{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,16]],"date-time":"2026-09-16T06:05:29Z","timestamp":1789538729028,"version":"build-2803163510"},"reference-count":21,"publisher":"Societatea Romana de Morfologie","issue":"2","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Rom J Morphol Embryol"],"published-print":{"date-parts":[[2026,9,15]]},"abstract":"<jats:p>Background and Objectives: Tumor budding (TB) phenomenon is recognized as one of the important adverse prognostic factors of colorectal carcinoma (CRC) and is currently assessed following to the International Tumor Budding Consensus Conference (ITBCC) recommendations on routine Hematoxylin and Eosin (H&amp;E)-stained slides. However, TB evaluation may become difficult in cases showing inflammatory infiltrates, stromal desmoplasia, or glandular fragmentation. Immunohistochemical (IHC) markers, including caudal type homeobox 2 (CDX2), may improve the identification of isolated tumor buds in such situations. Patients, Materials and Methods: The retrospective study included 170 CRC cases selected from the archives of a single regional pathology center. TB was evaluated on both H&amp;E-stained and CDX2-immunostained slides according to a modified ITBCC-based grading system including an additional Bd0 category for cases lacking identifiable tumor buds. Tumor buds were counted within a standardized field area. TB distribution was evaluated in the proximal, middle, and distal tumor regions. Results: Low-grade budding lesions predominated in all evaluated tumor regions on both H&amp;E and CDX2 assessment. Regional variation in TB distribution was observed along the invasive tumor front, supporting the presence of spatial heterogeneity in CRC. Comparative analysis of TB evaluation on H&amp;E-stained preparations and on CDX2 immunolabeled preparations revealed the existence of differences between the two methods, especially in cases with low or intermediate budding activity. CDX2 immunostaining facilitated the identification of additional tumor buds, leading to the reclassification of a number of cases to higher budding categories (intermediary and high-grade budding lesions), especially in difficult cases, characterized by intense stromal reaction, inflammation or glandular fragmentation. Conclusions: The present study demonstrated that IHC labeling should be considered primarily as a detection tool for accurate TB assessment, but other antibodies should be tested to increase the accuracy of tumor bud identification.<\/jats:p>","DOI":"10.47162\/rjme.67.2.04","type":"journal-article","created":{"date-parts":[[2026,9,15]],"date-time":"2026-09-15T18:08:14Z","timestamp":1789495694000},"page":"233-242","source":"Crossref","is-referenced-by-count":0,"title":["Beyond H&amp;E: CDX2 immunohistochemistry in tumor budding assessment of colorectal carcinoma"],"prefix":"10.47162","volume":"67","author":[{"name":"Doctoral School, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aminia Diana","family":"Ciob\u0103noiu","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gheorghe Gindrovel","family":"Dumitra","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"name":"Department of Family Medicine, University of Medicine and Pharmacy of Craiova, Romania","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Iancu Emil","family":"Ple\u015fea","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"name":"Doctoral School, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania; Department of Pathology, Bagdasar\u2013Arseni Emergency Clinical Hospital, Bucharest, Romania","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anwar","family":"Erchid","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"name":"Doctoral School, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Valentin Titus","family":"Grigorean","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"name":"Doctoral School, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania; Department of Surgery, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"26736","published-online":{"date-parts":[[2026,9,8]]},"reference":[{"key":"ref0","unstructured":"\"[1] World Health Organization (WHO) Classification of Tumours Editorial Board. Digestive system tumours. 