Review
Prevention
Heterogeneity in Colorectal Cancer Stem Cells
Akihiro Hirata1, Yuichiro Hatano2, Masayuki Niwa3, Akira Hara2, and
Hiroyuki Tomita2
Abstract
Cancer stem cells (CSC) have attracted a great deal of
interest for their clinical relevance in a range of cancers,
including colorectal cancer. CSCs were initially consid-
ered to be cell populations with homogeneous, well-
defined phenotypic and molecular characteristics. How-
ever, accumulating evidence suggests that CSCs repre-
sent phenotypically and functionally heterogeneous
populations. Recent studies demonstrate colorectal
CSCs to be dynamic rather than static, and continuously
altered by multiple extrinsic and intrinsic factors. Thus,
Introduction
It has long been recognized that malignant cells
within a single tumor display significant heterogeneity
in morphology, proliferative activity, and function (1).
The cancer stem cell (CSC) concept provides a con-
vincing explanation for the mechanisms underlying
this heterogeneity. CSCs, also called tumor-initiating
cells, are defined by their capacity to self-renew and
generate diverse cells that comprise the tumor (2). They
are thought to initiate and continually sustain tumor
growth.
The first evidence for the existence of CSCs came from
studies on acute myelogenous leukemia in the 1990s, in
which a rare subset of leukemic cells with a CD34þ/
CD38 phenotype was shown to induce leukemia in
immunocompromised mice (3, 4). A decade following
the identification of leukemic stem cells, the discovery of
a CSC subset in breast cancers (5) expanded the concept
to solid tumors and thereafter CSCs were identified in
multiple solid tumors, including colorectal cancer (6–8).
Because CSCs share phenotypic and molecular charac-
1
Division of Animal Experiment, Life Science Research Center, Gifu University,
Gifu, Japan. 2Department of Tumor Pathology, Gifu University Graduate
School of Medicine, Gifu, Japan. 3Medical Science Division, United Graduate
School of Drug Discovery and Medical Information Sciences, Gifu University,
Gifu, Japan.
Corresponding Author: Hiroyuki Tomita, 1-1 Yanagido, Gifu City, Gifu 501-1194,
Japan. Phone: 81-58-230-6225; Fax: 81-58-230-6226; E-mail:
h_tomita@gifu-u.ac.jp
Cancer Prev Res 2019;12:413–20
doi: 10.1158/1940-6207.CAPR-18-0482

2019 American Association for Cancer Research.
www.aacrjournals.org
Cancer
Research
CSCs no longer should be viewed as a fixed target
population, and we should note that their heteroge-
neous and dynamic nature presents a serious problem
for the development and implementation of specific
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therapeutic strategies. This review summarizes past and
current literature related to the heterogeneity and
dynamics of colorectal CSC populations, focusing on
evidence for distinct subpopulations, and signaling
pathways, and intra- and extratumoral factors involved
in their regulation in cancer tissues.
teristics with their corresponding normal tissue-resident
stem cells, and intestinal stem cells (ISC) play a crucial
role in maintenance of homeostatic epithelial renewals
in the normal colonic tissues (9), colorectal cancer pro-
vides a compelling model of a hierarchically organized
solid tumor, with CSCs at the apex. Furthermore, data
from ISCs should offer clues to understanding CSCs in
colorectal cancer.
In this review, we summarize the past and current
evidence related to heterogeneity within colorectal CSC
populations and our understanding of the potential
mechanisms underlying this heterogeneity.
Heterogeneity within Colorectal CSC
Populations
Markers for colorectal CSCs
Since the initial publication on brain tumors (10),
CD133 (also known as prominin-1) has been established
as a marker for CSC populations in a variety of cancers.
Human colorectal CSCs were first identified by CD133
expression (7, 8). CD133þ cells were consistently capable
of generating tumors that resembled the original patient
tumor when serially transplanted in immunocompro-
mised mice, while their CD133 counterparts failed to
give rise to xenografts. To date, other markers have been
reported to identify CSCs in human colorectal cancers
(Table 1), including CD44 (6), CD44v6 (11), and alde-
hyde dehydrogenase 1 (ALDH1) (12).
Overlap and nonoverlap among CSC markers
Flow-cytometric analysis has revealed overlaps between
populations of CD133þ colorectal cancer cells and
413
 Hirata et al.

