The role of tumour-associated macrophages in tumour progression: implications for new anticancer therapies

Potential prophylactic measures against postoperative immunosuppression: could they reduce recurrence rates in oncological patients?

BACKGROUND

Removing the primary tumor is indispensable for eliminating the major pool of metastasizing cells, but the surgical procedure itself is suspected of promoting metastases. This adverse effect is attributed to several mechanisms acting in synergy, including mechanical release of tumor cells, enhanced angiogenesis, secretion of growth factors, and immunosuppression. Here we provide new insights into mechanisms of postoperative immunosuppression and assess the assumptions underlying the hypothesis that, by suppressing cell-mediated immunity (CMI), surgery may render the patient vulnerable to metastases that otherwise could have been controlled.

METHODS

An extensive review of relevant articles in English identified by using the MEDLINE database and cross-referencing.

RESULTS

Current literature suggests that (1) CMI can control minimal residual disease, especially if surgery is performed early; (2) major surgery transiently but markedly suppresses CMI through multiple mechanisms now better understood; (3) surgical stress promotes experimental metastasis through immunosuppression, but the clinical evidence remains indirect because of ethical limitations.

CONCLUSIONS

Minimizing postoperative immunosuppression seems feasible, may limit recurrence, and should be introduced into the broader array of considerations when planning oncological surgeries. In the short run, physicians could try to avoid immunosuppressive anesthetic approaches, inadvertent hypothermia, excessive blood transfusions, and untended postoperative pain. When feasible, minimally invasive surgery should be considered. In the long run, clinical trials should evaluate prophylactic measures, including perioperative immunostimulation and several antagonists to cytokines and hormones specified herein.

Identification of a carcinoembryonic antigen binding protein on monocytes

Tumor-associated monocyte/macrophage cells are important stromal components involved in tumor development. A protein on human monocyte is identified that binds to carcinoembryonic antigen (CEA), a glycoprotein overexpressed in colon tumors. This implicates a role for this protein in CEA processing and establishes a link between monocytes and colon tumor cells. In vitro uptake of 125I-labeled CEA with isolated monocytes showed time and temperature dependence. The binding of 125I-CEA was specific and saturable as it could be inhibited by an excess of unlabeled CEA. To identify the binding protein on monocyte, we used a radiolabeled photoactivable heterobifunctional crosslinking agent and demonstrated that CEA reacts with a 115kDa protein as determined by SDS-polyacrylamide gel electrophoresis and autoradiography. Treatment of human monocytes in vitro with CEA resulted in a several fold increase in the production of proinflammatory cytokines TNF-alpha, IL-1 beta, and IL-6 compared to untreated controls. Binding of CEA to the monocyte protein may have implications in colon tumorigenesis.

Hypoxia Selectively Inhibits Monocyte Chemoattractant Protein-1 Production by Macrophages

Hypoxia, a local decrease in oxygen tension occurring in inflammatory and tumor lesions, modulates gene expression in macrophages. Because macrophages are important chemokine producers, we investigated the regulatory effects of hypoxia on macrophage-derived chemokines. We demonstrated that hypoxia inhibits the production of the macrophage and T lymphocyte chemotactic and activating factor, monocyte chemoattractant protein-1 (MCP-1). Exposure of mouse macrophages to low oxygen tension resulted in the down-regulation of constitutive MCP-1 mRNA expression and protein secretion. Hypoxia inhibitory effects were selective for MCP-1 because the chemokines macrophage inflammatory protein-1beta (MIP-1beta), RANTES, IFN-gamma-inducible protein-10, and MIP-2 were not affected, and MIP-1alpha was induced. Hypoxia also inhibited, in a time-dependent fashion, MCP-1 up-regulation by IFN-gamma and LPS. Moreover, the inhibitory action of hypoxia was exerted on human monocytic cells. MCP-1 down-regulation was associated with inhibition of gene transcription and mRNA destabilization, suggesting a dual molecular mechanism of control. Finally, we found that the triptophan catabolite picolinic acid and the iron chelator desferrioxamine, which mimic hypoxia in the induction of gene expression, differentially regulated the expression of MCP-1. This study characterizes a novel property of hypoxia as a selective inhibitor of MCP-1 production induced by different stimuli in macrophages and demonstrates that down-regulation of gene expression by hypoxia can be controlled at both transcriptional and posttranscriptional levels. Inhibition of MCP-1 may represent a negative regulatory mechanism to control macrophage-mediated leukocyte recruitment in pathological tissues.