6th edition, vol. 1, WHO Classification of Tumours, International Agency for Research on Cancer (IARC) Press, Lyon, France, 2025."},{"key":"ref1","doi-asserted-by":"publisher","unstructured":"[2] Zhang H, Simmer F, Lugli A, Nagtegaal ID. Tumor budding as a risk factor for lymph node metastasis and local recurrence in pT1 colorectal cancer: a systematic review and meta-analysis. Gastro Hep Adv, 2025, 4(9):100713. https:\/\/doi.org\/10.1016\/j.gastha.2025.100713","DOI":"10.1016\/j.gastha.2025.100713"},{"key":"ref2","doi-asserted-by":"publisher","unstructured":"[3] Vi\u00f1al D, Rueda-Lara A, Martinez-Perez D, Zwisler P, Garcia-Leal A, Ruiz-Gutierrez I, Jim\u00e9nez-Bou D, Pe\u00f1a-Lopez J, Alameda-Guijarro M, Martin-Montalvo G, Perez-Wert P, Mart\u00ednez-Recio S, Palacios ME, Ghanem I, Custodio AB., Guti\u00e9rrez-Sainz L, Feliu J, Rodriguez Salas N. Prognostic value of tumor budding in patients with stage II and III colon cancer: a single-institution experience. J Clin Oncol, 2023, 41(4 Suppl):247. https:\/\/doi.org\/10.1200\/JCO.2023.41.4_suppl.247","DOI":"10.1200\/JCO.2023.41.4_suppl.247"},{"key":"ref3","doi-asserted-by":"publisher","unstructured":"[4] Ueno H, Ishiguro M, Nakatani E, Ishikawa T, Uetake H, Matsuda C, Nakamoto Y, Kotake M, Kurachi K, Egawa T, Yasumasa K, Murata K, Ikawa O, Shinji S, Murotani K, Matsui S, Teramukai S, Tomita N, Sugihara K; SACURA Study Group. Prospective multicenter study on the prognostic and predictive impact of tumor budding in stage II colon cancer: results from the SACURA trial. J Clin Oncol, 2019, 37(22):1886-1894. https:\/\/doi.org\/10.1200\/JCO.18.02059","DOI":"10.1200\/JCO.18.02059"},{"key":"ref4","doi-asserted-by":"publisher","unstructured":"[5] Lugli A, Kirsch R, Ajioka Y, Bosman F, Cathomas G, Dawson H, El Zimaity H, Fl\u00e9jou JF, Hansen TP, Hartmann A, Kakar S, Langner C, Nagtegaal I, Puppa G, Riddell R, Ristim\u00e4ki A, Sheahan K, Smyrk T, Sugihara K, Terris B, Ueno H, Vieth M, Zlobec I, Quirke P. Recommendations for reporting tumor budding in colorectal cancer based on the International Tumor Budding Consensus Conference (ITBCC) 2016. Mod Pathol, 2017, 30(9):1299-1311. https:\/\/doi.org\/10.1038\/modpathol.2017.46","DOI":"10.1038\/modpathol.2017.46"},{"key":"ref5","doi-asserted-by":"publisher","unstructured":"[6] Zlobec I, B\u00e4chli M, Galuppini F, Berger MD, Dawson HE, Nagtegaal ID, Lugli A. Refining the ITBCC tumor budding scoring system with a \"zero-budding\" category in colorectal cancer. Virchows Arch, 2021, 479(6):1085-1090. https:\/\/doi.org\/10.1007\/s00428-021-03090-w","DOI":"10.1007\/s00428-021-03090-w"},{"key":"ref6","doi-asserted-by":"publisher","unstructured":"[7] Pihlmann Kristensen M, Korsgaard U, Timm S, Fr\u00f8strup Hansen T, Zlobec I, Kj\u00e6r-Frifeldt S, Hager H. Immunohistochemical analysis of tumor budding in stage II colon cancer: exploring zero budding as a prognostic marker. Virchows Arch, 2024, 485(4):691-701. https:\/\/doi.org\/10.1007\/s00428-024-03860-2","DOI":"10.1007\/s00428-024-03860-2"},{"key":"ref7","doi-asserted-by":"publisher","unstructured":"[8] Martinez-Ciarpaglini C, Fernandez-Sellers C, Tarazona N, Rosell\u00f3 S, Huerta M, Roda D, Mongort C, Ferr\u00e1ndez A, Navarro S, Cervantes A. Improving tumour budding evaluation in colon cancer by extending the assessment area in colectomy specimens. Histopathology, 2019, 75(4):517-525. https:\/\/doi.org\/10.1111\/his.13900","DOI":"10.1111\/his.13900"},{"key":"ref8","doi-asserted-by":"publisher","unstructured":"[9] Gwerder M, Demir CS, Williams HL, Lugli A, Martinez CG, Kowal J, Khan A, Kirchner P, Koessler T, Berger MD, Weigert M, Zlobec I. CDX2 expression dynamics in tumor clusters: a morpho-molecular biomarker in rectal cancer pretreatment biopsies revealed by sequential immunofluorescence. Sci Rep, 2026, 16(1):10129. https:\/\/doi.org\/10.1038\/s41598-026-40005-8","DOI":"10.1038\/s41598-026-40005-8"},{"key":"ref9","doi-asserted-by":"publisher","unstructured":"[10] Yu J, Li S, Xu Z, Guo J, Li X, Wu Y, Zheng