668?The?Journal?of?Clinical?Investigation? ? ? http://www.jci.org? ? ? Volume 120? ? ? Number 3? ? ? March 2010
CD99 inhibits neural differentiation
of human Ewing sarcoma cells and thereby
contributes to oncogenesis
Anna Rocchi,1 Maria Cristina Manara,1 Marika Sciandra,1 Diana Zambelli,1 Filippo Nardi,1
Giordano Nicoletti,1 Cecilia Garofalo,1 Stefania Meschini,2 Annalisa Astolfi,3 Mario P. Colombo,4
Stephen L. Lessnick,5 Piero Picci,1 and Katia Scotlandi1
1Laboratory of Experimental Oncology, CRS Development of Biomolecular Therapies, SSN Emilia Romagna Istituti Ortopedici Rizzoli IRCCS, Bologna, Italy.
2Department of Technology and Health, Italian National Institute of Health, Rome, Italy. 3Centro Interdipartimentale di Ricerche sul Cancro “G. Prodi,”
Università di Bologna, Italy. 4Molecular Immunology Division, Department of Experimental Oncology, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy.
5Center for Children’s Cancer Resarch, Huntsman Cancer Institute, and Division of Pediatric Hematology/Oncology, University of Utah, Salt Lake City.
Ewing sarcoma (EWS) is the second most common bone tumor
of children and young adults (1). These tumors are very aggressive
and require either surgery and/or radiation therapy for control
of the primary tumor site, along with intensive chemotherapy to
treat micrometastatic deposits. These treatments are associated
with significant short- and long-term side effects. New therapeutic
approaches are likely to come from an improved understanding of
the molecular basis of this tumor.
EWSs have a “small round blue cell tumor” histologic phenotype
that is characterized by predominantly undifferentiated sheets of
cells with relatively little stroma (1). This lack of differentiation
has led to difficulty in understanding the tumor cell of origin. In
some cases, however, EWSs have evidence of limited neural differ-
entiation, including Homer-Wright rosettes, neural processes, neu-
rosecretory granules, and neural immunohistochemical markers
(2–6). This phenotype has suggested that EWSs may arise from the
neural crest. Recently, a number of investigators have suggested
that the tumor has a mesenchymal stem cell origin (7–11).
EWS is characterized by the presence of recurrent chromosomal
translocations that fuse the EWSR1 gene (encoding the EWS pro-
tein) on chromosome 22 with various ETS genes (12). The most
common fusion, EWS/FLI, is present in 85% of cases, with other
fusions accounting for the remaining cases (13). In each case, the
DNA-binding domain of the ETS factor and a transcriptional
activation domain contributed by EWS are retained, supporting
experimental data suggesting that EWS/FLI functions as an aber-
rant transcription factor (14, 15).
The effects of EWS/FLI expression are strongly dependent on
cellular background (reviewed in ref. 16). For example, EWS/FLI
transforms immortalized murine NIH3T3 fibroblasts and is
required for the oncogenic phenotype of patient-derived EWS cells
(14, 17). Conversely, introduction of EWS/FLI into primary human
or murine fibroblasts leads to growth arrest or cell death, respec-
tively (18, 19). In other contexts, EWS/FLI expression induces
transdifferentiation and thus induces cells to exhibit a neural phe-
notype (20–22). These data suggest that oncogenic transforma-
tion by EWS/FLI requires a permissive cellular background. The
critical factors in the permissive background are largely unknown
but may include disruption of the p53 and RB pathways and the
presence of an intact IGF pathway (18, 19, 23). Furthermore, these
studies suggest that EWS/FLI itself may induce the neural pheno-
type of EWS, rather than the phenotype resulting from the cell of
origin of the tumor.
While assays for EWS/FLI expression are becoming widely used
as a molecular diagnostic approach for EWS, the most commonly
used diagnostic marker is CD99 (1). CD99 (also known as MIC2,
and recognized by antibodies 12E7, HBA71, and O13) is a 32-kDa
integral membrane glycoprotein that is highly expressed in most
cases of EWS (24). CD99 has a key role in several biological pro-
cesses, including cell adhesion, migration, and apoptosis; differ-
entiation of T cells and thymocytes; diapedesis of lymphocytes to
inflamed vascular endothelium; maintenance of cellular morphol-
ogy; and regulation of intracellular membrane protein trafficking
(25–30). While the expression of CD99 is high in EWS, and in some
Conflict?of?interest: The authors have declared that no conflict of interest exists.
Citation?for?this?article: J Clin Invest. 2010;120(3):668–680. doi:10.1172/JCI36667.
? The?Journal?of?Clinical?Investigation http://www.jci.org Volume 120 Number 3 March 2010
cases of rhabdomyosarcoma, mesenchymal chondrosarcoma, and
T-lineage leukemias and lymphomas, in other tumors, such as
osteosarcoma and Hodgkin lymphoma, CD99 is expressed at low
levels and may function as a tumor suppressor (24, 31–38).
In EWS, engagement of CD99 with antibodies results in apopto-
sis and enhances sensitivity to chemotherapeutic agents (39, 40).
However, the normal function of CD99 in EWS is unknown. In
this study, we found that CD99 is required for EWS transforma-
tion. Reduction of CD99 expression in patient-derived EWS cells
abrogated oncogenic transformation and induced cells toward
a neural differentiation phenotype. Interestingly, we found that
CD99 is normally expressed on the surface of human mesenchymal
stem cells, which have been recently suggested to be the EWS cell
of origin, indicating that CD99 is a key component of the cellular
context that allows ongoing EWS/FLI expression without growth
arrest or cell death. Furthermore, gene expression profiling studies
identified a CD99 signature that contributed to previously report-
ed EWS/FLI signatures and supported the hypothesis that CD99
affects differentiation and malignancy of EWS cells. These data
define a new role for CD99 as an inhibitor of neuronal differentia-
tion and suggest that blockade of basal CD99 function may be a
new therapeutic approach for EWS.
