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Aldehyde dehydrogenase 1 (ALDH1) positivity correlates with poor prognosis in

cervical cancer
Tingting Yao, Zhuna Wu, Yukun Liu, Qunxian Rao and Zhongqiu Lin
Journal of International Medical Research published online 14 May 2014
DOI: 10.1177/0300060514527060
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Clinical Note

Aldehyde dehydrogenase
1 (ALDH1) positivity
correlates with poor
prognosis in cervical cancer

Journal of International Medical Research

0(0) 15
! The Author(s) 2014
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DOI: 10.1177/0300060514527060
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Tingting Yao1,2,*, Zhuna Wu3,*, Yukun Liu1,*,

Qunxian Rao1 and Zhongqiu Lin1

Abstract
Objective: To analyse the associations between aldehyde dehydrogenase 1 (ALDH1) tumour
immunopositivity and disease-free survival in cervical carcinoma.
Methods: ALDH1 immunohistochemistry was performed on formalin-fixed, paraffin waxembedded cervical tumour tissue samples obtained from hospital archives. Data regarding
disease-free survival were obtained. KaplanMeier survival analyses and Cox proportional hazards
regression models were performed.
Results: Patients with ALDH1-positive tumours (n 31) had significantly shorter disease-free
survival than those with ALDH1-negative tumours (n 167; 41.99  0.90 vs 53.64  2.67 months).
ALDH1 positivity was associated with poor prognosis (relative risk 2.727; 95% confidence intervals
1.253, 5.914).
Conclusions: ALDH1 positivity is associated with poor prognosis of cervical carcinoma, and may
be an independent predictor of prognosis.

Keywords
Cervical cancer, cancer stem cell, aldehyde dehydrogenase 1 (ALDH1), immunohistochemistry
Date received: 13 December 2013; accepted: 17 February 2014

1
Department of Gynaecological Oncology, Sun Yat-sen
Memorial Hospital, Sun Yat-sen University, Guangzhou,
Guangdong Province, China
2
Key Laboratory of Malignant Tumour Gene Regulation
and Target Therapy of Guangdong Higher Education
Institutes, Sun Yat-sen University, Guangzhou, Guangdong
Province, China

Department of Gynaecology and Obstetrics, The Second

Affiliated Hospital of Fujian Medical University, Quanzhou,
Fujian Province, China
*
Co-first authors, Tingting Yao, Zhuna Wu and Yukun Liu
contributed equally to this study.
Corresponding author:
Zhongqiu Lin, Department of Gynaecological Oncology,
Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107
Yan Jiang West Road, Guangzhou 510120, China.
Email: linzhongqiu@hotmail.com

Creative Commons CC-BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial
3.0 License (http://www.creativecommons.org/licenses/by-nc/3.0/) which permits non-commercial use, reproduction and
distribution of the work without further permission
provided
the original work
is attributed
as 2014
specified on the SAGE and Open Access page
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Introduction
Cervical cancer is the third most common
malignant tumour in Chinese women.1
The widespread use of cervical cytology
screening has resulted in a substantial
decrease in disease incidence and mortality,2
but the 5-year survival rate in patients with
advanced disease is 3.213%.3 Recurrence
usually occurs within 2 years of diagnosis,4
and the median survival time of recurring
cases is only 7 months, due to resistance to
traditional treatments.5 Aldehyde dehydrogenase 1 (ALDH1) is a cancer stem-cell
marker, the presence of which strongly
correlates with tumour malignancy and
self-renewal properties of stem cells in
tumour types including breast cancer, hepatoma, lung and colon cancer.69
Our previous study used immunohistochemistry to evaluated ALDH1 in 109 samples of cervical carcinoma and found that
the presence of ALDH1 in tumour tissue
was signicantly related to lymph node
metastasis and recurrence.10 The aim of the
present study was to analyse the relationship
between ALDH1 positivity and cervical
cancer prognosis.

Patients and methods

Tissue samples
Samples of formalin-xed, paran waxembedded cervical tumour tissue were
obtained from the archives of the
Department of Gynaecology, Sun Yat-sen
Memorial Aliated Hospital, Sun Yat-sen
University, Guangzhou, China. Patients
underwent treatment between October
2003 and December 2007 for conrmed
cervical cancer (including squamous cell
carcinoma and adenocarcinoma). Patients
with evidence of disease on chest X-radiograph or magnetic resonance imaging
(MRI) were excluded. Tumours were
staged according to 2009 International
Federation of Gynaecology and Obstetrics
(FIGO) revised staging criteria.11 Data

regarding treatment, myometrial invasion,

vascular invasion and lymph node metastasis were obtained from medical records.
All patients provided written informed
consent for the use of their tissue samples
and the study was approved by the Ethics
Committee of Sun Yat-sen Memorial
Hospital, Sun Yat-sen University.

Follow up
Follow up continued until April 2009.
Patients were followed up every 3 months
in the rst year, every 4 months in the second
year, every 6 months for the next 3 years and
annually thereafter. Each visit included a
pelvic examination, cytology and colposcopy. Ultrasonography, MRI or computed
tomography scan were performed if
necessary.

