relatively rare and represent only 1% of all malignancies but they have higher incidence in children. Pediatric sarcomas comprise about 13% of all pediatric malignancies and are ranked third in childhood cancers. The highest incidence rates are reported among rhabdomyosarcoma, osteosarcoma and Ewing's sarcomas in children. All of these neoplasms often display highly aggressive behavior with tendency to form metastases. Important globally used management avenues include surgery with systemic chemotherapy and have success rate of 70% at 5-years. Furthermore, in the cases of advanced stages, the prognosis is poor, chances of treatment failure and recurrence are quite high. Utilization of cancer stem cells is the latest approach with great potential in management of above pathological state. The present review article discuss all-important aspects of commonly found pediatric sarcomas throughout the world.

Introduction

Osteosarcoma is one of the commonest tumors of the bone among pediatric sarcomas and is malignant in nature (1,2). It is histologically characterized by the presence of osteoid-producing neoplastic osteoblasts. Moreover, the reported incidence is 4.8 per million per year (3). The common sites of incidence of primary osteosarcomas typically occur in the metaphysis of long bones (Fig. 1A). The general nature, as discussed earlier, is highly aggressive leading to early systemic metastasis (4). The use of cytotoxic chemo-therapeutic protocols with various chemotherapeutics having diverse range resulted in 60–70% success rate (5). Furthermore, it is a common observation during diagnosis of many cases of pediatric sarcoma that patients confirm macroscopic signs of metastasis to lungs or rarely to lymph nodes. Also, in present scenario, 90% of the cases of metastasis remain undetected due to presence of micro-metastatic disease. Despite utilization of intensive chemotherapy with surgical and radiation approaches, the prognosis is still poor. Also, chances of recurrent osteosarcoma are high. The confirmed presence of cancer stem cells (CSC) in the cases of osteosarcoma was reported initially in 2005 (6). The observation revealed that osteosarcoma cell lines have self-renewing cells. In their study, Gibbs et al (6) showed that about 1 in 100–1,000 osteosarcoma cells were capable of growth in vitro under anchorage-independent and growth-constraining conditions to form spherical colonies, termed sarcospheres. Cells within these sarcospheres showed elevated presence of stem cell markers. Moreover, single cells repeatedly generated spheres during serial re-cloning.

Figure 1.

Most common primary tumor sites in osteosarcoma.

Later, Tsuchida et al (7) showed that treatment of osteosarcoma HOS cell line with cisplatin caused elevation in the side-population (SP) cells. Exposure of HOS cells to cisplatin resulted in the increase of colony-forming and migratory abilities of these cells in vitro. Moreover, SP in cisplatin-treated cells was enriched for cells with CSC properties but this population did not define CSCs absolutely. Similarly, another group revealed stem-like osteosarcoma cell line 3AB-OS by long-term treatment of MG-63 cells with 3-aminobenzamide (8).

Earlier studies confirmed utilization of CD133 as a marker for CSCs in several human malignancies but previously it was explored in cases of osteosarcoma (9). Further, experiments on osteosarcoma cell lines revealed the presence of subpopulation of CD133+ cells with self-renewal characteristics. In the same year, another research group confirmed the presence of CD133 and nestin in osteosarcoma cell lines (10). The identification of CD133+/nestin+ cells suggested the possible occurrence of a cell population with a stem-like phenotype. However, the aforementioned studies did not verify the CSC phenotype of CD133+ and nestin+ populations through the in vivo tumorigenicity assays. Surprisingly, when the tumorigenicity of osteosarcoma cells was tested, two cell lines that were shown to express CD133 did not form tumors after injection into NOD/SCID mice (11). Another study did not find any difference in expression of CD133 between SP cells that were enriched in tumorigenic cells and non-SP cells (12). All these observations finally reached a conclusion that expression of CD133 is a confirmed indicator of lung metastasis in osteosarcoma patients. Although CD133 seems to be of importance in osteosarcoma progression, its role in osteosarcoma CSCs remains controversial.