Table 1. Markers for colorectal cancer stem cells

Samples from which CSC candidates Methods used to demonstrate cancer
Phenotype were isolated initiating and/or metastatic capacitya Reference
CSC markers
CD133 Human CRC tissues (primary lesions) Xenotransplantation (SCID mouse, subcutaneous 8
transplantation)
Human CRC tissues (primary or metastatic Xenotransplantation (NOD-SCID mouse, renal capsule 7
liver lesions) transplantation)
CD44 (EpCAMhigh/CD44þ) Human CRC xenografts Xenotransplantation (NOD-SCID mouse, subcutaneous 6
transplantation)
high þ
CD166 (EpCAM /CD166 ) Human CRC xenografts Xenotransplantation (NOD-SCID mouse, subcutaneous 6
transplantation)
ALDH1 Human CRC tissues (primary lesions) Xenotransplantation (NOD-SCID mouse, subcutaneous 12
transplantation)
Human CRC xenografts
CD44v6 Human CRC tissues Xenotransplantation (NOD-SCID mouse, orthotopic 11
transplantation)
Human CRC sphere
CD26 (CD26þ/CD133/CD44)

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Human CRC tissues (primary lesions) Xenotransplantation (SCID mouse, subcutaneous and 21
orthotopic transplantation)
LGR5 Spheroids derived from human CRC tissues Xenotransplantation (nude mouse, subcutaneous 27
(primary lesions) transplantation)
Organoids derived from human CRC tissues Lineage tracing in human CRC orgaoids xenografted in 28
NOG mouse (renal capsule transplantation)b
CSC with metastatic capacity
CD133þ/CXCR4þ Human CRC cell line (HCT116) Xenotransplantation (nude mouse, tail-vein injection) 20
CD26þ (CD26þ/CD133þ or /CD44þ or ) Human CRC tissues (primary lesions of a Xenotransplantation (SCID mouse, orthotopic 21
patient with hepatic metastasis) transplantation)
CD44v6 Human CRC tissues Xenotransplantation (NOD-SCID mouse, orthotopic 11
transplantation)
Human CRC spheres
CSC with organ-specific metastatic potential
CD133þ/CD110 Human CRC tissues (primary lesions of Xenotransplantation (NOG mouse, orthotopic 25
CD133þ/CDCP1 patients with CRC with liver and lung transplantation)
metastases)
Abbreviations: ALDH1, aldehyde dehydrogenase 1; CRC, colorectal cancer; CSC, cancer stem cell; SCID, severe combined immunodeficient; NOD-SCID, nonobese
diabetic; NOG, Nod/Shi-SCID,IL-2Rg null.
a
Only the most reliable/conventional assays are listed for each study, although multiple assays were used to assess CSC properties in many studies.
b
CSC functions in tumor tissues, rather than cancer-initiating capacity, were examined in the xenografts.

populations expressing CD44, CD29, CD24, and CD166,
all of which have been described as enriched for colorectal
CSCs (13). This finding suggests that CD133 expression is
the most broadly distributed marker for colorectal CSCs.
However, as has been reported in human glioblasto-
mas (14–16), colorectal cancer cells with CSC properties
do not necessarily express CD133. It has been shown
that both CD133þ and CD133 subsets from hepatic
metastases of colorectal tumors are capable of reconstitut-
ing tumors when subcutaneously injected into immuno-
compromised mice; moreover, tumors derived from
CD133 cells grew at a more rapid rate (17). Further
analysis revealed that CD133 cells frequently expressed
CD44, another CSC marker (6), in colonospheres
derived from CD133 cells (17). The following finding
is also indicative of the existence of CSCs phenotypically
distinct from CD133þ cells in colorectal tumors: CD44þ/
EpCAMhigh cells with CSC properties were found even in
colorectal tumors in which CD133þ cells were not
contained (6).
Complicating matters further, it has been shown that
CD133 and CD44 can be nonmutually exclusive markers,
as a partial overlap between the two cell subsets in colo-
rectal cancers has been repeatedly reported (6, 13, 18).
CD133þ/CD44þ cells induced tumors in immunocom-
promised mice under conditions in which the same num-
ber of CD133þ/CD44 cells failed to engraft, indicating
that CD44 provides further enrichment of CSCs in the
CD133þ subset (18).
CSCs with metastatic capacity
Distant metastasis is the primary cause of lethality in
patients with colorectal cancer. Previous studies have
suggested that only certain subsets of CSCs are capable
of distant metastasis (Table 1). Experiments showing
differences in metastatic capacity between CSC subsets
are the most convincing demonstrations of functional
heterogeneity.