Immunohistochemistry
Tissue was cut into 3-mm sections and
mounted on glass slides pretreated with
poly-L-lysine. Sections were boiled for
15 min in citrate buer (10 mM, pH 6.0),
cooled in the same buer, then incubated for
10 min in 0.3% hydrogen peroxide to block
endogenous peroxidase activity. Slides were
incubated in mouse antihuman ALDH1
antibody (1 : 100 dilution; Santa Cruz
Biotechnology, Santa Cruz, CA, USA) overnight at 4 C in a humid chamber, and
washed three times at room temperature in
phosphate buered saline (PBS; 0.01 M, pH
7.2; 3 min each wash). Sections were then
incubated with horseradish peroxidase-conjugated antimouse secondary antibody
(1 : 100 dilution; Zymed, San Francisco,
CA, USA) for 60 min at room temperature,
washed three times with PBS at room temperature (3 min each wash), then stained
using the ABC Vectastain kit (Vector
laboratories, Burlingame, CA, USA)
according to the manufacturers instructions. All assays included positive and

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Yao et al.

negative controls (replacement of primary

antibody with mouse immunoglobulin G1
used
as
negative
control).
Immunohistochemical staining of ALDH1
was classied as negative (, no staining),
weakly positive (, light-brown or yellow
cells) or positive (, brown staining). For
the purpose of the study, positive staining
included both weakly positive and positive
staining. All slides were evaluated by two
independent pathologists.

Statistical analyses
Data were presented as mean  SD.
KaplanMeier analysis was used to estimate
the probability of survival, and log-rank test
was used to compare the survival dierences.
Potential
prognostic
factors
(including age, pathological type, clinical
stage, tumour dierentiation, vessel invasion, deep myometrial invasion, lymph node
metastasis, preoperative chemotherapy and
ALDH1 immunopositivity) were analysed
by multivariate Cox proportional hazards
regression models and expressed as relative
risk (RR) with 95% condence intervals
(CI). Statistical analyses were performed
using SPSS version 13.0 (SPSS Inc.,
Chicago, IL, USA) for Windows .
P-values <0.05 were considered statistically
signicant.

Results
The study included tumour tissue samples
from 198 patients with cervical cancer (mean
age 44.6  8.7 years, age range 2467 years).
Patients were diagnosed with invasive squamous carcinoma (n 155) or adenocarcinoma (n 43). A total of 112 patients had
undergone no preoperative radiotherapy or
chemotherapy, four had undergone preoperative radiotherapy and 82 had received
preoperative chemotherapy. Tumours were
stage IB-1 (n 53), stage IB-2 (n 82), stage
IIA (n 49) and stage IIB (n 14). A total

of 28 patients were lost to follow-up (followup rate 85.9%). Mean follow-up duration
was 35.13  15.78 months (range 1177
months).
Patients with ALDH1-positive tumours
(n 31) had signicantly shorter disease-free
survival than those whose tumours were
ALDH1-negative (n 167; 41.99  0.90 vs
53.64  2.67 months; P < 0.05; Figure 1).
Lymph node metastasis (RR 5.445; 95%
CI 2.014, 14.722) and ALDH1 positivity
(RR 2.727; 95% CI 1.253, 5.914) were
associated with poor prognosis.

Discussion
In the current study of well-characterized
patients with cervical carcinoma and longterm follow-up, ALDH1 positivity was
associated with poor disease-free survival.
ALDH1 plays a role in the biological
synthesis of retinoic acid and is involved in
the early dierentiation of stem cells by
mediating the oxidation of retinol into retinoic acid.12 Retinoic acid is involved in cell
dierentiation and proliferation via binding
to the retinoic acid receptor.13
It is thought that cancer stem cells may
be the original cells in tumour metastases.14 ALDH1 is a marker for the identication of dierent types of cancer stem
cell.9,15,16 In bladder cancer, ALDH-1
levels are higher in lymph node-positive
patients than in lymph node-negative
patients,17 suggesting that ALDH-1-positive cells promote invasion and metastasis.
A clinical study indicated that breast
cancer cells also express ALDH1.18 The
prognosis of patients with breast cancer
who were ALDH1 positive was poor, and
ALDH1 positivity was closely correlated
with tumour grade, estrogen receptor/progestogen receptor status, overexpression
of the oncogene ERBB2 and formation of
cytokeratin.6,19
In conclusion, ALDH1 positivity is associated with poor prognosis in cervical

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Figure 1. KaplanMeier analysis of disease-free survival in patients with cervical carcinoma, stratified
according to the results of aldehyde dehydrogenase 1 (ALDH1) tumour immunohistochemistry (negative,
n 31; positive, n 167). P < 0.05; log-rank test.
, ALDH1 negative; , , ALDH1 positive;  miss, ALDH1 negative patients lost to follow-up; , miss,
ALDH1 positive patients lost to follow-up.

carcinoma and may be an independent

predictor of prognosis.
Declaration of conflicting interest
The authors declare that there are no conicts of
interest.