CD99 contributes to cell proliferation, migration, and metastasis of EWS
cells and inhibits their neural differentiation. To define the role of CD99
expression in EWS, we took a loss-of-function approach.
Plasmids expressing either an shRNA targeting the 3ʹ untrans-
lated region (UTR) of CD99 (called CD99-shRNA) or a scram-
bled shRNA control (CTR-shRNA) were used to generate
stable transfectants of TC-71 and IOR/BRZ patient-derived
EWS cell lines. Efficient knockdown of CD99 was confirmed
at the RNA level (data not shown) and at the protein level
using Western blot analysis and flow cytometry (Figure 1, A
and B). In addition, to verify that the biological effects were
dependent on diminished CD99 expression, and to exclude
off-target or other nonspecific effects, we performed “knock-
down/rescue” experiments. TC-71 and IOR/BRZ cells express-
ing the CD99-shRNA construct were transfected with a CD99
cDNA that did not contain the endogenous 3ʹ UTR and was
thus resistant to the RNAi effect (Figure 1C). We found that
cells with reduced expression of CD99 showed a concomitant
reduction in both monolayer and anchorage-independent
growth (Figure 2, A and B) and reduced cell motility (Fig-
ure 2C). Additionally, these cells demonstrated an increase
in adhesion to extracellular matrix components, including
collagen I and IV (Figure 2D). The magnitude of the effects
correlated with the level of CD99, with TC-71 exhibiting the
strongest effects and IOR/BRZ showing a more modest effect.
The reexpression of CD99 in silenced clones (Figure 1C) com-
pletely rescued growth and migratory capacities to the same level
as in the parental cell lines (Figure 2, A–C). Nearly identical results
were obtained using 3 additional siRNA constructs in a transient
transfection assay, in which EWS cells demonstrated reduced cell
motility and increased cell adhesion to collagen I and IV (Supple-
mental Figure 1; supplemental material available online with this
article; doi:10.1172/JCI36667DS1). These effects were not simply
due to global changes in cellular membrane protein content, as
the expression levels of integrins β1 and αVβ3 and several growth
factor receptors were unchanged in response to CD99 knockdown
(data not shown).
To determine the effects of CD99 knockdown in vivo, we per-
formed mouse xenograft experiments (Table 1). Reduction of
CD99 expression in either TC-71 or IOR/BRZ EWS cells with the
CD99-shRNA construct resulted in a reduction in local tumor
growth, as measured by an increased time to tumor development
and a reduction in tumor size. Furthermore, the development of
bone metastasis was also significantly reduced. Both tumorigenic-
ity and metastasis ability of EWS cells were regained when CD99
was reexpressed. Taken together, these data demonstrate that
ongoing CD99 expression is required for the oncogenic phenotype
of EWS cells in vitro and in vivo.
The cell growth inhibition induced by CD99 knockdown was due
to a block at the G2/M phase of cell cycle (Figure 3A) and increased
apoptosis (Figure 3B). In fact, the analysis of some cell cycle regu-
lators and apoptosis mediators indicated an upregulation of p21
Silencing of CD99 by shRNA plasmid. (A) Stable transfection of
TC-71 and IOR/BRZ cells with CD99-shRNA plasmid results in
a substantial reduction in CD99 protein levels as determined by
Western blotting. GAPDH is shown as loading control. (B) CD99
expression in derived TC-71 and IOR/BRZ clones by cytofluorom-
etry. (C) Reexpression of CD99 in knockdown/rescue cells visual-
ized by Western blotting. GAPDH is shown as loading control.
670? The?Journal?of?Clinical?Investigation http://www.jci.org Volume 120 Number 3 March 2010
or p27, two molecular effectors that participate in the G1 and G2
checkpoints causing cell arrest (41), as well as a downregulation of
the antiapoptotic protein Bcl-2 in cells deprived of CD99 (Figure
3C). No differences were observed with respect to expression of
cyclins and cyclin-dependent kinases (CDKs). However, this was
expected, since most of these genes are downstream targets of
EWS/FLI, which is present on the CD99-knockdown cells (data
not shown). Upregulation of p21 or p27 is reported to be sufficient
to compensate cyclin D1 activity, thus allowing cell arrest (42).
Increased expression of p21 is independent of p53 activity in these
In vitro growth features of EWS cells silenced for CD99. (A) CD99-silenced cells showed reduced growth in monolayer conditions compared
with controls. Reexpression of CD99 rescued the growth inhibition caused by CD99 knockdown in TC-71 and IOR/BRZ cells. Data are pre-
sented as mean ± SEM of experiments performed in triplicate. Absorbance was measured at a wavelength of 550 nm. *P < 0.05, Student’s t test
with respect to parental and CD99-reexpressing cells. (B) CD99-silenced cells showed reduced growth in anchorage-independent conditions.
Reexpression of CD99 rescued the growth inhibition. Data are presented as mean ± SEM of experiments performed in triplicate. *P < 0.05,
**P < 0.001, Student’s t test versus parental and CD99-reexpressing cells. Representative photomicrographs are shown for TC-71–derived cells.
Digital images were taken under identical conditions at the same time. Scale bars: 600 μm. (C) Migratory ability of CD99-silenced cells was
significantly reduced compared with that of controls. Reexpression of CD99 rescued the migration deficit caused by CD99 knockdown in TC-71
and IOR/BRZ cells. Data are presented as mean ± SEM of experiments performed in triplicate and indicate the number of cells that migrated
12 hours after cell seeding. **P < 0.001, Student’s t test versus parental and CD99-reexpressing cells. (D) Cell adhesion tests to extracellular
matrix components demonstrate that CD99-deprived cells adhere faster to collagen I and IV. Data are presented as mean ± SEM of experiments
performed in triplicate. *P < 0.05 versus parental and CD9-reexpressing cells, Student’s t test.