Hermann and colleagues were the first to identify a
specific subset of CSCs responsible for metastasis in human
pancreatic cancer cell lines, based on the cell-surface
expression of CD133 and CXCR4, a receptor for the che-
mokine CXCL12 (19). When orthotopically injected into
nude mice, both CD133þ/CXCR4þ and CD133þ/CXCR4
cells could produce tumors at the injection site, but only
CD133þ/CXCR4þ cells produced liver metastases (19). A
subsequent study showed that the colorectal cancer cell
line HCT116 also contains CD133þ/CXCR4þ cells, which

414 Cancer Prev Res; 12(7) July 2019 Cancer Prevention Research

have a significantly higher metastatic capacity in nude mice
than CD133þ/CXCR4 cells (20).
Pang and colleagues demonstrated that a subpopula-
tion of colorectal CSCs expressing CD26 has both tumor-
initiating and metastatic capacities (21). Orthotopic
implantation into mice of CD133þ/CD26þ cells isolated
from the primary tumor of a colorectal cancer patient
with hepatic metastasis produced liver metastases follow-
ing tumor formation in the cecal wall, while their CD26
counterparts induced tumor growth only at the site
of injection (21). They also showed that circulating
CD133þ/CD26þ/CD44þ cells could be detected in port-
al blood after cecal-wall injection and that intraportal
injection of CD133þ/CD26þ/CD44þ cells, but not
CD133þ/CD26/CD44þ cells, led to liver metastasis
(21). In vitro evaluations revealed that CD26 knockdown
by small interfering RNA (siRNA) reduced the migratory
and invasive capacities of the CD26þ cells, with a down-
regulation of epithelial–mesenchymal transition (EMT)
markers (21). Consistent with these findings, clinical
studies have reported that CD26 expression in colorectal
cancer is correlated with poor prognoses (22–24). Inter-
estingly, CD26þ/CD326 circulating cancer cells have
been proposed as prognostic markers for the recurrence
of colorectal cancer (24).
In a recent study, Todaro and colleagues pheno-
typically identified colorectal CSCs with metastatic
capacity based on their expression of the variant form
6 of CD44 (CD44v6; ref. 11). CD44v6þ cells were able
to induce tumor growth in gut, lung, and liver after
orthotopic injection into mice, while their CD44v6
counterparts were not metastatic (11). Interestingly,
while there was a substantial overlap between CD44v6þ
and CD26þ populations, CD44v6þ/CD26 cells show-
ed considerable metastatic potential in the orthotopic
model (11), suggesting phenotypic heterogeneity even
within metastatic CSCs.
Interestingly, a recent study suggested that preferential
metastasis to particular target organs could be attributable
in part to phenotypic/functional diversity within metastat-
ic CSCs. Gao and colleagues reported that only colorectal
CSCs expressing CD110, a specific receptor for thrombo-
poietin, were able to colonize the liver after orthotopic
implantation in immunocompromised mice, while CSCs
expressing CUB-domain-containing protein 1 (CDCP1)
produced lung metastases (25). They showed that knock-
down of either CD110 or CDCP1 by siRNA reduced liver or
lung metastasis, respectively, but neither had a discernible
effect on primary tumor growth. In addition, they showed
that CD110 and CDCP1 functioned in extravasation into
the liver parenchyma and adhesion on the pulmonary
endothelium, respectively (25). It is notable that both
CD110þ and CDCP1þ CSCs were exclusively contained
within the CD133þ population with no overlap between
these subpopulations (25), indicating that distinct meta-
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Colorectal Cancer Stem Cells
static CSC subsets can be contained within CD133þ CSC
populations.
Dynamics of Colorectal CSCs
Recent studies demonstrate colorectal CSCs to be
dynamic rather than static populations that are continu-
ously altered by multiple factors including genetic and
epigenetic alterations, interactions between tumor cells,
microenvironmental factors, hormone action, and cancer
therapy. Any or all of these factors could contribute to
producing heterogeneity in colorectal CSC populations.
This section summarizes past and current findings related
to the dynamics of colorectal CSCs, particularly the sig-
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naling pathways and intra- and extratumoral factors
involved in their regulation. While ISCs are not the primary
focus of this section, we have provided a brief description
of them, focusing on ISC findings that offer clues to
understanding CSC dynamics in colorectal cancer.