Adhikari et al (13) reported that double positivity for CD117 (c-kit) and Stro-1 (a marker of osteogenic progenitors in bone marrow) marked CSCs in mouse and human osteosarcoma cell lines. These results suggested CD117 and Stro-1 to be potential therapeutic targets in osteosarcoma. However, no further study has been published to support the utility of CD117 in osteosarcoma. Previously, two independent groups have reported that CD49f may serve in osteosarcoma as another marker that can distinguish CSCs from the cells with limited tumorigenic capacity (14). Nevertheless, these two studies brought contradictory results. Whereas Ying et al (15) initially identified CD49f−/CD133+ cells that possessed strong tumorigenic activity, the other study suggested that high levels of CD49f correlate with stemness so, clinical significance of CD49f in identifying CSCs in osteosarcoma is not yet confirmed.

Human ATP-binding cassette (ABC) transporters are considered to cause the resistance of CSCs to chemotherapy and are therefore studied as prospective CSC markers (16). The results concerning expression of ABC transporters in osteosarcoma seem to be partly controversial. Nevertheless, previous study demonstrated that exposure of osteosarcoma cells to chemotherapeutic agents (doxorubicin, cisplatin and methotrexate) induce their stem-like phenotype and result in upregulation of ABC transporters and aldehyde dehydrogenases (ALDH) via Wnt/β-catenin signaling (17).

Examinations of ALDH activity showed the presence of subpopulation of cells with high ALDH activity (ALDH+) in several osteosarcoma cell lines (18). Another study revealed that ALDH+ cells have high cancer inducing capacity (19). ALDH+ cells also showed elevated cell growth rate, clone formation ability, and expression of stem cell marker genes in vitro. However, these results were obtained only when ALDH+ cells were isolated directly from osteosarcoma xenograft tumors but not from the parental cell line. These observations countered the use of ALDH activity as a specific marker for osteosarcoma CSC. Nevertheless, further studies reported that ALDH activity was associated with metastatic potential in murine and human osteosarcomas (20). Previous, Martins-Neves et al (18) provided evidence that ALDH+ cells overexpress Sox2 in osteosarcoma. During the last 5 years, Sox2 has been shown to associate with clinical outcome and/or mediate the maintenance of CSC subpopulation in various types of cancer including osteosarcoma (21). Additionally, Sox2 overexpression enhanced osteosphere formation by murine primary osteoblasts (22). Previous study demonstrated that Sox2 interferes with the tumor-suppressive Hippo pathway to maintain CSCs in osteosarcoma (23). Thus, blocking of Sox2 function might provide a novel therapeutic strategy.

Ewing's sarcoma

Ewing's sarcoma is the second commonest among malignant bone tumors observed both in children and young adults (24). This group of malignancies comprises a spectrum of aggressive tumors, including Ewing's sarcoma or peripheral primitive neuroectodermal tumor. In the diagnosis, these tumors showed the presence of specific fusion oncoproteins as result of chromosomal translocations. Although the exact functions of these fusion oncoproteins are still a matter of research, expression of EWS-Fli-1 has been demonstrated to be essential for the Ewing's sarcoma oncogenesis (25). Tirode et al (26) demonstrated EWS-Fli-1 to block terminal mesenchymal differentiation of mesenchymal stem cells (MSCs) and suggested that these cells may represent the origin of Ewing's sarcoma cells. Thus, MSCs have been recently utilized as a model to investigate and manipulate oncogenesis in Ewing's sarcoma. The most frequent primary sites of Ewing's sarcomas include pelvis and femur; metastatic disease often affects lungs (Fig. 1A). Further, a quarter of patients have detectable metastases at diagnosis and their survival remain at 40% (27).

