The dual role of tumor lymphatic vessels in dissemination of metastases and immune response development

Figures & data

Figure 1. (A) The lymphatic vessel in normal and mouse melanoma tumor tissue. Left. In normal skin, basement membrane-supported lymphatic vessels (L) can be morphologically distinguished after identification of intravascular valves (V) from blood capillaries (c) and adipocytes (F). Normal tissue is also free from tenascin C, extracellular matrix characteristic for tumor remodeled tissue. Middle. At the tumor margin, new extracellular matrix is deposited and pre-existing lymphatic (L) and blood vessels (BV) are remodeled. Also, new, poorly organized vessels are formed (nL). Right. In the center of the tumor, deposition of new matrix paralleled the loss of organized tissue architecture with large tortuous granulation tissue-like blood (c) vessels and a collapse of lymphatics. (B) The overview of LECs, tumor and tumor-associated immune cells' interactions during tumor lymphangiogenesis and lymphatic vessels enlargement. Secretion of a variety of cytokines and growth factors mobilize tumor cells as well as dendritic cells to get inside the initial lymphatic vessels. (C) COX-2 increases level of prostaglandin receptor (EP2) and enhances expression of VEGF-C, CCR7 as well as CCL21. Binding of VEGFR-3, Tie1/2 and TNFR1 ligands induces LECs proliferation and capability of tube formation.

Table 1. Molecules potentially involved in tumor cells trafficking through the lymphatic vessels.

Molecule involved in cell migration	Role in leucocytes trafficking by lymphatic vessels	Expression on tumor cells	Influence on tumor progression
CCR7	Upregulated CCR7 during activation and maturation of DCs to respond to lymphatic-secreted CCL21 and elicits directional migration^62	Melanoma, colorectal, mammary, gastric, non-small cell lung, head and neck cancers, thyroid and squama cell carcinomas^42,63	Expression is correlated with lymph node metastasis.
CCR4	Selectively expressed on Th2 cells and regulatory T cells	Breast, lung, gastric cancer ^64	Expression is associated with lung and lymph nodes metastasis. In breast cancer, correlated with HER2 positive tumors and poor prognosis
ICAM-1	ICAM-1 knockout mice have defects in lymph node recruitment of DCs^43	Melanoma, breast cancer, gastric cancer, esophageal cancer, colorectal carcinoma^65	The results are controversial. In some cases ICAM-1 plays a major role in invasion of cancerous cells while in others decreased expression inhibits formation of metastases^66
COX-2	COX-2 plays an important role in leucocytes migration and adhesion, likely by modulating p110g PI3K–mediated cell signaling^67	Breast cancer, esophageal cancer pancreatic cancer, various colorectal tumors, adenocarcinoma, prostate and bladder cancers^68	Upregulates CCR7 via EP2/EP4 receptor signaling pathways and enhances lymphatic metastasis
CD99	Involved in transmigration of monocytes, neutrophils, lymphocytes and DCs	Ewing sarcoma, synovial sarcoma and low-grade fibromyxoid sarcoma^69	Knocking down CD99 in Ewing sarcoma reduces tumor ability to form metastases

Table 2. Overview of lymphangiogenesis inhibitors investigated in pre-clinical studies.