Relationship between ISCs and colorectal CSCs
CSCs share phenotypic and molecular characteristics
with their normal counterparts, tissue-resident, adult stem
cells. Notably, the colorectal CSC markers identified to date
are also expressed by normal ISCs (12, 26). Conversely, the
human homolog of the best-documented marker for
murine ISCs, leucine-rich repeat-containing G-protein–
coupled receptor 5 (LGR5), could also serve as a marker
for CSCs in human colorectal cancers (27). A recent
study showed that LGR5-expressing cells possess CSC
properties in xenografted organoids derived from human
colorectal cancer (28). CSCs do not necessarily originate
from the transformation of normal stem cells, but in
the case of colorectal cancer, the similarity could be attrib-
utable, at least in part, to the origin of CSCs. Colorectal
cancer develops and progresses by the sequential accumu-
lation of genetic alterations, in which activation of the
Wnt/b-catenin signaling pathway, via an APC or CTNNB1
(b-catenin) mutation, marks the first step in tumor forma-
tion. Given that intestinal epithelial cells are consistently
renewed for a shorter period than that required to accu-
mulate causative genetic alterations, it is reasonable to
hypothesize that CSCs arise from long-lived ISCs. The
discovery of reliable murine ISC markers, including
Lgr5 (9) and B lymphoma Mo-MLV insertion region 1 (Bmi1;
ref. 29), enables the testing of this hypothesis. Actually, it
has been demonstrated that specific activation of Wnt/
b-catenin signaling in ISCs expressing Lgr5, Bmi1, or Cd133
results in adenoma formation in mice (29–31).
These findings do not necessarily preclude the
possibility that intestinal epithelial cells other than
ISCs can be the founders of intestinal tumors under
specific conditions. In fact, activation of Wnt and Notch
signaling in basic helix–loop–helix family member
a15 (Bhlha15)-positive progenitor cells resulted in the
Cancer Prev Res; 12(7) July 2019 415
 Hirata et al.
rapid development of intestinal tumors in mice (32).
Unlike observations from ISCs (29–31), Wnt activation
alone in Bhlha15þ cells was insufficient to drive colonic
carcinogenesis (32), suggesting that ISCs are at higher
risk for tumorigenic transformation. Similarly, activation
of Wnt signaling in doublecortin-like kinase 1 protein
(Dckl1)-positive tuft cells led to colorectal tumor devel-
opment in mice under inflammatory conditions, but not
under normal conditions (33).
Convertibility of ISCs and colorectal CSCs
ISCs are one of the most intensively studied subjects in
stem cell biology. While previous works based on label-
retaining cells (34) hypothesized the existence of a single
quiescent population of stem cells residing in a specific
location of the intestinal crypt, it is currently accepted that
both quiescent and active ISCs coexist in distinct
niches (35). Both populations possess the capacity to
self-renew and give rise to all differentiated intestinal
epithelial cell types, despite having entirely different pro-
liferative activities. In the small intestine of mice, Lgr5
is the best-known marker for active ISCs (9), while quies-
cent ISCs have multiple markers including Bmi1 (29),
homeodomain-only protein (Hopx; ref. 36), telomerase reverse
transcriptase (Tert; ref. 37), and leucine-rich repeats and
immunoglobulin-like domains protein 1 (Lrig1; ref. 38). Active
and quiescent ISCs represent functionally distinct ISC
populations: actively cycling Lgr5þ ISCs contribute to
homeostatic epithelial renewal, while slow-cycling Bmi1þ
ISCs are considered to be a reserve stem cell pool, based on
their active contribution to regeneration after radiation
damage (39). Consistently, it has been reported that Bmi1þ
ISCs give rise to Lgr5þ ISCs in the small intestine of mice
after the selective ablation of Lgr5þ cells (40). Conversely,
Takeda and colleagues showed that Lgr5þ cells can give rise
to Hopxþ cells in mice and in organoid cultures (36). These
results indicate that active and quiescent ISCs can inter-
convert and/or replenish each other. In the colon of mice,
Lgr5þ cells also reside at the crypt base and serve as active
ISCs (9), while Lrig1 marks predominately quiescent stem
cells (38). Asfaha and colleagues identified Lgr5 cells with
ISC properties within a Krt19þ population distributed
above the crypt base in the colon of mice (41). Genetic
lineage-tracing experiments revealed that Krt19þ/Lgr5
colonic cells generated entire colonic crypts, including
Lgr5þ cells at the colonic crypt base (41).
