World J Gastroenterol 2014 July 21; 20(27): 8910-8920
ISSN 1007-9327 (print) ISSN 2219-2840 (online)
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DOI: 10.3748/wjg.v20.i27.8910
© 2014 Baishideng Publishing Group Inc. All rights reserved.
TOPIC HIGHLIGHT
WJG 20th Anniversary Special Issues (5): Colorectal cancer
Possible biological and translational significance of mast
cells density in colorectal cancer
Ilaria Marech, Michele Ammendola, Claudia Gadaleta, Nicola Zizzo, Caroline Oakley, Cosmo Damiano
Gadaleta, Girolamo Ranieri
Ilaria Marech, Caroline Oakley, Cosmo Damiano Gadaleta,
Girolamo Ranieri, Interventional Radiology Unit with Integrated
Section of Translational Medical Oncology, National Cancer Research Centre Istituto Tumori “Giovanni Paolo Ⅱ”, 70124 Bari,
Italy
Michele Ammendola, Department of Clinical Surgery, University of Catanzaro “Magna Graecia” Medical School, 88100 Catanzaro, Italy
Claudia Gadaleta, Nicola Zizzo, Department of Pathology, Veterinary Medical School, University of Bari, Valenzano, 70010
Bari, Italy
Author contributions: Marech I, Gadaleta CD and Ranieri G
ideated the manuscript and performed a critical review of the
literature; Ammendola M, Gadaleta C and Zizzo N contributed to
literature research and data analysis; Oakley C edited the manuscript; all authors wrote the manuscript.
Correspondence to: Girolamo Ranieri, MD, Interventional
Radiology Unit with Integrated Section of Translational Medical Oncology, National Cancer Research Centre Istituto Tumori
“Giovanni Paolo Ⅱ”, Via Orazio Flacco 65, 70124 Bari,
Italy. giroran@tiscalinet.it
Telephone: +39-80-5555561 Fax: +39-80-5555563
Received: September 23, 2013 Revised: January 24, 2014
Accepted: April 21, 2014
Published online: July 21, 2014
proteinase-activated receptor-2) take pivotal part in
tumor angiogenesis after the MCs activation, contributing to tumor cells invasion and metastasis. In this
review, we focused on crucial MCs density (MCD) role
in colorectal cancer (CRC) development and progression angiogenesis-mediated; then, we will analyze the
principal studies that have focused on MCD as possible
prognostic factor. Finally, we will consider a possible
role of MCD as novel therapeutic target mainly by c-KitR
tyrosine kinase inhibitors (imatinib, masitinib) and tryptase inhibitors (gabexate and nafamostat mesylate)
with the aim to prevent CRC progression.
© 2014 Baishideng Publishing Group Inc. All rights reserved.
Key words: Tryptase; Mast cell density; Proteinase-activated receptor-2; c-Kit receptor; Vascular endothelial
growth factor; Angiogenesis; Colorectal cancer; Tumor
progression; Tryptase inhibitors; c-Kit receptor tyrosine
kinase inhibitors
Core tip: In several malignancies it has been well demonstrated that mast cell (MC), activated c-Kit receptor
(c-KitR) and tryptase secreted after MC degranulation
play a pivotal role in tumor angiogenesis, helping tumor
cell invasion and metastasis. The close relationship between MC density, angiogenesis and tumor progression
could suggest a role for MCs as a possible prognostic
factor in colorectal cancer (CRC). Moreover, considering
MC-mediated CRC development, c-KitR tyrosine kinase
inhibitors (imatinib, masitinib) and tryptase inhibitors
(gabexate and nafamostat mesylate) could be used to
block MC activation/degranulation and the tryptase/proteinase-activated receptor-2 axis respectively, and may
be evaluated in future clinical trials in CRC patients.