Association of macrophages, mast cells and eosinophil leukocytes with angiogenesis and tumor stage in non-small cell lung carcinomas (NSCLC)

The association between inflammatory cells, including tumor associated macrophage (TAM), mast cell (MC) and eosinophil leucocyte (EL) densities and angiogenesis, as well as the relation of TAM, MC and EL densities and angiogenesis to tumor stage were investigated in specimens of 63 non-small cell lung carcinoma (NSCLC). Fifteen cases were in stage I, 12 were in stage II, 33 were in stage III and 3 were in stage IV. ELs and MCs were identified by hematoxilen-eosin and toluidine-blue histochemical stains, respectively. TAMs were shown by immunohistochemistry for CD68. Microvessels demonstrated by immunohistochemistry for CD31 were quantified by a stereological method and vascular surface density (VSD) and microvessel number (NVES) were calculated. There was not any statistically significant correlation between tumor's stage and VSD, TAM and EL counts. MC count and NVES were found to be higher in early stages. VSD and NVES were not associated with EL, MC and TAM counts. The lack of consistent correlation of angiogenesis to the stage of disease in this study supports the view that tumor angiogenesis is not a significant prognostic factor in NSCLCs. The absence of correlation between MCs, ELs and TAM counts and angiogenesis and absence of any relation between ELs and TAMs and tumor stage are discordant with the results of some of the previous studies in NSCLCs and in other tumors. The differing results may be due to wide variations in methodologies which were used for demonstration of inflammatory cells and vessels and variations in the degree of activation and complexity of functions of these cells.

Polyphenols, Inflammatory Response, and Cancer Prevention: Chlorination of Isoflavones by Human Neutrophils

An important aspect of the risk of cancer is the involvement of the inflammatory response. Currently, antiinflammatory agents are used in chemopreventive strategies. For example, aspirin is recommended for the prevention of colon cancer as well as breast and other cancers. The inflammatory response involves the production of cytokines and proinflammatory oxidants such as hypochlorous acid (HOCl) and peroxynitrite (ONO2-) produced by neutrophils and macrophages, respectively. These oxidants react with phenolic tyrosine residues on proteins to form chloro- and nitrotyrosine. Diets rich in polyphenols (green tea catechins, soy isoflavones) have also been shown to be chemopreventive. The aromatic nature of polyphenols makes them potential targets of HOCl and ONO2-. These reactions may create novel pharmacophores at the site of inflammation. Previous studies in the neutrophil-like cell line, differentiated HL-60 cells, demonstrated the formation of chlorinated and nitrated isoflavones. In this study we have examined whether similar reactions occur in freshly isolated human neutrophils. After induction of a respiratory burst with a phorbol ester, isoflavones and their metabolites were identified by liquid chromatography-tandem mass spectrometry and then quantitatively measured by LC-mass spectrometry using multiple-reaction ion monitoring. The data obtained indicate that both chlorinated and nitrated genistein are formed by human neutrophils. The extent of chlorination of genistein was markedly increased by the phorbol ester whereas the low level of nitration of genistein was constitutive and unaffected. These data imply a potential role for modified forms of genistein that would be produced in the inflammatory environment in and around a tumor.

Phagocytosis by dendritic cells rather than MHC IIhigh macrophages is associated with skin tumour regression

Dendritic cells (DC) are important for the induction of anti-tumour immunity and are currently being used in clinical trials. Whether DC in tumours behave the same as DC in normal tissues or whether the tumours subvert DC phenotype and function remains unknown. To address this, we have used a unique animal tumour model to compare the DC infiltrating regressing tumours with the DC infiltrating progressing skin tumours. Compared to progressor tumours, the regressor tumours were infiltrated by greater numbers of DC that were also less mature, based on MHC II expression. Apart from this, the phenotype of DC in both tumours was similar. However, compared to various control DC, they could not be classed as either mature or immature. Similar to terminally maturated DC but in contrast to fresh DC, tumour-derived DC did not express CCR5 or CXCR4, suggesting that they most closely resembled terminally matured DC. Macrophages that expressed high MHC II levels were found infiltrating progressor but not regressor tumours and in vivo were the major phagocytic cell. In contrast, DC were found to be the major phagocytic cell in regressor tumours. The results show that immune destruction and eventual regression of skin tumours occurs if DC rather than MHC II(high) macrophages are the major phagocytic cell.

Monocyte chemoattractant protein-1 increases microglial infiltration and aggressiveness of gliomas

Macrophages are thought to represent a first line of defense in anti-tumor immunity. Despite infiltration by microglial cells, however, malignant gliomas are still highly aggressive tumors. We here identify monocyte chemoattractant protein-1 (MCP-1) as a critical chemoattractant for glioma-infiltrating microglial cells. MCP-1-transfected rat CNS-1 gliomas were massively infiltrated by microglial cells. Whereas MCP-1 did not promote the growth of CNS-1 cells in vitro, intracerebral CNS-1-transfected tumors grew more aggressively than control-transfected tumors. This provides the first functional evidence that MCP-1 recruits microglial cells to gliomas and promotes their growth in vivo. Microglial cells may support rather than suppress glioma growth.