J, Sun X. CDX2 inhibits epithelial-mesenchymal transition in colorectal cancer by modulation of Snail expression and \u03b2-catenin stabilisation via transactivation of PTEN expression. Br J Cancer, 2021, 124(1):270-280. https:\/\/doi.org\/10.1038\/s41416-020-01148-1","DOI":"10.1038\/s41416-020-01148-1"},{"key":"ref10","doi-asserted-by":"publisher","unstructured":"[11] Bodmer N, Uth K, Mehmeti R, Demir CS, Stroka D, Ghaffari-Tabrizi-Wizsy N, Lugli A, de Wever O, Zlobec I, Tschan MP. CDX2 loss in colorectal cancer cells is associated with invasive properties and tumor budding. Sci Rep, 2025, 15(1):24113. https:\/\/doi.org\/10.1038\/s41598-025-07278-x","DOI":"10.1038\/s41598-025-07278-x"},{"key":"ref11","unstructured":"[12] College of American Pathologists (CAP). Cancer Protocol Templates. Protocols and Guidelines, Cancer Protocols, CAP, Northfield, IL, USA, 2026."},{"key":"ref12","doi-asserted-by":"publisher","unstructured":"[13] Gologan D, \u015etefan AE, Militaru M, Sanda AC, Arjan S, Mu\u015fat S, Leavitt MO, Stan R. Quality assurance and cost reduction in histopathology laboratories using tissue microarrays. Vet Sci, 2023, 10(4):280. https:\/\/doi.org\/10.3390\/vetsci10040280","DOI":"10.3390\/vetsci10040280"},{"key":"ref13","unstructured":"[14] \u015etefan AE, Gologan D, Nitescu DAM, Mu\u015fat S, Stan R, Sanda CA, Arjan S, Militaru M. Pre-processed tissue microarray biomimetic material - applications and benefits. Rev Rom Med Vet, 33(1):26-32."},{"key":"ref14","doi-asserted-by":"publisher","unstructured":"[15] Landau MA, Zhu B, Akwuole FN, Pai RK. Histopathological predictors of recurrence in stage III colon cancer: reappraisal of tumor deposits and tumor budding using AJCC8 criteria. Int J Surg Pathol, 2019, 27(2):147-158. https:\/\/doi.org\/10.1177\/1066896918787275","DOI":"10.1177\/1066896918787275"},{"key":"ref15","doi-asserted-by":"publisher","unstructured":"[16] Werling RW, Yaziji H, Bacchi CE, Gown AM. CDX2, a highly sensitive and specific marker of adenocarcinomas of intestinal origin: an immunohistochemical survey of 476 primary and metastatic carcinomas. Am J Surg Pathol, 2003, 27(3):303-310. https:\/\/doi.org\/10.1097\/00000478-200303000-00003","DOI":"10.1097\/00000478-200303000-00003"},{"key":"ref16","doi-asserted-by":"publisher","unstructured":"[17] Hinoi T, Tani M, Lucas PC, Caca K, Dunn RL, Macri E, Loda M, Appelman HD, Cho KR, Fearon ER. Loss of CDX2 expression and microsatellite instability are prominent features of large cell minimally differentiated carcinomas of the colon. Am J Pathol, 2001, 159(6):2239-2248. https:\/\/doi.org\/10.1016\/s0002-9440(10)63074-x","DOI":"10.1016\/S0002-9440(10)63074-X"},{"key":"ref17","doi-asserted-by":"publisher","unstructured":"[18] Lugli A, Tzankov A, Zlobec I, Terracciano LM. Differential diagnostic and functional role of the multi-marker phenotype CDX2\/CK20\/CK7 in colorectal cancer stratified by mismatch repair status. Mod Pathol, 2008, 21(11):1403-1412. https:\/\/doi.org\/10.1038\/modpathol.2008.117","DOI":"10.1038\/modpathol.2008.117"},{"key":"ref18","doi-asserted-by":"publisher","unstructured":"[19] Bokhorst JM, Nagtegaal ID, Zlobec I, Dawson H, Sheahan K, Simmer F, Kirsch R, Vieth M, Lugli A, van der Laak J, Ciompi F. Semi-supervised learning to automate tumor bud detection in cytokeratin-stained whole-slide images of colorectal cancer. Cancers (Basel), 2023, 15(7):2079. https:\/\/doi.org\/10.3390\/cancers15072079","DOI":"10.3390\/cancers15072079"},{"key":"ref19","doi-asserted-by":"publisher","unstructured":"[20] Sajjad U, Chen W, Rezapour M, Su Z, Tavolara T, Frankel WL, Gurcan MN, Niazi MKK. Enhancing colorectal cancer tumor bud detection using deep learning from routine H&E-stained slides. Proc SPIE Int Soc Opt Eng, 2024, 12933:129330T. https:\/\/doi.org\/10.1117\/12.3006796","DOI":"10.1117\/12.3006796"},{"key":"ref20","doi-asserted-by":"publisher","unstructured":"[21] Su Z, Chen W, Leigh PJ, Sajjad U, Niu S, Rezapour M, Frankel WL, Gurcan MN, Niazi MKK. Few-shot tumor bud segmentation using generative model in colorectal carcinoma. 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