Funding
This study was supported by National Natural
Science Foundation of China (81101979 and
30872743), Doctoral Programme of Educational
Ministry
(20120171110097),
Guangdong
Province
Natural
Scientic
Grant
(S2011040004639
and
2012020010913),
Guangdong
Province
Medical
Science

Technology
Grant
(B2011088),
Yat-sen
Scholarship for Young Scientists and Program
for training project Young Scientists in Sun Yatsen University.

References
1. Shi JF, Canfell K, Lew JB, et al. The burden
of cervical cancer in China: synthesis of the
evidence. Int J Cancer 2012; 130: 641652.
2. Cuzick J, Myers O, Hunt WC et al. A
population-based evaluation of cervical
screening in the United States: 20082011.
Cancer Epidemiol Biomarkers Prev 2014 Apr
9. [Epub ahead of print].
3. Lai CH. Management of recurrent cervical
cancer. Chang Gung Med J 2004; 27: 711717.

Downloaded from imr.sagepub.com by guest on June 29, 2014

XML Template (2014)

[9.5.20145:44pm]
[15]
//blrnas3/cenpro/ApplicationFiles/Journals/SAGE/3B2/IMRJ/Vol00000/140030/APPFile/SG-IMRJ140030.3d (IMR) [PREPRINTER stage]

Yao et al.

4. Sankaranarayanan R and Ferlay J.

Worldwide burden of gynaecological cancer:
the size of the problem. Best Pract Res Clin
Obstet Gynaecol 2006; 20: 207225.
5. Croker AK and Allan AL. Cancer stem cells:
implications for the progression and treatment of metastatic disease. J Cell Mol Med
2008; 12: 374390.
6. Ginestier C, Hur MH, Charafe-Jauffret E,
et al. ALDH1 is a marker of normal and
malignant human mammary stem cells and a
predictor of poor clinical outcome. Cell Stem
Cell 2007; 1: 555567.
7. Ma S, Chan KW, Lee TK, et al. Aldehyde
dehydrogenase discriminates the CD133
liver cancer stem cell populations. Mol
Cancer Res 2008; 6: 11461153.
8. Huang EH, Hynes MJ, Zhang T, et al.
Aldehyde dehydrogenase 1 is a marker for
normal and malignant human colonic stem
cells (SC) and tracks SC overpopulation
during colon tumorigenesis. Cancer Res
2009; 69: 33823389.
9. Jiang F, Qiu Q, Khanna A, et al. Aldehyde
dehydrogenase 1 is a tumor stem cell-associated marker in lung cancer. Mol Cancer
Res 2009; 7: 330338.
10. Yao T, Chen Q, Zhang B, et al. The expression of ALDH1 in cervical carcinoma. Med
Sci Monit 2011; 17: HY21HY26.
11. Serour GI. A vision for FIGO 20092012. Int
J Gynaecol Obstet 2010; 108: 9396.
12. Lohberger B, Rinner B, Stuendl N, et al.
Aldehyde dehydrogenase 1, a potential
marker for cancer stem cells in human sarcoma. PLoS One 2012; 7: e43664.
13. Li J, Feng ZC, Yeung FS, et al. Aldehyde
dehydrogenase 1 activity in the developing

14.

15.

16.

17.

18.

19.

human pancreas modulates retinoic acid

signalling in mediating islet differentiation
and survival. Diabetologia 2014; 57: 754764.
Li F, Tiede B, Massague J, et al. Beyond
tumorigenesis: cancer stem cells in metastasis. Cell Res 2007; 17: 314.
Chen YC, Chen YW, Hsu HS, et al.
Aldehyde dehydrogenase 1 is a putative
marker for cancer stem cells in head and neck
squamous cancer. Biochem Biophys Res
Commun 2009; 385: 307313.
Ran D, Schubert M, Pietsch L, et al.
Aldehyde dehydrogenase activity among
primary leukemia cells is associated with
stem cell features and correlates with adverse
clinical outcomes. Exp Hematol 2009; 37:
14231434.
Su Y, Qiu Q, Zhang X, et al. Aldehyde
dehydrogenase 1 A1-positive cell population
is enriched in tumor-initiating cells and
associated with progression of bladder
cancer. Cancer Epidemiol Biomarkers Prev
2010; 19: 327337.
Neumeister V, Agarwal S, Bordeaux J, et al.
In situ identification of putative cancer stem
cells by multiplexing ALDH1, CD44, and
cytokeratin identifies breast cancer patients
with poor prognosis. Am J Pathol 2010; 176:
21312138.
Tanei T, Morimoto K, Shimazu K, et al.
Association of breast cancer stem cells
identified by aldehyde dehydrogenase 1
expression with resistance to sequential
Paclitaxel and epirubicin-based chemotherapy for breast cancers. Clin Cancer Res 2009;
15: 42344241.

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