? The?Journal?of?Clinical?Investigation http://www.jci.org Volume 120 Number 3 March 2010
cells, since both the 2 parental cell lines (TC-71 and IOR/BRZ) have
truncated and inactive forms of p53 (data not shown). In addition,
the increased expression of p21 and p27 in CD99-deprived cells
was observed despite the presence of EWS/FLI, which was reported
to attenuate p21 and/or p27 expression levels (41, 43, 44), and may
be due to inhibition of PI3K/Akt pathway (Figure 3C), which is
known to negatively regulate these 2 cell cycle inhibitors (45).
Not only are both p21 and p27 necessary to restrain cell cycle
progression, but they may also exert positive or negative effects
on apoptosis, cell movement, and differentiation (41) through
a complex and still not entirely understood network of molecu-
lar mechanisms. Here we found that introduction of the CD99-
shRNA construct induced a phenotype consistent with neural
differentiation. Reduction of CD99 expression resulted in neurite
outgrowth and increased expression of β-III tubulin and H-neuro-
filament (H-NF), a late and very specific marker of neuronal differ-
entiation (7–11, 46) (Figure
4, A and B). Neurofilaments
are composed of 3 groups
of microheterogeneous sub-
units with molecular mass-
es of 65 kDa (L-NF), 160
kDa (M-NF), and 200 kDa
(H-NF). L-NF and M-NF
are expressed at early stages
of neuronal development,
while H-NF is expressed
later in the terminal phase.
Exposure of cells to nerve
growth factor (NGF; 20
ng/ml) or low-serum medi-
um (1% Iscove’s modified
Dulbecco’s medium [IMDM]) for 72 hours induced high expres-
sion of H-NF in cells with reduced expression of CD99 but not
in parental cells (Figure 4C), further sustaining the association
between CD99 expression and neural differentiation. Quantita-
tive analysis of neurite outgrowth showed modulation of neu-
ritis number according to the expression of CD99. A significant
increase in cells with long cytoplasmic extensions was observed
in cells silenced for CD99 (40 of 282, 14% in TC-71 vs. 123 of 290,
42% in TC-CD99-shRNA#1; P < 0.001, χ2 test). Reexpression of
CD99 reversed the morphologic changes (number of neurites: 50
of 294, 17% in TC-CD99-shRNA#1-CD99 cells) and expression of
H-NF or β-III tubulin back to baseline, again demonstrating that
this was not due to off-target or other nonspecific effects (Figure
4A). A similar trend was observed for IOR/BRZ cells: the percent-
age of cells that stained for H-NF increased from 32% in control to
90% in BRZ-CD99-shRNA#1 cells. Transient downregulation of
Tumorigenicity and metastasis of CD99-silenced cells
16 ± 2
28 ± 4
45 ± 14
15 ± 2
19 ± 3
31 ± 6
50 ± 0
75 ± 4
60 ± 5
59 ± 9
2.09 ± 0.6
1.87 ± 0.8
0.04 ± 0.02A
3.23 ± 1.52
3.17 ± 0.9
0.37 ± 0.2A
AP < 0.01, Student’s t test, compared with controls. Volume was measured when the first control mice were sacrificed due
to maximum tumor volume achievement. Latency and volume values are shown as mean ± SEM. nd, not determined.
CD99 influences cell proliferation and apoptosis of EWS cells. (A) Cell cycle analysis of TC-71–derived cells. Cells were stained with propidium
iodide (a DNA stain) and DNA content analyzed by ModFit LT software. Data are from an experiment representative of 2 independent experi-
ments. Percentages of cells in G2/M phase were significantly different in CD99-silenced cells compared with controls; P < 0.05, Student’s t test.
(B) Detection of annexin V–FITC–labeled apoptotic cells by flow cytometric analysis in TC-71–derived cells. The simultaneous application of
propidium iodide as a DNA stain allows the discrimination of necrotic cells (upper right) from the apoptotic cells positively stained for annexin V
(lower right). Data are from an experiment representative of 2 independent experiments. Percentages of apoptotic cells (annexin V–positive and
propidium iodide–negative) were significantly different in CD99-silenced cells compared with controls; P < 0.05, Student’s t test. (C) Western blot
analysis of a series of cell cycle and apoptosis regulators. Induction of the cell cycle inhibitors p21 or p27 was observed together with repression
of the antiapoptotic protein Bcl-2. The phosphorylation of Akt was also inhibited in CD99-silenced cells.
672? The?Journal?of?Clinical?Investigation http://www.jci.org Volume 120 Number 3 March 2010
? The?Journal?of?Clinical?Investigation http://www.jci.org Volume 120 Number 3 March 2010
p21 in TC-CD99-shRNA#2 cells was associated with a decrease in
H-NF expression (Figure 4B), thus indicating in p21 one possible
functional connector between CD99-induced cell cycle inhibition
and neural differentiation. Indeed, in specific cellular systems, p21
has been reported to have a role in the process of commitment
to terminal differentiation (47). To assess the relationship among
CD99 expression, transformation, and neural differentiation more
broadly in EWS, we analyzed a panel of patient-derived EWS cells
for CD99 and H-NF expression (Table 2). We found an inverse cor-
relation between CD99 and H-NF expression (Pearson correlation
test, r = –0.93; P = 0.0003) and a positive association between CD99
and oncogenic transformation (Pearson correlation test, r = 0.85;
P = 0.005 with respect to soft agar). There was also an inverse corre-
lation between neural differentiation (as measured by H-NF expres-
sion) and oncogenic transformation in vitro and in vivo (Pearson
correlation test, r = –0.82; P = 0.04,
with respect to soft agar growth).
A further confirmation comes
from the EWS cell line 6647. By
continuous exposure of 6647 cells
to the anti-CD99 mAb 0662 (40),
we obtained a cell variant with
stable downregulation of CD99
(Table 2). This cell variant, here
named 6647/CD99low, displayed
significantly increased expres-
sion of H-NF (P = 0.03, Student’s
t test) and reduced soft agar growth
(P = 0.001, Student’s t test). These
data suggest that CD99 contrib-
utes to oncogenic transformation
by preventing terminal neural dif-
ferentiation of EWS cells.