Abstract
Mast cells (MCs), located ubiquitously near blood ves+
sels, are descended from CD34 hematopoietic stem
cells. Initially, although their role has been well defined
in hypersensitivity reactions, the discovery of their
sharing in both innate and adaptive immunity has allowed to redefine their crucial interplay on the regulatory function between inflammatory and tumor cells
through the release of mediators granule-associated
(mainly tryptase and vascular endothelial growth factor). In particular, in several animal and human malignancies it has been well demonstrated that activated
c-Kit receptor (c-KitR) and tryptase (an agonist of the
WJG|www.wjgnet.com
Marech I, Ammendola M, Gadaleta C, Zizzo N, Oakley C,
Gadaleta CD, Ranieri G. Possible biological and translational
8910
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Marech I et al . Mast cells density in colorectal cancer
significance of mast cells density in colorectal cancer. World J
Gastroenterol 2014; 20(27): 8910-8920 Available from: URL:
http://www.wjgnet.com/1007-9327/full/v20/i27/8910.htm DOI:
http://dx.doi.org/10.3748/wjg.v20.i27.8910
(e.g., histamine, tryptase) and synthesized de novo mediators
(i.e., leukotrienes, prostaglandins)[10,20]. Regarding innate
immunity, MCs express some receptors for components
of complement (CR3, CR4, CR5), and others belonging
to the Nod-like receptors family. The recognition of pathogens by the innate immune cells and the link between
innate and adaptive immunity however are via toll-like receptors (TLR type 1, 2, 3, 4, 6, 7 and 9)[21].
Many experimental studies have assessed MCs as protagonists both in inflammation and angiogenesis[20,22,23],
processes closely interconnected and related to tumor
development and progression[24-27]. Following the abovementioned synthetic review of the various functions of
MCs, in the upcoming sections we focus on the crucial
role of MCs in angiogenesis-mediated tumor development and progression and illustrate the most common
identification methods of MCs. In particular, as well as
playing a role in tumor angiogenesis, it has been demonstrated that the number of MCs, so-called MC density
(MCD), increases in several human and animal malignancies, and this increased MCD correlates with increased
angiogenesis. On this basis, we analyze the principal studies that have focused on MCD as a possible prognostic
factor, considering the MC as a possible novel therapeutic
target in colorectal cancer (CRC).
INTRODUCTION
In 1869 Nettleship and Tay[1] described a particular form
of pigmented rash (“urticaria pigmentosa”), which presented a dermographism entirely similar to some urticaria
forms. Mast cells (MCs) were identified by Ehrlich[2] in
1879 and named “mastzellen”(from the German mast =
well-fed) because it was believed that they were particularly numerous in overfed animals. It was subsequently
shown that cutaneous lesions observed in these animals
were characterized by a focal accumulation of some of
these mast cells[2]. In 1949 Ellis[3] described a form of
systemic mastocytosis characterized by an abnormal
infiltration of MCs into extracutaneous organs. Historically, “mastocytosis” is a morbid condition characterized
by a marked increase (usually about ten times compared
to normal) of the density of tissue MCs in specific anatomical sites[4]. Currently, “mastocytosis” includes a wide
spectrum of clinical disorders (with an extremely heterogeneous clinical course and prognosis) sharing particular
tyrosine kinase c-Kit receptor (c-KitR) mutations that
confer its increased activation, determining stem cell factor (SCF)-independent MC proliferation[5,6].
MCs are the progeny of CD34+ hematopoietic stem
cells and require SCF for their differentiation, activation and proliferation[7]. MCs are located throughout the
body; on the epithelial surface, in blood vessels, nerves
and glands [8]. Classically, MCs are divided into three
subgroups according to the protease expression in their
granules: the first type of MC contains only tryptase, the
second only chymase, and the third tryptase, chymase and
other proteases[8,9].
Although the role of mast cells has long been well
defined in hypersensitivity reactions, since 1990[10,11] it
has been discovered that they also have a role in both
innate and adaptive immunity. This has allowed us to
redefine their crucial interplay on the regulatory function
between inflammatory and tumor cells[12-15] by means of
the release of various granule-associated mediators [histamine, serotonin, heparin, tryptase, chymase, thymidine
phosphorylase, tumour necrosis factor, vascular endothelial growth factor (VEGF), fibroblast growth factor-2
(FGF-2), platelet-derived growth factor-β (PDGF-β),
epidermal growth factor (EGF)]; lipid-derived mediators
(leukotrienes, prostaglandins, platelet-activating factor);
cytokines (transforming growth factor-β, interleukins,
IL-6); and chemokines[16-19].