The differentiation of intestinal epithelial cells normally
proceeds in a unidirectional manner, from ISCs to the
terminally differentiated cells via lineage-committed pro-
genitor cells, but recent studies have demonstrated the
dedifferentiation capacity of the intestinal epithelial cells.
In the small intestine of mice, Alkaline phosphatase intestinal
(AlPi)-expressing enterocyte progenitors can dedifferenti-
ate into Lgr5þ ISCs upon the depletion of Lgr5þ cells (42);
416 Cancer Prev Res; 12(7) July 2019
similarly, Delta-like 1 (Dll1)high secretory progenitor cells
regenerate stem cell compartments that contain Lgr5þ cells
following irradiation damage (43). In the colon, atonal
homolog-1 (Atoh1)þ or Bhlha15þ secretory progenitor cells
significantly contribute to colonic crypt regeneration after
mucosal damage (32, 44–46). These findings indicate the
dedifferentiation capacity of the intestinal epithelium;
however, this capacity seems limited to fated progenitors
rather than to terminally differentiated cells.
Recent studies have demonstrated the reversion of
differentiated non-CSC populations to CSCs in novel
colorectal cancer models using genetically engineered
organoids (28, 47). By xenotransplantation of organoids
derived from human colorectal cancer cells, Shimokawa
and colleagues demonstrated that KRT20þ differentiated
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tumor cells revert to LGR5þ CSCs and contribute
to tumor growth after selective ablation of LGR5þ
CSCs (28). Likewise, the recovery of functional Lgr5þ
CSCs was also observed in transplanted mouse colon
cancer organoids, in which Lgr5 cells rapidly replen-
ished Lgr5þ CSC populations after the ablation of Lgr5þ
cells (47).
Regulatory factors for colorectal CSCs
Consistent with the importance of Wnt/b-catenin sig-
naling in both intestinal stemness and colon carcinogen-
esis, Wnt signaling plays a central role in the regulation of
colorectal CSCs. Although other signaling pathways have
been implicated in the control of colorectal CSCs, here we
focus on Wnt/b-catenin signaling. Vermeulen and collea-
gues demonstrated that colorectal cancer cells show vari-
able levels of Wnt activation and that only those with the
highest levels possess CSC properties (48). A study from
our group also supports the notion that the Wnt activity
levels define colorectal CSCs. We investigated the dose-
dependent effect of Wnt activation in the mouse colonic
epithelium by regulating the expression levels of S33Y
mutant b-catenin (49). Higher levels of mutant b-catenin
expression induced the amplification of Lgr5þ cells in
colonic crypts with de novo crypt formation, whereas lower
levels of expression only enhanced cell proliferation (49).
Consistent with these findings, Ordonez-Moran and col-
leagues showed that HOXA5 induction counteracted CSC
traits, preventing tumor growth and metastasis by inhibit-
ing Wnt signaling activity in colorectal cancers (50). Colo-
rectal CSCs is regulated through the interaction between
Wnt and other signaling pathways, as is the normal ISCs.
For example, bone morphogenetic protein 4 (BMP4) pro-
motes differentiation and apoptosis by antagonizing Wnt
signaling in colorectal CSCs (51). In a recent study,
Whissell and colleagues identified the transcription factor
GATA-binding factor 6 (GATA6) as a key regulator of Wnt
and BMP signaling in colorectal cancers (52). GATA6
enabled CSC self-renewal through the repression of BMP
Cancer Prevention Research

gene expression, competing with b-catenin/Tcf4 to bind to
a regulatory region of the BMP4 locus (52).
Microenvironmental factors are important in the regu-
lation of colorectal CSCs as well as of their normal
counterparts, ISCs (53). Tumor stroma undergoes dra-
matic changes during the process of tumor progression
and therefore could produce more complex effects than
it does in normal homeostatic conditions. Hepatocyte
growth factor (HGF) secreted from myofibroblasts
induced CSC properties in WntLow colorectal cancer cells
by enhancing Wnt signaling activity (48). When cocul-
tured with colorectal cancer cell lines, mesenchymal
stem cells increased the number of cancer cells with
tumor-initiating capacity by producing prostaglandin
E2 and cytokines that activated Wnt/b-catenin signal-
ing (54). It is possible that CSCs acquire a metastatic
capacity by the actions of cytokines secreted from cancer-
associated fibroblasts (CAF) during tumor progression.