To determine whether these
results were specific to EWS cells
or were more generalized, we analyzed the relationship between
CD99 and neural differentiation in human mesenchymal stem
cells (MSCs). MSCs have recently been proposed to be the cell of
origin of EWS (7–11). We first confirmed that our preparation of
human bone marrow–derived MSCs expressed cell surface mark-
ers that have been previously reported for this cell type, including
CD166, CD105, and CD29 (48–50) (Supplemental Figure 2A). As
expected, these cells did not express the hematopoietic markers
CD45 and CD34. We found that MSCs expressed CD99 at levels
comparable to those found on patient-derived 6647 EWS cells.
Seven additional independent preparations of MSCs demonstrated
moderate to high levels of CD99 expression (data not shown).
These data suggest that the putative EWS cell of origin has an
appropriate cellular background to tolerate EWS/FLI expression
without undergoing terminal differentiation.
We next assessed the levels of CD99 under differentiating condi-
tions. MSCs can be induced to differentiate toward various lin-
eages, including osteocytes, chondrocytes, and adipocytes (49, 50).
MSCs can also be induced to differentiate toward a neural phe-
notype under specific conditions (51, 52). We found that under
osteoblastic differentiating conditions, MSCs retained basal lev-
els of CD99 protein expression (Supplemental Figure 2B). How-
ever, CD99 expression was significantly reduced when MSCs were
induced to undergo neural differentiation (Figure 4E). These data
suggest that neural differentiation cannot proceed without down-
regulation of CD99 levels.
We also confirmed a functional role for CD99 in a recently
described murine model of EWS (53, 54). Because there is no well-
defined CD99 allele in the mouse genome (54), this system allows
for an analysis of CD99 activity in the absence of endogenous
CD99 expression. The C3H10T1/2 murine mesenchymal multipo-
tent cell line loses its ability to differentiate down osteoblastic and
adipocytic lineages following EWS/FLI transfection but instead
acquires a neural phenotype and tumorigenic properties (53).
Introduction of the CD99 cDNA into this model system (Fig-
ure 5A) repressed features of neural differentiation, as shown by
reduced expression of β-III tubulin and H-NF (Figure 5B). Fur-
thermore, CD99 expression increased both cell motility (Figure
5C) and soft agar colony formation (Figure 5D). In vivo, CD99
expression increased tumor growth. The C3H10T1/2-CD99 cells
CD99 influences neural differentiation in EWS and human MSCs. (A)
H-NF and β-III tubulin expression in CD99-silenced cells that were
maintained in standard culture conditions. Neural differentiation was
reversed when CD99 was reexpressed in knockdown/rescue cells.
Representative photomicrographs are shown for TC-71–derived cells.
Scale bars: 120 μm. (B) Western blot analysis of H-NF and β-III tubulin
expression in CD99-silenced cells that were maintained in standard
culture conditions. Expression of H-NF was observed only in CD99-
deprived cells, while β-III tubulin expression was induced. (C) West-
ern blot analysis of H-NF TC-71 and TC-CD99-shRNA#1 cells after
exposure to low-serum medium (1% IMDM) or NGF (20 ng/ml) for 72
hours. Again, expression of H-NF was observed only in CD99-silenced
cells. (D) Downregulation of p21 in TC-CD99-shRNA#2 by transient
silencing of the molecule, as detected by Western blotting, resulted
in inhibition of the neural differentiation, as shown by H-NF expres-
sion. Cells were exposed to shRNA against p21 for 24 hours and then
evaluated for H-NF expression. Representative photomicrographs are
shown for TC-71–derived cells. Scale bars: 120 μm. (E) MSCs were
cultured in neural differentiation medium, and terminal differentiation
was monitored by H-NF and β-III tubulin staining that visualized neural
development. The expression of CD99 is lost during neural develop-
ment, as shown by avidin-biotin immunostaining. All digital images
were taken under identical conditions, at the same time, and using the
same image analysis software (Quips-XL genetic workstation). Scale
bars: 600 μm; enlarged sections, 300 μm.
Relationship among level of CD99 expression, neural differentiation, and malignancy in a panel
of EWS cell lines
132.5 ± 18.7
113.5 ± 16.3
102 ± 12.0
97.2 ± 20
57.5 ± 10.3
42.2 ± 1.7
51.6 ± 8.7
54.2 ± 4.6
49.6 ± 4.6
17.9 ± 8.6B
10.1 ± 4.3
27.6 ± 3.1
21 ± 3.1
52.6 ± 13.2
56.6 ± 15.0
68.7 ± 11.0
54 ± 2.6
53 ± 5.2B
1663.8 ± 52.7A
1463.1 ± 22.8
908.6 ± 41.9
800 ± 87
768.9 ± 64.5
562.3 ± 73.2
12.0 ± 3.0
51.5 ± 16.7
614 ± 39A
7.0 ± 0
13.0 ± 2.0
18.0 ± 2.5
20.2 ± 6
Values are shown as mean ± SEM. AP = 0.001, Student’s t test, 6647 versus 6647/CD99low. BP = 0.03; Pear-
son correlation test indicated significant associations of CD99 with H-NF expression (inverse correlation) as
well as with malignancy (positive correlation) (see Results for details).
674? The?Journal?of?Clinical?Investigation http://www.jci.org Volume 120 Number 3 March 2010
gave rise to tumors in all of the animals, compared with 50% of
mice when the parental cells were injected, and the tumor growth
rate was significantly increased (Figure 5E). Taken together, these
data suggest that CD99 blocks neural differentiation in multiple
cell types and contributes to the oncogenic phenotype of EWS.