MCs express many types of receptors allowing them
to recognize different stimuli and to respond accordingly[8,9]. For the fragment crystallisable portion of Immunoglobulin (Ig)G and IgE, MCs express various receptors,
and in response to several antigens they release preformed
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INVOLVEMENT OF MAST CELLS IN
ANGIOGENESIS-MEDIATED TUMOR
DEVELOPMENT AND PROGRESSION
During inflammatory reactions, immune cells (MCs, macrophages, neutrophils, and lymphocytes) synthesize proangiogenic factors that induce first neovascularization,
then the further migration of inflammatory cells to the
site of inflammation, amplifying the process[25,28]. At the
same time, there is well-established evidence that tumor
cells are surrounded by an infiltrate of inflammatory
cells, which synergize with stromal cells and malignant
cells in a paracrine manner[29-31]. As a consequence, there
is a stimulation of endothelial cell proliferation and blood
vessel formation[32-34]. It is important to underline that
MCs are located near blood vessels and regulate many
functions of endothelial cells[35-37].
In particular, the c-KitR activated by SCF and tryptase after MC degranulation play pivotal part in tumor
angiogenesis[38,39].
The increased activation of the c-KitR pathway leads
to MC activation, which induces pro-angiogenic cytokines
(such as VEGF, PDGF, FGF-2) and tryptase degranulation[38,39]. MC c-KitR activation induces cross-talk between
MCs and the tumor cell microenvironment (endothelial
and other cells), leading consequentially to the strengthening of pro-angiogenic signaling[6].
Tryptase is also an agonist of proteinase-activated
receptor-2 (PAR-2)[40], which is expressed in epithelial and
endothelial cells with proteolytic activities. It belongs to
the unique superfamily of G-protein-coupled receptors
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Marech I et al . Mast cells density in colorectal cancer
Migration
Proliferation
Mast cell
SCF
VEGF
FGF-2
Other mast cells
Precursors of mast cells
Degranulation
Collagenase MMP
Gran
ules
Inflammatory cells recruitment
Lymphocytes
Neutrophils
Macrophages
Histamine
Heparin
Tryptase
Chymase
+
ECM remodeling
IL-1, IL-3
IL-4, IL-5
IL-8, IL-13
GM-CSF
TNF-α
PAF
Inflammation
VEGF
FGF-2
PDGF-β
EGF
Angiogenesis
Angiogenesis
Endothelial
cells
Leukotriens
Prostaglandins
Thromboxans
Tumor growth
Invasion
Metastases
Figure 1 Close relationship between mast cells and angiogenesis-mediated tumor progression. FGF-2: Fibroblast growth factor-2; VEGF: Vascular endothelial
growth factor; PDGF-β: Platelet-derived growth factor-β; EGF: Epidermal growth factor; IL: Interleukin; GM-CSF: Granulocyte/macrophage colony stimulating factor;
TNF-α: Tumor necrosis factor-α; ECM: Extracellular matrix; MMP: Matrix metalloproteinase.
and is activated by tryptase. Tryptase activation leads to
cell proliferation and the release of IL-6 and granulocytemacrophage colony-stimulating factor, which act as proangiogenic molecules[41]. Moreover, tryptase degrades
extracellular matrix components[42], activating in its stored
matrix metalloproteinases[43] and plasminogen activators
that together help the invasion and metastasis of tumor
cells[44] (Figure 1). In vitro studies on matrigel and in vivo
studies on the chick embryo chorioallantoic membrane
displayed the capillary growth induced by tryptase and,
conversely, suppressed by tryptase inhibitors[45,46].
Apart from the above biological background, the role
of MCs in tumor development has emerged from observation of a strong correlation between an increase of
MCD and an increase of microvascular density (MVD)
in many human and animal malignancies such as oral
squamous carcinoma[13,47], breast cancer[11,12,16], gastrointestinal cancer[26,48-50], hepatocarcinoma[51], pancreatic
adenocarcinoma[52], renal cell carcinoma[53], non-small
cell lung cancer[54,55], melanoma[56], endometrial carcinoma[27,57], non-Hodgkin’s lymphomas[58], and multiple
myeloma[59]. With particular reference to hematological
disorders, some evidence suggest that high MCD infiltration is directly correlated with tumor progression and
worse disease outcome[60-62].