For the first time, the presence of CSCs in Ewing's sarcoma was reported using isolation CD133+ cells from primary tumors (28). CD133+ cells displayed ability to start and maintain tumor growth via xenotransplantations, The CD133+ cells also expressed elevation in the levels of both OCT4 and NANOG, but not SOX2 or CD133− counterparts. In the subsequent study, the same research group expressed fusion gene EWS-FLI1 in pediatric MSCs (MSCsEWS-FLI-1) and demonstrated that EWS-Fli-1 induced expression of CD133 in 6–10% of these cells (29). Sorted CD133+ MSCsEWS-FLI-1 displayed higher expression levels of OCT4 and NANOG, but did not differ in EWS-FLI1 expression level compared with CD133-fraction. Additionally, unsorted MSCsEWS-FLI-1 were able to form spheres and more importantly these cells expressed significantly reduced expression of miR-145 than wild-type pediatric MSCs. Downregulation of miR-145 indicated its tumor suppressor role in multiple cancers. Indeed, miR-145 expression was found low in self-renewing human ESCs but highly upregulated during differentiation, repressing expression of SOX2, OCT4 and KLF4 (30). Inhibition of miR-145 in dermal skin fibroblasts led to upregulation of pluripotency-associated genes including SOX2, KLF4, OCT4 and MYCC, and increased efficiency of reprogramming these fibroblasts to induced pluripotent stem cells (31). Moreover, the loss of the above miRNA might promote tumorigenesis (Fig. 2). It is not surprising that several studies have demonstrated anti-proliferative and differentiating effects of miR-145 onto CSCs in various cancers (32). In the aforementioned study of pediatric MSCs, repression of miR-145 upon EWS-FLI1 expression resulted in upregulation of SOX2. More importantly, overexpression of miR-145 or depletion of SOX2 in Ewing's sarcoma cell lines led to reduced tumorigenicity of the cells in vivo. Consistent with this study, knockdown of EWS-FLI1 in Ewing's sarcoma cell lines dramatically increased the levels of miR-145, and forced miR-145 expression halted growth of the cells. In the light of these findings, ‘EWS-Fli-1/miR-145/Sox2’ axis may represent the key regulatory pathway in Ewing's sarcoma tumorigenesis reprogramming preneoplastic cells towards the CSC phenotype. In contrast to the first study reporting CD133 as marker of CSCs in Ewing's sarcoma (28), no differences in the tumorigenicity or chemoresistance between CD133+ and CD133− cell fractions in three of four Ewing's sarcoma cell lines tested. Thus, the significance of CD133 as CSC marker in Ewing's sarcoma remains elusive. Further, CD57 is another potential marker proposed to reflect enhanced tumorigenicity in Ewing's sarcoma (33). CD57 high cells were more tumorigenic, formed spheres at higher frequency and had enhanced migratory potential than CD57 low cells. Interestingly, only partial overlap was observed among CD57 high and CD133+ populations of cells, suggesting that CD57 identify different population of Ewing's sarcoma cells with CSC phenotype. Previously, Leuchte et al (34) argued against a role of CD133 and CD57 as markers of CSCs in Ewing's sarcoma.

Figure 2.

Regulation of self-renewal and pluripotency is mediated by miR-145.

Leucine-rich repeat-containing G-protein coupled receptor 5 (LGR5) is the latest CSC marker in Ewing's sarcoma (35). Lgr5 activation potentiates Wnt/β-catenin signaling, contributing to stem cell proliferation and self-renewal in various tissues (36). In Ewing's sarcoma, expression of LGR5 was identified in both tumor tissues and cell lines, and elevated levels of LGR5 were associated with clinically aggressive tumors. Increased expression of LGR5 also corresponded with CD133 positivity and high ALDH activity in Ewing's sarcoma cell lines. Similarly to osteosarcoma, high ALDH activity was reported to identify stem-like chemotherapy-resistant population in Ewing's sarcoma. More importantly, these cells are highly tumorigenic in vivo. As few as 160 of ALDH high cells were sufficient to initiate tumors in NOD/Shi-scid/IL-2Rγnull (NOG) mice whereas, the same number of CD133+ cells did not result in tumor formation. Furthermore, direct cytotoxicity and loss of clonogenic activity after treatment with YK-4-279 indicated the dependence of the ALDH high cells on EWS-FLI1 oncogene expression. These findings further supported the crucial role of the aforementioned ‘EWS-Fli-1/miR-145/Sox2’ axis for maintenance of CSC phenotype in Ewing's sarcoma.