As described above, colorectal CSCs with metastatic
capacity are phenotypically identified by CD44v6 ex-
pression (11). Cytokines secreted from CAFs, including
HGF, osteopontin, and stromal-derived factor 1a,
enhanced CD44v6 expression by activating Wnt signal-
ing, transforming nonmetastatic progenitors into meta-
static CSCs (11). In addition to stromal cells, Paneth
cells and cKitþ secretory cells constitute niches for Lgr5þ
ISCs in the murine small intestine and colon, respec-
tively, where they provide essential signals for stem cell
maintenance, including the Notch ligand Dll4 (55, 56).
As Notch signaling is elevated in colorectal CSCs (57)
and antibody blockade of DLL4 reduces CSC frequency
in colorectal cancers (57), the CSC state might also be
regulated through interactions between tumor cells in
colorectal cancers.
The regulation of Wnt and BMP4 signaling pathways
by activated thyroid hormones has been reported in
colorectal CSCs (58). Type 3 deiodinase 3 (D3), a chief
thyroid hormone T3–inactivating enzyme, has been
shown to be expressed at high levels in CD133þ and
Wnthigh cell populations (58). T3 treatment induced
CSC differentiation, decreasing the tumorigenic poten-
tial in CSCs, accompanied by the upregulation of BMP4
and attenuation of Wnt signaling (58). These findings
suggest that colorectal cancers may be regulated not only
by local factors within or surrounding a lesion, but also
by hormonal action.
Clinical Implications of Colorectal CSCs
The CSC concept has attracted a great deal of interest for
its potential clinical implications. Colorectal cancer
remains the fourth leading cause of cancer-related deaths
worldwide. Although its occurrence is declining in devel-
oped countries, its incidence is still rapidly rising in many
developing countries (59).
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Colorectal Cancer Stem Cells
Multiple reports have shown that colorectal CSCs
are more resistant to chemotherapy (60, 61) and there-
fore likely play an essential role in recurrence follow-
ing conventional anticancer treatments. Enrichment
of colorectal CSCs in xenografts after chemotherapy
clearly showed the limitation of conventional therapies
for colorectal cancers (28, 60). Therefore, CSCs repre-
sent an attractive target for more effective therapies,
and several potential CSC-targeted drugs or strategies
have been actually proposed (62). However, consider-
ing the heterogeneity and dynamism of colorectal
CSC populations, CSCs no longer represent a fixed tar-
get population, making it necessary to establish improv-
ed strategies, designed to counteract to their dynamic
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nature.
Recent studies have indicated that the selective ablation
of colorectal CSCs is not sufficient to produce complete
tumor regression (28, 47). In allografts of mouse colorectal
cancer organoids, continuous ablation of Lgr5þ CSCs
restricted tumor growth but did not produce tumor regres-
sion, because proliferative Lgr5 cells maintained the
tumors even with depletion of Lgr5þ CSCs (47). Further-
more, Lgr5 cells can rapidly replenish the Lgr5þ popula-
tion to reinitiate tumor growth after cessation of Lgr5þ
cell ablation (47). A similar phenomenon was observed
in xenografted human colorectal cancer organoids
(28). Upon ablation of LGR5þ CSCs, tumor size was
reduced (28). However, compensatory proliferation of
KRT20þ non-CSC cells reduced the effectiveness of the
ablation and the tumor eventually regrew in parallel with
the reappearance of LGR5þ cells (28).
Conclusion
Although CSCs were initially considered to be cell
populations with well-defined phenotypic and molec-
ular characteristics, CSCs have more recently been
shown to be phenotypically/functionally heterogeneous
and highly dynamic populations. These characteristics
present a serious problem in establishing therapeutic
strategies targeting CSCs. Considering that the stemness
of colorectal cancer cells is a dynamic state that is
constantly altered by multiple extrinsic factors, in addi-
tion to intrinsic cellular factors (genetic and epigenetic
alterations), a better understanding of the tumor envi-
ronment should lead to improved strategies for the
eradication of colorectal CSC by regulating their CSC
state.
Disclosure of Potential Conflicts of Interest
No potential conflicts of interest were disclosed.
Received December 12, 2018; revised April 7, 2019; accepted May
14, 2019; published first May 17, 2019.
Cancer Prev Res; 12(7) July 2019 417
 Hirata et al.
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