Conversely, a few studies have shown that high MCD
is linked to good prognosis[63,64].
To further emphasize that MC activation plays a pivotal role in tumor progression, it was shown in breast
cancer that degranulated MCs (MCs-Try) are mainly present in peri-tumoral tissue (to strengthen the hypothesis
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that they are tumor-reactive), unlike those rich in granules
MCs (MCs-TB) which are especially present in tumor
infiltration and contribute to stromal remodeling and differentiation of myofibroblasts (through tryptase released
in stromal microenvironment)[11].
The close relationship between MCD, angiogenesis
and tumor progression could suggest a role for MCs and
the pro-angiogenic factors released from them as novel
therapeutic targets in cancer. In particular, it is possible to
block MC activation/degranulation by means of c-KitR
tyrosine kinase inhibitors (TKI) such as imatinib and masitinib, and also to block the tryptase released from MCs
by means of tryptase inhibitors (gabexate and nafamostat
mesylate)[12,65-67].
PRINCIPAL METHODS FOR
IDENTIFICATION OF TISSUE MAST
CELLS
MCs can be classically or conventionally identified by
means of histochemical methods. Among these, Toluidine blue histochemistry (Undritz Stain) metachromatically stains MC granules, making them appear red or
blue-red due to the presence of sulphated proteoglycans
(heparin)[68]. With the above histochemistry, MCs appear
as rather large oval or elongated cells (diameter of 20-30
μm) containing numerous basophilic granules in their cytoplasm that can hide the nucleus[12,69].
By immunohistochemistry MCs can be stained with
antibodies towards c-KitR (e.g., human-specific mono-
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Table 1 Principal studies correlating mast cell density with survival/stage in colorectal cancer patients
Ref.
Xia et al[83]
Xia et al[84]
Nielsen et al[85]
Tan et al[86]
Fisher et al[88]
Yodavudh et al[89]
Elezoğlu et al[87]
Acikalin et al[49]
Gulubova et al[50]
Disease stage/main
stages
Neoadjuvant
therapy
Patients
(n )/site
All TNM stages
(mainly Ⅱ-Ⅲ)
Stage ⅢB
No
All Dukes’ stage
(mainly B-C)
All TNM stages
No
155
CC
93
CC
584
CRC
60
CRC
331
RC
130
CRC
204
CRC
60
CRC
106
CRC
All Dukes’ stage
(mainly B-C)
All TNM stages
(mainly Ⅱ-Ⅲ)
All TNM stages
(mainly Ⅱ-Ⅲ)
All TNM stages
(mainly Ⅱ-Ⅲ)
All TNM stages
(mainly Ⅱ)
No
NR
No
No
NR
No
No
Methods of MCs identification
Correlation with
overall survival/stage
Immunohistochemistry
No with OS
primary anti-tryptase and anti-chymase abs
Immunohistochemistry
No with OS
primary anti-tryptase ab
Immunohistochemistry
Yes, high MCD with
primary anti-tryptase ab
high OS
Immunohistochemistry
Yes, high MCD with
primary anti-tryptase and anti-chymase abs
high OS
Giemsa method
Yes, high MCD with
low OS
Immunohistochemistry
Yes, high MCD with
primary anti-tryptase ab
low OS
Toluidine blue histochemistry
Yes, high MCD with
high OS
Giemsa method
Yes, high MCD with
low OS
Immunohistochemistry
Yes, high MCD with
primary anti-tryptase ab; toluidine blue
low OS
histochemistry
P value
NS
NS
0.02
< 0.01
NE
< 0.0001
0.035
0.0013
0.038
CC: Colon cancer; OS: Overall survival; NS: Not significant; CRC: Colorectal cancer; MCD: Mast cell density; NR: Not reported; MCs: Minimal consistent set.
clonal antibodies anti-CD117), towards the content of
their granules, i.e., tryptase or chymase[68]. With a primary
anti-c-KitR antibody, a membrane, cytoplasmic or mixed
staining is observed[68]. With primary anti-chymase and
anti-tryptase antibodies a diffuse cytoplasmic staining is
observed[68].