Expression profiling of CD99 in EWS identifies MAPK pathway modula-
tion. To determine the molecular basis for CD99 function in EWS,
we analyzed the gene expression profile of EWS cells expressing the
CD99-shRNA construct and compared it with that of cells express-
ing a control construct using Agilent G4110B oligonucleotide
microarrays. We identified the pathways differentially expressed
in CD99-shRNA cells with respect to control by a functional class
scoring analysis (see Supplemental Methods) applied to gene
lists selected in a blinded manner on TC-71 and IOR/BRZ cells
(Supplemental Table 1). Analysis of the most silenced TC-71 cells
confirmed the role of CD99 on differentiation and transforma-
tion. Analysis using Kyoto Encyclopedia of Genes and Genomes
(KEGG) annotations identified a number of pathways that were
significantly modulated by CD99 (P < 0.05) (Table 3). The most
differentially regulated pathway was neuroactive ligand receptor
interaction. The hedgehog signaling pathway, which is associated
with neuronal differentiation in the central nervous system, was
also modulated, as were pathways involved in oncogenic transfor-
mation, such as adhesion, metabolism, and signaling. Clustering
analysis also indicated that among the 30 most deregulated genes
(P < 0.05, log ratio >2 or <0.5), 19 (63%) are expressed in and/or
functionally connected with nervous system development (listed
in bold in Supplemental Figure 3A; Supplemental Table 2). To gain
new insights into functional mechanisms underlying the CD99-
mediated phenotype, we considered together the genetic profiles
of TC-71 and IOR/BRZ cells (Supplemental Table 3). KEGG and
BioCarta pathway analysis revealed that the expression level of
genes involved in the MAPK pathway are significantly altered in
CD99-silenced cells (Supplemental Figure 3B). This was of interest
because the MAPK pathway is known to be involved in neuronal
development and differentiation (55–59). Furthermore, while tran-
Analysis of CD99 activity in the absence
of endogenous CD99 expression.
(A) Induction of CD99 expression in
a murine model of EWS. The murine
mesenchymal multipotent C3H10T1/2
cell line was transfected with EWS/FLI1
(C3H10T1/2 EF) (53) and with CD99
(C3H10T1/2 EF-CD99). (B) CD99
expression repressed neural differen-
tiation, as shown by β-III tubulin and
H-NF immunostaining. Digital images
were taken under identical condi-
tions, at the same time and using the
same image analysis software (Quips-
XL genetic workstation). Scale bars:
120 μm. (C) Expression of CD99 in
C3H10T1/2 EF increased cell migration.
Data are presented as mean ± SEM of
experiments performed in triplicate.
**P < 0.001, Student’s t test. (D) Expres-
sion of CD99 in C3H10T1/2 EF increased
colony formation in soft agar. Mean val-
ues and standard errors obtained for
triplicate experiments are indicated.
**P < 0.001, Student’s t test. (E) In vivo
tumor growth of C3H10T1/2 EF com-
pared with C3H10T1/2 EF cells express-
ing CD99. CD99 clearly enhances tumor
? The?Journal?of?Clinical?Investigation http://www.jci.org Volume 120 Number 3 March 2010
sient activation of the MAPK pathway induces cellular proliferation
of PC12 cells, prolonged activation promotes neural differentiation
of these cells (60). We therefore asked whether the MAPK pathway
might be involved in the neural differentiation blockade mediated
by CD99. We observed an increase in ERK1/2 activation in CD99-
silenced cells by cytofluorometric analysis (Figure 6A), ELISA cell-
based tests (Figure 6B), and Western blotting (Figure 6C). Confocal
microscopy confirmed that knockdown of CD99 led to an increase
in levels of phosphorylated ERK1/2 (Figure 6D), which was par-
ticularly evident in the nucleus (Supplemental Figure 3C), whereas
total ERK1/2 protein was distributed uniformly throughout the
cytoplasm and nucleus. We next used the ERK inhibitor PD98059
to determine the functional consequences of MAPK pathway activ-
ity (Supplemental Figure 3D). In parental TC-71 cells, PD98059
treatment resulted in diminished proliferation (Figure 6E), as
expected. In TC-71 cells containing the CD99-shRNA construct,
however, PD98059 did not prevent the observed growth inhibition
but prevented the neural differentiation induced by CD99 knock-
down (Figure 6, E and F). Both H-NF and β-III tubulin staining
were in fact reversed by 48-hour treatment with PD98059. These
effects were reversed when expression of CD99 was regained (data
not shown). These data suggest that CD99 prevents neural differ-
entiation of EWS via a MAPK-dependent pathway.
CD99 and EWS/FLI interact in sustaining the EWS phenotype. Both
EWS/FLI and CD99 are required for the oncogenic phenotype of
EWS. We first considered the epistatic relationship between EWS/
FLI and CD99 using gene expression profiling data. We reasoned
that if one protein alters the expression of the other, then there
will be significant similarities in their gene expression profiles. We
used the CD99 signature that included 106 genes (76 upregulated
and 30 downregulated in both TC-71 and IOR/BRZ CD99-silenced
cells; Figure 7A and Supplemental Table 3) and compared that with
Affymetrix microarray platform gene expression data for EWS/FLI
generated by RNAi experiments in SK-N-MC and EW-24 cells
(10) and in EWS502 and TC-71 cells (61). Genes were mapped to
their UniGene identifiers to allow for comparison across different
microarray platforms. The EWS/FLI knockdown datasets were first
limited to those genes that represent the CD99 expression signa-
ture and subsequently used to perform Spearman correlation tests
(P = 0.02, r = 0.23), principal component analysis (PCA) (Figure 7B),
and hierarchical clustering (Supplemental Figure 4A). Using these
approaches, we found that the CD99 signature allowed for a clear
separation of EWS/FLI knockdown cells from controls, suggesting
that the CD99 signature overlaps with the EWS/FLI signature.
Previous studies have suggested that EWS/FLI induces a neural
phenotype in a variety of cellular contexts (20–22). Interestingly,
in some studies, EWS/FLI also induces CD99 expression (18, 20,
62). While regulation of CD99 by EWS/FLI was not reported in
EWS cells that were treated with RNAi against the fusion protein
(17, 63), inspection of the raw data from one of these studies (17)
demonstrated that knockdown of EWS/FLI resulted in a modest
decrease in CD99 expression (data not shown). Here we provide
evidence that CD99 is a putative target of EWS/FLI1. A ChIP assay
was performed in TC71 and IOR/BRZ EWS cell lines, and we
found that EWS/FLI1 was associated to CD99 promoter (Figure
7C). Taken together, these data suggest that CD99 is regulated by
EWS/FLI and thus contributes to the oncogenic phenotype medi-
ated by the fusion.
