Aberrant Cdx2 expression in endometrial lesions with squamous differentiation: important role of Cdx2 in squamous morula formation

SummaryOnly a few reports have described Cdx2 expression in endometrial lesions of the uterus. Our aim was to determine whether Cdx2 expression is related to squamous differentiation in endometrial lesions. Furthermore, we examined whether there is any correlation between Cdx2 and β-catenin, a well-known marker of aberrant nuclear accumulation in endometrial squamous foci secondary to mutation. We performed immunohistochemical analysis of 225 cases (29 normal endometrium, 28 nonproliferative conditions, 21 polyps, 46 hyperplasias, and 101 endometrioid carcinomas) that included 72 cases (4 polyps, 16 hyperplasias, and 52 carcinomas) showing morular or keratinizing squamous differentiation (SD+). Normal endometrium and nonproliferative conditions showed no staining for Cdx2. Whereas there was a low rate of Cdx2 positivity in SD− polyps (5.9%) and hyperplasias (10%), all SD+ lesions expressed Cdx2 (P < .001). Thirty-eight (73%) of the SD+ carcinomas were positive for Cdx2, whereas only 6 SD− cases (14.0%) were positive (P < .001). Furthermore, the larger the number of squamous foci, the greater the number of Cdx2-positive cells that was found. The labeling indices of Cdx2 were significantly higher in morular components than in keratinizing or glandular ones (P < .001). There was a strong correlation of the labeling indices of Cdx2 and β-catenin in squamous foci of hyperplasias and carcinomas. Using immunofluorescence, we confirmed the coexpression of the 2 markers. The Cdx2 protein is expressed frequently in endometrial lesions with squamous differentiation, especially morular-type differentiation, and correlates strongly with nuclear β-catenin expression. These facts suggest that Cdx2 plays an important role in squamous morula formation.