Under the electron microscope MCs present a small,
round nucleus, few mitochondria, some meandering tanks
of rough endoplasmic reticulum and a small Golgi complex. The numerous specific granules (some hundreds)
measure 0.3-0.8 μm in diameter and appear bordered by
a membrane showing a variable fine granular or lamellar
structure[70,71].
Following their activation, MCs degranulate and
exocytose the content into the surroundings. Piecemeal
degranulation is typified by variable losses of the granule
content[71-73].
pared to in that of IL-10-deficient mice without MCs.
Thus, this result emphasizes the protective role of MCs
within the colonic microenvironment by enhancing the
efficacy of the mucosal barrier. In reality, these data suggest that MCs can play a dual and opposite function, and
this is probably due to the presence in the intestinal tract
of different types of MCs, each with a specific role, with
specific granules, and expressing various receptors[74].
It is noted that patients affected by IBD have an increased cumulative incidence of CRC than the general
population and that this incidence increases with the duration of the bowel disease[78]. In particular, it was found
that high MCD in intestinal adenomatous polyps[75,79-81]
could drive a cascade of events to boost the progressive
growth of adenomatous polyps, the immediate precursors of CRC[75].
In this regard, Taweevisit, considering 192 CRC patients, displayed a direct correlation between MCD, tumor development and grading[82].
With the aim to find a correlation between MCD and
stage/prognosis in CRC patients, many studies (summarized in Table 1) have been conducted with mixed results.
One Author showed no correlation between MCD and
prognosis[83,84]. Other Authors have shown a direct and
significant correlation between high MCD and improved
prognosis[85-87]. The majority of studies however have
shown that high MCD is related to tumor aggressiveness[48-50] and reduced survival[88-90].
Xia et al[83] studied MCD in 39 patients with colon adenoma and in 155 colon cancer (CC) patients of all TNM
stages, evaluating a relationship between MCD (positive
to both tryptase and chymase) and tumor progression.
Interestingly, a significant increase of MCD localized in
adjacent normal colon mucosa in CC patients was noted
compared to those with colon adenomas (P < 0.05)[83].
Moreover, MCD located in adjacent normal colon mu-
MAST CELL DENSITY INVOLVEMENT
IN COLORECTAL CANCER AND ITS
POSSIBLE ROLE AS PROGNOSTIC
FACTOR
Normally, MCs are present in the mucosa and submucosa
of the gastrointestinal tract in humans and mice[74].
In a preclinical study in mice, MCs played a crucial
role in epithelial tumorigenesis, appearing in early dysplastic tissue and expanding in polyps[75]. However, when
analysing the potential role of MCs in tumor development in several mice studies, Heijmans et al[76] were unable
to draw certain conclusions due to a lack of a suitable animal model to study CRC. In fact, in IL-10-deficient mice
with MCs Chichlowski et al[77] showed a reduced risk of
development of inflammatory bowel disease (IBD) com-
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Marech I et al . Mast cells density in colorectal cancer
cosa in CC patients was significantly related to pathologic
classification (i.e., papillary plus tubular or other), depth
of penetration (i.e., high T according to TNM), distant
metastases (i.e., M1 according to TNM), and hepatic metastases (P = 0.029, P = 0.054, P = 0.008, P = 0.027)[83].
Instead, there is no correlation between MCD located in
the invasive margin or in adjacent normal colon mucosa
and survival (P = 0.092 and P = 0.003)[83]. Similarly, in 93
CC patients only in stage ⅢB (according to TNM staging), the same Author observed a higher MCD positive to
tryptase in non-metastatic regional-draining lymph nodes
than in metastatic lymph nodes (P = 0.000)[84].