Drug name	Molecular target	Treatment	Mechanism of action	Outcome
Soluble VEGFR-3^70	VEGF-C	Pre-clinical studies in endometrial cancer model	Inhibits lymphatic endothelial cell growth in vitro	Suppresses in vivo lymph node and lung metastasis
Canstatin^71	Ang1/Ang2	Pre-clinical studies in colon carcinoma model	Reduces tumor blood and lymphatic vessel densities	Reduces final volume and weight of tumors
Endostatin^72	VEGFR-3	Pre-clinical	Causes inhibition of bFGF-induced corneal angiogenesis and lymphangiogenesis	—
16K hPRL^73	VEGFR-3	Pre-clinical studies in melanoma model	Induces apoptosis and inhibits proliferation, migration and tube formation of human dermal lymphatic microvascular endothelial cells	Prevents lymphatic metastasis
SAR131675^74	VEGFR-3	Pre-clinical studies in breast cancer model	Reduces TAM infiltration	Reduces lymph node and lung metastasis
cVE-199^75	VEGF-D	Pre-clinical studies in neuroblastoma model	Inhibits lymphangiogenesis	Prevents lymphatic metastasis of neuroblastoma
Nrp2^76	Semaphorin	Pre-clinical studies in breast cancer model	Inhibits VEGF-C-induced phosphorylation of VEGFR-3, ERK1/2, and AKT	Tumor cells expressing sema3C contained a lower concentration of lymph vessels and form lymph nodes metastasis much less effectively
Biomimetic peptide SP2012^53	c-MET	Pre-clinical studies in breast cancer model	Inhibits blood and lymphatic endothelial cell viability, migration, adhesion and tube formation	Inhibits lymphangiogenesis in primary tumors
Rapamycin^77	mTOR	Pre-clinical studies in head and neck cancer model	Inhibits lymphangiogenesis	Prevents dissemination to the cervical lymph nodes

Table 3. Overview of lymphangiogenesis inhibitors investigated in clinical studies.

Drug name	Molecular target	As a monotherapy	As a combined therapy
VGX-100	VEGF-C	—	With bevacizumab – Phase I ongoing (NCT01514123) in treatment of advanced solid tumors
Lenalidomide	VEGF-C	Lenalidomide is used in pre-clinical studies to inhibit growth of peritumoral lymphatic vessels
Bevacizumab	VEGF	Bevacizumab is an inhibitor of angiogenesis studied in various pre-clinical trials as anti-lymphangiogenic drug. Approved for various treatment: breast, lung, colorectal, renal and brain cancer
AMG-386 (Trebananib)	Ang1/Ang2	Treatment of endometrial adenocarcinoma – Phase II ongoing (NCT01210222).	Used in the treatment of renal cell carcinoma with sorafenib – Phase II completed (NCT00467025). No data have been published so far
		Treatment of advanced solid tumors – Phase I completed (NCT00102830). No data have been published so far	Used in the treatment of renal cell carcinoma with sunitinib – Phase II ongoing (NCT00853372)
MEDI3617	Ang1/Ang2	—	Used in treatment of melanoma with tremelimumab – Phase I ongoing (NCT02141542).
			Used in the treatment of advanced solid tumors with bevacizumab/paclitaxel/carboplatin/gemcitabine – Phase I completed (NCT01248949). No data have been published so far
CVX-060	Ang1/Ang2	Treatment of advanced solid tumors – Phase I completed (NCT00879684). 0.3, 1, 3, 6, 12, 15 mg/kg of b.w. intravenous infusion in Stage 1 and 15 mg/kg of b.w. intravenous infusion in Stage 2, administered once-weekly in a 4-week cycle	—
Sorafenib	VEGFR-3	Sorafenib inhibits VEGFR-2 and VEGFR-3, blocks proliferation of different tumor cells and inhibits tumor lymphangiogenesis.^78 Was approved for renal cell carcinoma and hepatocellular carcinoma treatment.
Sunitinib	VEGFR-3	In pre-clinical studies, sunitinib blocked VEGFR-2 and VEGFR-3 phosphorylation induced by VEGF-C or VEGF-D and inhibited LECs proliferation and migration.^79 Was clinically approved for renal cell carcinoma and gastrointestinal stromal tumor treatment
Axitinib	VEGFR-3	In pre-clinical studies used as VEGFR-3 inhibitor.^55 Approved for renal cell carcinoma treatment
Regorafenib	VEGFR-3	Regorafenib is used in pre-clinical studies to inhibit VEGFR-2 and VEGFR-3 autophosphorylation, VEGFR-3 intracellular signaling and to block LECs migration.^80
Pazopanib	VEGFR-2/ VEGFR-3	Pazopanib exert anti-angiogenic and anti-lymphangiogenic potential in pre-clinical studies as VEGFR-2 and VEGFR-3 inhibitor.^55 In clinical studies is use in combination with bevacizumab. Approved for renal cell carcinoma treatment
IMC-3C5	VEGFR-3	Treatment of neoplasma – Phase I completed (NCT01288989). No data have been published so far	—

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