Rhabdomyosarcoma

Rhabdomyosarcoma is the most common malignant mesenchymal tumor encountered in children with the peak of incidence in patients younger than 5 years (37). Previously revised classification of rhabdomyosarcoma distinguishes four subtypes: i) Alveolar rhabdomyosarcoma; ii) embryonal rhabdomyosarcoma; iii) pleomorphic rhabdomyosarcoma; and iv) sclerosing/spindle cell rhabdomyosarcoma. Embryonal subtype represents about 70% of all childhood rhabdomyosarcomas, mainly affecting infants and children under 10-years of age, and is usually associated with a favorable prognosis. Embryonal rhabdomyosarcomas predominantly localize to the head and neck, the genitourinary tract and the retroperitoneum. In contrast, alveolar rhabdomyosarcoma is a high-grade malignancy with 5-year survival of <50% and occurs mostly in adolescents and young adults, usually arising in the extremities and trunk. This subtype of rhabdomyosarcoma typically harbors one of two characteristic chromosomal translocations t(2;13) (q35;q14) or t(1;13) (p36;q14) that juxtapose PAX3 or PAX7 and FOXO1A genes, resulting in Pax3 and Pax7-FKHR fusion proteins (38).

Similarly to Ewing's sarcomas, MSCs were suggested as the cells of origin of alveolar rhabdomyosarcomas. Ren et al (39) showed that Pax3 and Pax7-FKHR induced skeletal myogenesis in murine MSCs, although additional secondary genetic event was needed for their transformation towards alveolar rhabdomyosarcoma and tumor formation in vivo. No characteristic cytogenetic abnormality has been associated with tumorigenesis of embryonal rhabdomyosarcoma. Nevertheless, this rhabdomyosarcoma subtype may probably develop from a whole range of muscle cells, including muscle satellite cells and downstream myogenic progenitors such as maturing myoblasts (40).

Embryonal rhabdomyosarcoma cell lines cultured as spherical colonies (rhabdospheres) that possessed stem cell properties including elevated expression of stem cell markers POU5F1, NANOG, MYCC, SOX2, and PAX3. Rhabdosphere cells were highly tumorigenic compared with adherent cells and showed upregulated CD133 expression both on RNA and protein levels. CD133+ sorted cells formed tumors at lower cell densities than CD133− and unsorted cells, and were more resistant to treatment with the chemotherapy drugs cisplatin and chlorambucil. Furthermore, high expression of CD133 in tumor tissue samples correlated with poor survival of embryonal rhabdomyosarcoma patients. Later, Pressey et al (41) suggested CD133 as a marker of CSCs also in alveolar rhabdomyosarcoma. The authors showed that both alveolar and embryonal rhabdomyosarcoma-derived CD133+ cells have enhanced colony-forming ability and resistance to chemotherapy, and are characterized by a myogenically primitive phenotype. In contrast, no difference in tumorigenicity of CD133+ and CD133− cells was found in a previous study of three embryonal rhabdomyosarcoma cell lines (42). The investigators tested a panel of potential CSC markers and found that only cell fractions positive for fibroblast growth factor receptor 3 (FGFR3) were enriched for CSCs. Previously, ALDH1 has been found to mark population of embryonal rhabdomyosarcoma cells showing higher capacity for self-renewal and tumor formation (43). ALDH high cells were more chemoresistant and expressed higher levels of SOX2 than their ALDH low counterparts. Thus, ALDH1 is a potential marker of CSCs at least in embryonal subtype of rhabdomyosarcoma.