In 1999, Nielsen et al[85] analysis in a large cohort of
CRC patients (n = 584) of all Dukes’ stages displayed
a significant correlation between high MCD positive to
tryptase and good prognosis (P = 0.02); 50% of all patients with high MCD positive to tryptase were still alive
at 3 years.
Subsequently, Tan et al[86] observed that high MCD
(positive to tryptase and chymase) is also related to a
significantly higher 5-year survival rate (SR). In their
study on 60 CRC patients of all TNM stages, a 59% SR
was recorded for patients with high MCD compared to
33.3% in those with low MCD (P < 0.01). Curiously, low
MCD was significantly related to deeper depth of invasion, but also to low rates of lymph node and distant
metastases[86].
Recently, Elezoğlu and Tolunay[87] displayed a significant correlation between MCD positive to tryptase,
MVD, and survival in 204 CRC patients of all TNM
stages. In the MC group, for values < 10, the five-year
SR was 48%, whereas for values > 10 it rose to 58% (P =
0.035). In the MVD arm for values < 10, the five-year SR
was 46%, while for values ≥ 10 it was 58% (P = 0.042)[87].
In 1989 Fisher et al[88] was one of the first researchers
to identify high MCD as an unfavorable prognostic factor
independent from disease stage or lymph nodal status in
331 rectal cancer patients of all Dukes’ stages.
In 60 patients with CRC of all TNM stages Acikalin
et al[49] showed that MCD (evaluated by means of the Giemsa stain) was higher in patients with disease recurrence
compared to those patients who had been disease free
for at least 24 mo (P < 0.001), and that it was correlated
to short disease-free survival (P = 0.0013), vascular invasion (P = 0.06), depth of penetration (P = 0.05), lymph
nodes metastases (P = 0.05), liver metastases (P = 0.05)
and high TNM stage (P = 0.05).
Yodavudh et al[89] confirmed Elezoğlu and Tolunay[87]’
s report of a strong correlation between MCD positive
to tryptase, MVD, and survival in 130 CRC patients of all
TNM stages. Contrarily however, they showed that low
MVD (hypovascular tumor tissue) and low MCD are related to significantly longer survival rates (P < 0.0001).
Gulubova and Vlaykova[50] also confirmed a significant
correlation between MCD positive to tryptase, MVD,
and survival in 106 CRC patients of all TNM stages. Patients with low MCD had a significantly better prognosis
compared to those with high MCD (P = 0.038)[50]. In the
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same way, hypovascular tumor tissue was related to highly
significantly longer survival than hypervascular tumor tissue (P < 0.0001)[50].
In a recent series of 41 gastrointestinal cancer patients (of whom 22 had CRC of TNM stage ⅢC), Ammendola et al[30] showed a significant correlation between
MCD positive to tryptase and the number of metastatic
lymph nodes harvested (P = 0.01), and between MCD in
primary tumor tissue and in metastatic lymph node tissue
(P = 0.02). These data suggest that MCD in primary tumor tissue could be a useful prognostic marker[30,49], surrogating the number of postoperative metastatic lymph
nodes after surgical treatment in gastrointestinal cancer
patients[91-94].
Even more recently, Malfettone et al[90] showed in 115
CRC patients of all TNM stages that high MCD positive
to tryptase correlates with the advanced stages of CRC
(P = 0.025). In particular, the expression of PAR-2 (especially at the sites most infiltrated by MCs) is related to
MCD expression[90]. Due to the pro-angiogenic activity
of tryptase, which stimulates PAR-2 on endothelial cells,
it is possible to suggest an involvement of tryptase in
CRC angiogenesis[90].
MAST CELLS, c-KIT RECEPTOR
AND PRO-ANGIOGENIC FACTORS
FROM MAST CELLS RELEASED AS
POSSIBLE THERAPEUTIC TARGETS IN
COLORECTAL CANCER
Ducroc et al[95] demonstrated a pivotal role of MC tryptase in inducing PAR-2 activation in several human CC
cell lines (T84, Caco-2, HT-29, Cl.19A), promoting their
proliferation.
Yoshii et al[96] investigated the distribution of MCD
(positive to tryptase) in 30 human CC, showing the prevalence of MCD in the invasive front rather than in either
the central tumor part or the normal tissue. In addition,
the Authors showed a higher density of PAR-2 in the tumor tissue compared to the normal tissue[96].