EWS has served as a paradigm for translocation-associated tumors
because it is highly associated with the expression of the EWS/FLI
(and other EWS/ETS) translocation oncoproteins. In this regard,
it has been thought that understanding the function of EWS/FLI
would be the key to understanding the process of oncogenesis for
this unusual tumor, which may then provide a new understanding
for oncogenic pathways in general. It has become clear in recent
years, however, that EWS/FLI is not the whole story in EWS and
that studying both downstream and parallel pathways will be
required for a full comprehension of oncogenesis in this tumor.
Cell surface expression of CD99 is a very consistent feature of
EWS (24, 31, 34). Indeed, CD99 is currently considered to be one
of the best diagnostic immunohistochemical markers for this dis-
ease (1). In this report, we demonstrate that CD99 expression is
critical for the oncogenic phenotype of EWS. We provide evidence
that modulations in the expression levels of CD99 significantly
Significant variations in TC-CD99-shRNA cells compared with controls for KEGG pathways according to the gene set comparison toolA
Neuroactive ligand-receptor interaction
Regulation of autophagy
Metabolism of xenobiotics by cytochrome P450
Hedgehog signaling pathway
Androgen and estrogen metabolism
Fatty acid metabolism
1- and 2-methylnaphthalene degradation
AThe gene set comparison tool analyzes predefined gene sets (based on Gene Ontology categories, BioCarta pathways, KEGG pathways) for differential
expression among predefined classes. KS, Kolmogorov-Smirnov; LS, Fisher least-significant difference statistic, defined as the mean negative natural
logarithm of the P values of the appropriate single-gene univariate tests.
676? The?Journal?of?Clinical?Investigation http://www.jci.org Volume 120 Number 3 March 2010
modify cell growth in anchorage-independent conditions and
also cell migration, tumorigenesis, and metastasis ability. CD99
participates in the transformed phenotype by serving to prevent
terminal differentiation of EWS cells toward a neural phenotype.
This effect is important because EWS/FLI itself appears to drive
cells toward a neurally differentiated fate.
The cell of origin of EWS remains uncertain, but emerging evi-
dence suggests that it arises from an MSC. For example, RNAi-
Insights into the mechanisms of CD99-silenced cells. (A) Increased expression of activated p-ERK in cells deprived of CD99 as shown by
cytofluorometric analysis. (B) Cell-based ELISA evaluation of activated p-ERK. Once normalized to cell number, the phosphorylation level is
directly related to the extent of activation. Cells deprived of CD99 showed a higher levels of p-ERK. Wavelength, 550 nm. Data are presented as
mean ± SEM of experiments performed in triplicate; *P < 0.05 versus controls, Student’s t test. (C) Western blot analysis of ERK and p-ERK
confirmed the higher levels of activation in CD99-silenced cells. (D) Confocal microscopy further confirmed higher expression of the activated
ERK in CD99-silenced cells compared with controls. No remarkable differences were observed between parental and transfected cells versus
total ERK. Scale bars: 120 μm. (E) Forty-eight hours of treatment of TC-71 and derived cells with the ERK inhibitor PD98059 (50 μM) resulted
in growth inhibition of the parental cells but not of the CD99-silenced cells. Data are presented as mean ± SEM of experiments performed in
triplicate. (F) H-NF and β-III tubulin staining of CD99-silenced cells after 48-hour treatment with the ERK inhibitor PD98059. ERK inactivation
inhibited expression of H-NF in CD99-silenced cells. Nuclei are counterstained with bisbenzimide Hoechst 33258. Digital images were taken
under identical conditions, at the same time, and using the same image analysis software (Quips-XL genetic workstation). Scale bars: 120 μm.
? The?Journal?of?Clinical?Investigation http://www.jci.org Volume 120 Number 3 March 2010
mediated silencing of EWS/FLI in EWS cells allows those cells to
exhibit a gene expression pattern that is similar to that of MSCs
(10). Furthermore, silencing of EWS/FLI allows EWS cells to be
differentiated toward adipocytic, chondrocytic, and osteocytic
lineages (10). Conversely, introduction of EWS/FLI into murine
MSCs blocked their ability to differentiate into osteocytic or adi-
pocytic lineages, induced markers of neural differentiation, and
resulted in oncogenic transformation (9, 11). Introduction of
EWS/FLI into human MSCs induced a gene expression pattern
that was similar to that of EWS
cells (including the expression of
NKX2.2, a neural marker that is
critical for EWS oncogenesis; ref.
17) and caused them to adopt
a more invasive phenotype in a
Matrigel invasion assay (8).
Introduction of EWS/FLI into
other nontransformed cell types
results in growth arrest (reviewed
in ref. 16). Our observation that
human MSCs express CD99 at
baseline suggests a mechanism by
which MSCs serve as a permissive
cellular environment for EWS/FLI
expression. We propose that EWS/
FLI induces cells to undergo neural
differentiation but that the basal
and possibly inducible expression
of CD99 prevents terminal differ-
entiation. The net result of these
balancing effects is a cell that exhib-
its some features of the neural phe-
notype but maintains its growth
capacity. Subsequent activation
or repression of other molecular
pathways would then be required
for these cells to express the full
oncogenic phenotype of EWS.
Previous studies showed that
CD99 was capable of eliciting
modulation of several intracellular
pathways, including PI3K/Akt and
RAS/MAPK (64, 65) We found that
CD99 knockdown inhibited Akt
while increasing ERK1/2 phos-
phorylation. The effects on PI3K/
Akt may explain the blockade of
CD99-silenced cells in G2/M cell
cycle phase and their increased
expression of the growth inhibi-
tors p21 and/or p27, since this
pathway has been shown to be
required for G2/M phase progres-
sion and to play a key role in the
stabilization of p21 and p27 (45).