Pancreatic ductal adenocarcinoma

Pancreatic ductal adenocarcinoma (PDAC) is the most lethal of all pediatric malignancies. Although its incidence is relatively low, PDAC represents the forth-leading cause of cancer-related deaths in Western countries (44). Despite previous advances in the diagnosis and treatment, the 5-year survival rate does not generally reach 5%. More than 90% of mortality rate has been reported in PDAC patients (45). Distinct subpopulation of CD133+ cells that co-expressed CXCR4 was further identified in the invasive front of the PDAC tumors. These CD133+ CXCR4+ cells were shown to have migratory capacity in vitro and were demonstrated to be essential for metastatic phenotype of the PDAC in vivo. Although CD133+ CXCR4− formed tumors at the same rate, only mice injected with CD133+ CXCR4+ cells developed metastases. In accordance with these results, another study showed that CXCR4 is expressed in pancreatic intraepithelial neoplasias (PanIN) and its expression is increased during PanIN progression towards invasive carcinoma (46; Fig. 3). The possible prognostic significance of CXCR4 in PDAC was further confirmed by a meta-analysis study showing correlation between CXCR4 expression and poor prognosis (47). More importantly, strong association of CXCR4 expression and metastatic disease was found in this study. Consistent with these findings, previous experimental data demonstrated increased proliferation and invasiveness of pancreatic cancer cells after induction of CXCR4 by its ligand CXCL12 (48).

Figure 3.

PanIN progression towards invasive carcinoma. (A) Schematic diagram; (B) H&E, ×200 magnification.

Although CD133 was initially suggested as a CSC marker in PDAC, further published studies argued against the usefulness of this protein alone to specifically identify pancreatic CSCs. Immervoll et al (49) showed that CD133 is expressed not only in pancreatic cancer cells but also in normal pancreas. Moreover, no correlation of CD133 and patient survival was found in subsequent studies. Co-expression of CD44 and CD133 was then proposed as more specific phenotype of CSCs and was shown to predict worse survival in PDAC patients (50). However, significance of CD133 expression in PDAC tumorigenesis has been previously supported by two independent studies reporting CD133 as efficient negative prognostic factor (51). Expression of ALDH isoenzymes and their enhanced activity represent another putative marker of CSCs that has been evaluated in PDAC. ALDH1-positive cells were detected in primary tumor tissues, and their presence was associated with shorter survival. Importantly, ALDH1- positivity was found in metastatic lesions of primary PDAC tumors that were ALDH1-negative. Further experiments demonstrated that sorted ALDH-high cells were considerably more clonogenic in vitro and tumorigenic in vivo than ALDH low cells. Interestingly, only minor overlap of ALDH-high and CD44+/CD24+ cell populations was found in PDAC cell lines.

However, these ALDH-high/CD44+/CD24+ cells showed increased tumorigenic potential compared to ALDH-high or CD44+/CD24+ cells only. Contrary to these results, another study reported much higher rates of tumor formation after injection of ALDH-high cells into NOD/SCID mice. In some cases, as few as 100 ALDH-high cells were able to initiate tumor growth in 100% of mice, suggesting that sorting for ALDH-high cells alone is sufficient to enrich for CSCs. Thus it still needs to be determined whether ALDH-high/CD44+/CD24+ cells might represent more primitive cells that give rise to phenotypically distinct but still (to a certain extent) tumorigenic pancreatic cancer cells.

Previously, ALDH1B1 expression was shown to correlate with invasiveness of PDAC tumors and proliferation of PDAC-derived cells (52). In vivo experiments in mice showed that administration of disulfiram in combination with low-dose gemcitabine significantly suppressed tumor growth and reduced ALDH-positivity of xenografted CFPAC-1 cells. Thus targeting ALDH-high therapy-resistant CSCs with specific inhibitors, such as disulfiram, may provide better therapeutic response and reduced toxicity of chemotherapy in PDAC patients.

Conclusions

It was concluded from the above that CSC markers are more informative with regard to clinical outcome or tumor progression. Further, in pediatric sarcomas and PDAC, more selective marker is needed for further investigations of CSCs for better management.