Interestingly, two Authors explored the tryptase/PAR-2
axis in one human colon carcinoma cell line (DLD-1)[96,97].
Specifically, the proliferation signal induced by tryptase
on DLD-1 cells is mediated by PAR-2, that in turn leads
to the increase of calcium[98] and transient phosphorylation of mitogen-activated protein kinase/extracellular
signal-related kinase (MEKK) and the mitogen-activated
protein kinase (MAPK) pathway[96]. In addition, the increase of calcium PAR-2/Phospholipase C-mediated led
to the activation of CycloOXygenase-2 (COX-2) and
prostaglandin E2 (PGE2) synthesis, suggesting that the
MEKK and MAPK pathway activation and PGE2 synthesis were together essential for DLD-1 proliferation[96]
(Figure 2).
Sodium-hydrogen antiporter 3 regulator 1 (NHERF-1)
is a cytoplasmic adaptor protein present in various cel-
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Imatinib
Masitinib
Mast Cell
c-KitR
PAR-2
+
+
SCF
VEGF
Tryptase
VEGFR
-
Tryptase
Degranulation
Endothelial Cell
Gabexate mesylate
Nafamostat mesylate
+
-
Gabexate mesylate
Nafamostat mesylate
Tryptase
PAR-2
+
+
GDP
VEGFR
GTP
P
Sos
Src
NHERF-1
b2
Gr
P
MEKK-1 SAPK
Shc
Phospholipase-C
GDP
MEKK-4 P
JNK
DAG
Ras
GTP
P
P
2+
Ca
Mek-1/2
c-Jun
PK-A
IP-3
Raf
P
rin
Ez
PK-C
P
P
Erk1/2 P
COX-2
PGES1
PGE2
Intestinal cell
Gene transcription
Cell proliferation
Immunomodulation
Angiogenesis
Figure 2 In both intestinal and endothelial cells, the tryptase/proteinase-activated receptor-2 and vascular endothelial growth factor/vascular endothelial
growth factor receptor axes, induced by mast cells, lead to tumor angiogenesis and intestinal cell growth. Note that targeting mast cells with molecular agents
(c-KitR tyrosine kinase and tryptase inhibitors) could prevent angiogenesis-mediated colorectal cancer progression. c-KitR: c-Kit receptor; PAR-2: Proteinase-activated
receptor-2; VEGFR: Vascular endothelial growth factor receptor; SCF: Stem cell factor: VEGF: Vascular endothelial growth factor; NHERF-1: Na+/H+ exchanger regulatory factor-1; MEKK-1: Mitogen-activated protein kinase/extracellular signal-related kinase-1; MEKK-4: Mitogen-activated protein kinase/ extracellular signal-related
kinase-4; JNK: c-Jun N-terminal kinase; c-Jun: Jun proto-oncogene; SAPK: Mitogen-activated protein kinase-9; GEF: Rho/rac guanine nucleotide exchange factor;
Rho: Rhodopsin transcription termination factor; SOS: Son of sevenless protein; Grb2: Growth factor receptor-bound protein 2; Shc: Shc transforming protein kinase;
Ras: Ras protein kinase; Raf: Raf protein kinase; Mitogen-activated protein kinase/extracellular signal-related kinase-1/2; Erk: Elk-related tyrosine kinase; DAG:
Diacylglycerol; IP-3: Inositol triphosphate; PK-C: Protein kinase-C; COX-2: Cyclooxygenase-2; PGE2: Prostaglandin E2; PGES-1: Prostaglandin E synthase-1; PK-A:
Protein kinase-A.
lular types (including intestinal cells). NHERF-1 regulates
several transmembrane receptors, transporters and other
proteins localized near the plasma membrane, and via the
Ezrin/protein kinase-A- mediated network seems to lead
to CRC progression[99,100].