The lack of p27 degradation can
be sufficient to stop RAS-induced
proliferation (55). In addition,
in normal primary cells, the RAS
pathway may contribute to induc-
tion of p53-independent p21 upregulation (55), thus contribut-
ing to cell growth inhibition. In CD99-deprived cells, however,
we found that the major role of RAS/MAPK pathway is related
to regulation of differentiation. Activation of the RAS/MAPK
pathway is well known to be involved in neural differentiation
and survival (56–59, 66). This may be related to signal duration,
as experiments in PC12 pheochromocytoma cells demonstrated
that transient activation of the pathway resulted in cellular pro-
liferation, whereas prolonged pathway activation resulted in neu-
Relationship of CD99 expression and EWS/FLI expression. (A) Hierarchical clustering of CD99-asso-
ciated signature based on TC-71 and IOR/BRZ silenced cells. The signature included 106 genes: 76
upregulated and 30 downregulated (Supplemental Table 1; t test, P < 0.05). The top 10 CD99 up- (red)
or downmodulated genes (blue) are shown. (B) We applied PCA using the CD99-associated signature
(Supplemental Table 1) on EWS/FLI1-silenced EWS cells derived from SK-M-NC and EW24 (dataset
from ref. 10) or from EWS502 and TC-71 cell lines (dataset from ref. 55). CD99 signature allowed for a
clear separation of EWS/FLI knockdown cells from controls. Circles indicate EWS/FLI1 silenced cells;
triangles indicate controls. (C) Interaction between EWS/FLI1 and CD99 promoter (prom). ChIP was
carried out in TC71 and IOR/BRZ cells as described in Supplemental Methods by using anti-Fli1 anti-
body. The CD99 promoter region containing the ets sequence was detected by PCR with specific prim-
ers listed in Supplemental Methods. One microliter of initial preparations of soluble chromatin (Input)
was amplified to control input DNA. In control samples (N), normal rabbit IgG was used instead of the
primary Ab as control of Ab specificity. The occupancy of EWS/FLI1 on the TGFβR2 promoter was
tested with specific primers as a control for ChIP reaction. The negative control promoter primers used
for ChIP were previously described (72).
678? The?Journal?of?Clinical?Investigation http://www.jci.org Volume 120 Number 3 March 2010
ral differentiation (60). In particular, prolonged nuclear ERK1/2
phosphorylation seems to be crucial for shifting the biological
functions of ERK1/2 toward neural development and differen-
tiation. It has previously been shown that EWS/FLI activates the
RAS/MAPK signaling pathway in immortalized murine fibro-
blasts (67). Our findings demonstrate that CD99 inhibits the
activation of ERK1/2. This suggests a model according to which
EWS/FLI activates, and CD99 represses, the MAPK pathway and
together they serve to fine-tune levels of pathway activation that
allow for proliferation but prevent terminal neural differentia-
tion. We demonstrate that the mechanism behind the block in
transformation mediated by CD99 relies on inhibition of RAS
signaling. This is surprising, because most tumors are thought
to rely on increased RAS activity for their proliferative capacity.
However, in some primary vertebrate cells, including neuronal,
adipocytic, and myeloid cells, RAS induces differentiation, in
some cases accompanied by growth arrest (55). Sustained activa-
tion of ERK1/2 accelerated neurite outgrowth and concomitantly
increased transcriptional activation of genes involved in the dif-
ferentiation process, such as p21 (68), expression of which was
also found to be enhanced in our neurally driven EWS cells. Thus,
our data suggest that unabated RAS signaling may drive a dif-
ferentiated phenotype under certain circumstances also in tumor
cells, challenging the classic paradigm according to which RAS is
a primary driver of oncogenic transformation (69). The fine defi-
nition of these mechanisms is clearly beyond the purposes of this
article. However, the fact that CD99 activates pathways that in
the normal context favor cell differentiation may be considered
a further confirmation of its importance in the reversal of malig-
nancy of EWS cells.
One question that remains is whether CD99 is a downstream
target of EWS/FLI. CHiP analysis in our hands supported the
hypothesis that CD99 is a direct target of EWS/FLI. However, the
data remain somewhat contradictory. On one hand, introduced
expression of EWS/FLI in some model systems, such as human
primary fibroblasts, human MSCs, and human rhabdomyosar-
comas, induces CD99 expression (8, 18, 20). On the other hand,
CD99 expression levels have not been reported to be changed in
experiments in which EWS/FLI was knocked down by RNAi in
EWS cells (17, 63). In the latter cases, CD99 expression was not
monitored explicitly, but rather was only evaluated via microarray.
Inspection of the raw microarray data from one of these studies
(17) revealed that CD99 expression was modestly reduced follow-
ing EWS/FLI knockdown in 3 of 4 experiments (S.L. Lessnick,
unpublished observations). These observations may be reconciled
by our finding that human MSCs express CD99 at baseline. If
EWS arises from MSCs, then CD99 may already be expressed at
or near a maximal level, and EWS/FLI may provide only a minor
contribution to its regulation. In other cell types that do not
normally express CD99, the contribution of exogenously intro-
duced EWS/FLI may be more significant. This may then explain
our observations of a modest overlap between the EWS/FLI and
CD99 gene expression signatures in EWS. Further work is needed
to fully evaluate this hypothesis.
In summary, we have shown that CD99 is required for the EWS
oncogenic phenotype. CD99 appears to function by blocking a ter-
minally differentiated phenotype that is induced by EWS/FLI, and
this process is dependent on changes in MAPK pathway signaling.
These data suggest a new therapeutic approach to EWS based on
modulating the differentiation of the tumor.
Isolation and differentiation of bone marrow MSCs. After receipt of informed
consent, human primary MSCs were obtained from bone marrow aspi-
rates (iliac crest) of 8 patients undergoing hip replacement surgery and
phenotyped as bone marrow MSCs by flow cytometry (negative for CD45
and CD34, positive for CD166, CD105, and CD29; dilution specified in
Supplemental Methods). MSC cultures were provided by E. Lucarelli
(Rizzoli Institute, Bologna, Italy). Osteoblastic and neural differentia-
tion of MSCs was obtained following procedures described in refs. 70
and 71, respectively.
