Theranostics 2019; 9(13):3879-3902. doi:10.7150/thno.31716

Research Paper

Forkhead box K2 promotes human colorectal cancer metastasis by upregulating ZEB1 and EGFR

Feng Du1,#, Chenyang Qiao1,#, Xiaowei Li1,2,#, Zhangqian Chen1,3,#, Hao liu1, Shengda Wu4, Sijun Hu1, Zhaoyan Qiu5, Meirui Qian1, Dean Tian6, Kaichun Wu1, Daiming Fan1,✉, Yongzhan Nie1,✉, Limin Xia1,6,✉

1. State key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, Shaanxi, China.
2. Department of Gastroenterology, Navy General Hospital, Beijing, 100048, China.
3. Department of Infectious Diseases, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, Shaanxi, China.
4. The Department of Orthopedics, Tangdu Hospital, Fourth Military Medical University, 1 Xinsi Road, Xi'an, Shaanxi, 710038, China.
5. Department of General Surgery, Chinese People's Liberation Army General Hospital, Fuxing Road No. 28, Haidian District, Beijing, 100853, China.
6. Department of Gastroenterology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei, China
#These authors contributed equally to this work.

This is an open access article distributed under the terms of the Creative Commons Attribution (CC BY-NC) license ( See for full terms and conditions.
Du F, Qiao C, Li X, Chen Z, liu H, Wu S, Hu S, Qiu Z, Qian M, Tian D, Wu K, Fan D, Nie Y, Xia L. Forkhead box K2 promotes human colorectal cancer metastasis by upregulating ZEB1 and EGFR. Theranostics 2019; 9(13):3879-3902. doi:10.7150/thno.31716. Available from

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Background: Metastasis is the major reason for high recurrence rates and poor survival among patients with colorectal cancer (CRC). However, the underlying molecular mechanism of CRC metastasis is unclear. This study aimed to investigate the role of forkhead box K2 (FOXK2), one of the most markedly increased FOX genes in CRC, and the mechanism by which it is deregulated in CRC metastasis.

Methods: FOXK2 levels were analyzed in two independent human CRC cohorts (cohort I, n = 363; cohort II, n = 390). In vitro Transwell assays and in vivo lung and liver metastasis models were used to examine CRC cell migration, invasion and metastasis. Chromatin immunoprecipitation and luciferase reporter assays were used to measure the binding of transcription factors to the promoters of FOXK2, zinc finger E-box binding homeobox 1 (ZEB1) and epidermal growth factor receptor (EGFR). Cetuximab was utilized to treat FOXK2-mediated metastatic CRC.

Results: FOXK2 was significantly upregulated in human CRC tissues, was correlated with more aggressive features and indicated a poor prognosis. FOXK2 overexpression promoted CRC migration, invasion and metastasis, while FOXK2 downregulation had the opposite effects. ZEB1 and EGFR were determined to be direct transcriptional targets of FOXK2 and were essential for FOXK2-mediated CRC metastasis. Moreover, activation of EGFR signaling by EGF enhanced FOXK2 expression via the extracellular regulated protein kinase (ERK) and nuclear factor (NF)-κB pathways. The EGFR monoclonal antibody cetuximab significantly inhibited FOXK2-promoted CRC metastasis. In clinical CRC tissues, FOXK2 expression was positively correlated with the expression of p65, ZEB1 and EGFR. CRC patients who coexpressed p65/FOXK2, FOXK2/ZEB1 and FOXK2/EGFR had poorer prognosis.

Conclusions: FOXK2 serves as a prognostic biomarker in CRC. Cetuximab can block the EGF-NF-κB-FOXK2-EGFR feedback loop and suppress CRC metastasis.

Keywords: Forkhead box K2, colorectal cancer, metastasis, epidermal growth factor receptor, cetuximab