Tumour hypoxia, chemotherapeutic resistance and hypoxia-related therapies

Tissue hypoxia occurs where there is an imbalance between oxygen supply and consumption. Hypoxia occurs in solid tumours as a result of an inadequate supply of oxygen, due to exponential cellular proliferation and an inefficient vascular supply. It is an adverse prognostic indicator in cancer as it is associated with tumour progression and resistance to therapy. The expression of several genes controlling tumour cell survival are regulated by hypoxia, e.g., growth factors governing the formation of new blood vessels, and hypoxia-responsive transcription factors modulating the expression of genes, which promote tumour cell survival. This review outlines some of the pathways by which tumour hypoxia leads to chemotherapeutic resistance, directly due to lack of oxygen availability, and indirectly due to alterations in the proteome/genome, angiogenesis and pH changes. Some innovative therapies are also detailed which may potentially minimise or eliminate these problems associated with targeting solid tumours.

Immune responses in cancer

The complex of humoral factors and immune cells comprises two interleaved systems, innate and acquired. Immune cells scan the occurrence of any molecule that it considers to be nonself. Transformed cells acquire antigenicity that is recognized as nonself. A specific immune response is generated that results in the proliferation of antigen-specific lymphocytes. Immunity is acquired when antibodies and T-cell receptors are expressed and up-regulated through the formation and release of lymphokines, chemokines, and cytokines. Both innate and acquired immune systems interact to initiate antigenic responses against carcinomas. A new approach to the treatment of cancer has been immunotherapy, which aims to up-regulate the immune system in order that it may better control carcinogenesis. Currently, several forms of immunotherapy that use natural biological substances to activate the immune system are being explored therapeutically. The various forms of immunotherapy fall into three main categories: monoclonal antibodies, immune response modifiers, and vaccines. While these modalities have individually shown some promise, it is likely that the best strategy to combat cancer may require multiple immunotherapeutic strategies in order to demonstrate benefit in different patient populations. It may be that the best results are obtained with vaccines in combination with a variety of immunotherapy combinations. Another potent strategy may be in combining with more traditional cancer drugs as evidenced from the benefit derived from enhancing the efficacy of chemotherapy with cytokines. Through such concerted efforts, a durable, therapeutic antitumour immune response may be achieved and maintained over the course of a patient's lifespan.

Mechanisms of macrophage cytotoxicity in IL-2 and IL-12 mediated tumour regression

IL-2 and IL-12 are promising anti-tumour agents. However, little attention has been paid to the role of macrophages during IL-2/IL-12 mediated tumour rejection. We studied the role of macrophages during IL-2/IL-12 mediated tumour rejection in DBA/2 mice bearing syngeneic SL2 lymphoma. Local treatment with IL-2 and IL-12 cured 85% of mice with severe metastasised tumour load. In vivo depletion studies showed that macrophages were required for the anti-tumour effect of IL-2 and IL-12. Macrophages could kill tumour cells both non-specifically and by antibody-dependent cellular cytotoxicity (ADCC). Treatment with IL-2, IL-12 or IL-2/IL-12 enhanced production of specific IgG1 immunoglobulins, while treatment with IL-12 and IL-2/IL-12 additionally induced IgG2a production. FcgammaRII and/or III were essential for ADCC expression after treatment with IL-2 and IL-12. These data show for the first time the essential role of macrophages during IL-2/IL-12 mediated tumour rejection and also suggest that IL-2 and IL-12 act via different mechanisms.

Pathophysiological implications of stroma pattern formation in uveal melanoma

Clinical outcome of cancer patients is mainly determined by the rate of metastasis and, also by primary tumor growth. Formation of extracellular matrix and interactions of neoplastic and non-neoplastic (host) cells in solid tumors have been shown to be essential for these processes. One result of such interactions is the outgrowth of new blood vessels from existing ones, angiogenesis, to provide the tumor tissue with oxygen and nutrients. It is assumed that the neovascular bed also facilitates the escape of metastatic cells from the primary lesions. In addition, recent reports suggested the existence of blood-conducting channels lined by melanoma cells (so-called "vascular channels") accompanied by depositions of extracellular matrix patterns in cutaneous and uveal melanoma. Since the presence of these matrix structures has been negatively associated with prognosis, we hypothesize that they play a role in melanoma outgrowth or metastasis. In this review, we will discuss the morphological and functional properties of the extracellular matrix patterns in that may underlie these clinical phenomena.