Cell lines. EWS cell lines were grown as described previously (40).
Murine C3H10T1/2 and C3H10T1/2 cells transfected with EWS/FLI-1
(C3H10T1/2 EF) cell lines were cultured as described (53) and were pro-
vided by F. Lecanda (University of Navarra, Pamplona, Spain).
Transfection. For transient silencing of CD99 and CDKN1A, EWS cells were
transfected using Lipofectamine (Invitrogen) following the manufacturer’s
protocols. siRNA sequences are provided in Supplemental Methods.
For stable silencing, an shRNA plasmid (pSilencer 2.1-U6 Neo vector;
Ambion) expressing CD99 siRNA-1 (5ʹ-GATCCGGCTGGCCATTATTA-
created, and EWS cells were transfected using the calcium phosphate trans-
fection method. Stable transfectants expressing shRNA-CD99 (TC-CD99-
shRNA#1 and #2 or BRZ-CD99-shRNA#1 and #2) or negative controls
(TC-CTR-shRNA or BRZ-CTR-shRNA) were obtained after selection in neo-
mycin (500 μg/ml) (Sigma-Aldrich). The pcDNA3 CD99 vector, expressing
the entire CD99 open reading frame but lacking the 3ʹ UTR, and pcDNA6/
V5-His (Invitrogen), a plasmid that provides blasticidin resistance (5 μg/ml),
were cotransfected into TC-CD99-shRNA#1 and BRZ-CD99-shRNA#1 cells
using the calcium phosphate transfection method to induce reexpression
of CD99. Resistant cellular pools were isolated (TC-CD99-shRNA#1-CD99
and BRZ-CD99-shRNA#1-CD99). C3H10T1/2 EF cells were transfected
with the pcDNA3 CD99 vector or with empty vector using the calcium
phosphate transfection method. Cellular pools resistant to neomycin (500
μg/ml) were isolated (C3H10T1/2 EF CD99; C3H10T1/2 EF empty).
RNA extraction. Total RNA was extracted by the TRIzol extraction kit
(Invitrogen). Quality and quantity of RNA samples were assessed with
NanoDrop analysis (NanoDrop Technologies) and/or with an Agilent
2100 Bioanalyzer (Agilent Technologies).
Biochemical and cellular assays. Details about Western blotting, cell-based
ELISA, monolayer growth assay, motility assay, soft agar assay, ECM adhe-
sion test, cellular morphology study, and apoptosis and cell cycle analysis
are provided in Supplemental Methods.
Flow cytometry and immunostaining. Standard protocols were followed. Pro-
cedures are described in detail in Supplemental Methods. Cell cycle analy-
sis was performed by using ModFit software (Verity Software House).
Treatment with PD98059. Twenty-four hours after cell seeding, medium
was replaced by IMDM plus 10% FBS with or without (control) the MEK/
MAPK inhibitor PD98059 (50 μM) (Calbiochem). After 48 hours of treat-
ment, cell growth and expression of H-NF were assessed.
Tumorigenicity and metastasis. Female athymic 4- to 5-week-old Crl:CD-
1-nu/nu BR mice (Charles River) were used. Tumorigenicity was assessed
after s.c. inoculation of 5 × 106 cells. Metastases were determined by injec-
tion of 2 × 106 viable cells in a tail lateral vein. Animals were checked by
X-ray for the presence of bone metastases. Experiments were authorized by
the institutional review board of the University of Bologna and performed
according to Italian and European guidelines.
Microarray analysis. Experimental models were profiled by using 1A (V2)
Oligo Microarray G4110B slides (Agilent Technologies). Microarray data
are available at the Gene Expression Omnibus database (http://www.ncbi.
nlm.nih.gov/geo/) with the accession number GSE10993. A complete
? The?Journal?of?Clinical?Investigation http://www.jci.org Volume 120 Number 3 March 2010
description of the microarray analysis is provided as Supplemental Meth-
ods. Hierarchical clustering using Pearson correlation and principal com-
ponent analyses was performed using MeV TM4 software (http://www.
tm4.org). The KEGG pathways were analyzed by using a FatiGOPlus pro-
BioCarta pathway analysis. Pathway analysis was performed by using Bio-
ChIP. ChIP analysis was carried out in TC71 and IOR/BRZ cells as
described in Supplemental Methods. The negative control promoter prim-
ers used for ChIP were previously described (72, 73).
Statistics. Differences among means were analyzed using 2-tailed Stu-
dent’s t test. Fisher’s exact test was used for frequency data. Kaplan-Meier
and log-rank methods were used, respectively, to draw and evaluate the
significance of survival curves in EWS patients. A P value less than 0.05
was considered significant.
We thank G. Bernard and A. Bernard of the Faculté de Médecine de
Nice, France, for scientific assistance and discussion; and S. Beni-
ni and C. Ghinelli for their invaluable technical help. This work
was supported by grants from the Italian Association for Cancer
Research (K. Scotlandi), the European Project PROTHETS (no.
503036), Eurobonet (no. 018814), the Terri Anna Perine Sarcoma
Fund, the Liddy Shriver Sarcoma Initiative, and Huntsman Cancer
Institute/Huntsman Cancer Foundation (S.L. Lessnick), and NIH
support to the Huntsman Cancer Institute (P30 CA42014).
Received for publication July 3, 2008, and accepted in revised form
December 16, 2009.
Address correspondence to: Katia Scotlandi, CRS Development of
Biomolecular Therapies, Laboratory of Experimental Oncology,
SSN Emilia Romagna Istituto Ortopedico Rizzoli IRCCS, Bolo-
gna 40136, Italy. Phone: 39.051.6366760; Fax: 39.051.6366763;
Anna Rocchi’s present address is: Italian Institute of Technology,
Neuroscience and Brain Technologies Department, Genoa, Italy.
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