Interestingly, Malfettone et al[90], having confirmed the
close interplay between MCD and PAR-2 in tumour progression and invasiveness, showed that the PAR-2(+)/cytoplasmic NHERF-1(+) expression immunophenotype
is an unfavourable prognostic factor in CRC patients,
as it is associated with the presence of lymph nodal and
distant metastasis, poor differentiation grade and lymphovascular invasion. If further studies conducted in
stage Ⅱ CRC patients should confirm the role of the
PAR-2(+)/cytoplasmic NHERF-1(+) expression immunophenotype as a negative prognostic biomarker, it will
become a prerequisite to the treatment of patients with
adjuvant chemotherapy.
Finally, if future studies demonstrate that high MCD
positive to tryptase is an independent unfavourable
prognostic factor[30,49,50,88,89] related to a significant and in-
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creased risk of tumor progression, this parameter could
be considered in the decision to give chemotherapy associated with tryptase inhibitors (gabexate and nafamostat
mesylate).
Clearly, before being able to use MC targeted agents,
a more in-depth knowledge of MC-mediated angiogenic
mechanisms and the complex hierarchical relationships
between the various angiogenesis signaling pathways will
be necessary[101-104].
In this regard, tryptase may induce angiogenesis
mainly by the increase of VEGF expression mediated
via PAR-2, which is expressed also on endothelial cells
as well as intestinal cells[12,27,45,54]. Moreover, VEGF and
its receptors are widely expressed in intestinal carcinoma
cells, and VEGF stimulates VEGFR-2-positive tumor,
mast and endothelial cells directly, leading to tumor
growth and angiogenesis by paracrine and autocrine
stimulation signals[26,105,106].
Considering the central role of MCs in the activation
of gastrointestinal and endothelial cells which contribute
to tumor angiogenesis and progression, c-KitR could
8915
July 21, 2014|Volume 20|Issue 27|
Marech I et al . Mast cells density in colorectal cancer
also be a potential therapeutic target for inhibiting their
pro-angiogenic cytokine degranulation (VEGF, PDGF,
FGF, tryptase) and activation[6,38,67,107]. In fact, MC c-KitR
activation potentiates the cross-talk between MCs and endothelial cells (Figure 2), leading to the strengthening of
pro-angiogenic signaling. Therefore, MCs could represent
a possible therapeutic target through tryptase inhibitors
(gabexate and nafamostat mesylate) and c-KitR inhibitors
(imatinib, masitinib) to arrest angiogenesis-mediated tumor growth in gastrointestinal cancer[108-110].
6
CONCLUSION
10
7
8
9
Although the role of MCs was well defined in hypersensitivity reactions, the discovery of their regulatory function
in innate and adaptive immunity has allowed us to understand their complex interplay between inflammatory and
tumor cells. In fact, much evidence obtained from in vitro
and in vivo studies has demonstrated that common MCs
phenotypes, if adequately stimulated by various factors
(histamine, heparin, tryptase, chymase, VEGF, FGF-2,
PDGF-β, EGF), are able to interfere with tumor cells
and the tumor microenvironment inducing tumor angiogenesis and progression[10,12].
Although the majority of studies have reported that
several malignancies are associated with an increase of
MC infiltration, controversial data about the relationship between MCD and prognosis in CRC have been
reported. Considering these studies, conflicting conclusions[48-50], may in part depend on considerable bias
related to CRC disease (radical surgical treatment with
relative lymph node collection, type of resection, histology or stage tumor, colon plus rectal cancer, small sample
size)[83,85,86,88], and different methods of MC evaluation
(histochemistry with Toluidine blue, Giemsa stain, primary antibody anti-tryptase or anti-chymase for immunohistochemistry, standardization of MC counts with reference to magnification, MC location, microscopic field of
evaluation)[76,84,87,90]. Despite these biases, the majority of
the published studies suggest that high MCD in tumors
may play a role as an unfavourable prognostic marker.
Should this prognostic marker be validated in expected
future studies it would be intriguing to conduct clinical
trials employing chemotherapy plus tryptase inhibitors or
TK inhibitors MC c-KitR.
11
12
13
14
15
16
17
18
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P- Reviewers: Chen JL, Huang ZH, Stanojevic GZ
S- Editor: Gou SX L- Editor: A E- Editor: Wang CH
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