Vascular endothelial growth factor, CD68, and epidermal growth factor receptor expression and survival in patients with Stage II and Stage III colon carcinoma: a role for the host response in prognosis

BACKGROUND

The elucidation of new therapeutic targets of prognostic significance in colon carcinoma is necessary to improve outcomes. In the current study, the authors examined the expression of epidermal growth factor receptor (EGFR) and vascular endothelial growth factor (VEGF) in primary colon carcinoma cases and VEGF in tumor-associated macrophages (TAM)/stroma, and their correlation with survival.

METHODS

The authors identified 131 consecutive American Joint Committee on Cancer Stage II and Stage III colon carcinoma patients seen at the University of Rochester between 1990-1995. Expression of VEGF, EGFR, and CD68 were examined by immunohistochemistry in paraffin-embedded primary colon tumors and graded as the percentage of cells stained. Data were analyzed using a multivariate Cox proportional hazards model.

RESULTS

VEGF expression in tumor was not found to be significantly associated with survival. However, 42% of the patients expressed VEGF in TAM/stroma. The median survival in this group was 9.7 years versus 4.3 years in the VEGF-negative (TAM/stroma) group (hazards ratio of 0.57, 95% confidence interval [95% CI], 0.34-0.95; P = 0.03). Although TAM infiltration alone was not found to be significant in multivariate analysis, the presence of both CD68 and VEGF (TAM/stroma) was predictive of improved survival (hazards ratio of 0.48, 95% CI, 0.28-0.83; P = 0.006). High grades of EGFR expression (> or = Grade 2) were found to be associated with a trend toward worsened survival.

CONCLUSIONS

The greater than twofold increase in median survival associated with VEGF-expressing TAM suggests a hitherto unknown role for this subset of cells in the host response to colon carcinoma and requires further investigation. Overexpression of EGFR may be associated with worsened survival, providing a rationale for trials of anti-EGFR agents as adjuvant therapy.

Host microenvironment in breast cancer development: inflammatory and immune cells in tumour angiogenesis and arteriogenesis

Breast cancer progression is associated with and dependent upon robust neovascularization. It is becoming clear that tumour-associated 'normal' cells, such as immune/inflammatory cells, endothelial cells and stromal cells, conspire with cancer cells in promoting this process. In particular, infiltrating immune/inflammatory cells secrete a diverse repertoire of growth factors and proteases that enable them to enhance tumour growth by stimulating angiogenesis and, as we suggest here, by promoting 'tumour arteriogenesis' - enlargement of feeding vessels supplying the expanding tumour capillary bed. Macrophages and their chemoattractants (e.g. macrophage chemoattractant protein-1) are critical for the arteriogenic process in ischaemia, and probably also in breast neoplasia. A better understanding of these various cellular and molecular constituents of breast cancer neovascularization may be useful in designing more effective therapies.

Tumour-Induced Angiogenesis: A Review

Angiogenesis, the formation of new blood vessels, has become a broad subject and is a very active area for current research. This paper describes the main biological events involved in angiogenesis and their importance in cancer progression. In the first section, a fundamental overview of tumour biology is presented. In the second section, the biology of healthy blood vessels is described and, in the third section, the mechanisms of cell migration and proliferation, which are crucial to angiogenesis, are discussed. In the fourth section, a detailed account of tumour-induced angiogenesis is given, whilst the pro- and anti-angiogenic factors involved are reviewed in the fifth section. Finally, the processes of tumour invasion and metastasis are examined in the sixth section.

Requirement of macrophages and eosinophils and their cytokines/chemokines for mammary gland development

Epithelial/mesenchymal cell interactions are necessary for proper ductal morphogenesis throughout all stages of mammary gland development. Besides the well-established stromal components, such as adipocytes and fibroblasts, the mammary stroma is also infiltrated with migrating blood cells, mostly macrophages and eosinophils. The focus of this review is on the role of macrophages and their growth factor colony-stimulating factor 1 (CSF-1) in promoting branching morphogenesis during postnatal mammary gland development through to lactation. The more restricted role of eosinophils and their chemoattractant eotaxin during pubertal ductal morphogenesis is also discussed. A possible interaction between macrophages and eosinophils in ductal morphogenesis is considered, along with the roles of other chemokines. This role of macrophages in normal development also appears to be subverted by tumors of the mammary gland to promote the escape of the tumor cells from the local environment and enhance their rate of metastasis. These data emphasize the dual role of macrophages in the promotion of epithelial growth in normal and cancer states.