Seminars in Cancer Biology xxx (xxxx) xxx–xxx

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Seminars in Cancer Biology

journal homepage: www.elsevier.com/locate/semcancer

Review

Revisiting the hallmarks of cancer: The role of hyaluronan

Ilaria Caon, Barbara Bartolini, Arianna Parnigoni, Elena Caravà, Paola Moretto, Manuela Viola,
⁎ ⁎
Evgenia Karousou, Davide Vigetti , Alberto Passi
Department of Medicine and Surgery, University of Insubria – via J.H. Dunant 5, 21100, Varese, Italy

A R T I C LE I N FO A B S T R A C T

Keywords: Extracellular matrix (ECM) is a complex network of macromolecules such as proteoglycans (PGs), glycosami-
HAS2 noglycans (GAGs) and fibrous proteins present within all tissues and organs. The main role of ECM is not only to
HAS2-AS1 provide an essential mechanical scaffold for the cells but also to mediate crucial biochemical cues that are
CD44 required for tissue homeostasis. Dysregulations in ECM deposition alter cell microenvironment, triggering the
4-Methylumbelliferone
onset or the rapid progression of several diseases, including cancer. Hyaluronan (HA) is a ubiquitous component
Extracellular matrix
of ECM considered as one of the main players of cancer initiation and progression. This review discusses how HA
participate in and regulate several aspects of tumorigenesis, with particular attention to the hallmarks of cancer
proposed by Hanahan and Weinberg such as sustaining of the proliferative signaling, evasion of apoptosis,
angiogenesis, activation of invasion and metastases, reprogramming of energy metabolism and evasion of im-
mune response.

1. Introduction signaling pathways able to stimulate cell proliferation, motility, an-

In the first review article “The Hallmarks of cancer” Hanahan and
Weinberg explained widely and in detail the dense complexity of cancer
biology highlighting six major hallmarks of cancer [1]: self-sufficiency
in growth signals, insensitivity to anti-growth signals, evading apop-
tosis, limitless replicative potential, sustained angiogenesis and tissue
invasion and metastasis. This concept has been revisited introducing
further hallmarks as the ability of cancer cells to reprogram energy
metabolism and to evade the immune response [2]. During the fol-
lowing years, these notions have been solidified and developed, re-
vealing that the biology of tumors can no longer be understood simply
investigating the traits of cancer cells but instead must include the
study of tumor microenvironment and the contribution of extracellular
matrix (ECM). The remodeling of ECM during carcinogenesis plays a
key role in tumor progression [3,4]. ECM is able to bind secreted mo-
lecules and therefore can serve as a reservoir for growth factors and
cytokines, allowing their diffusion and activation status. Moreover,
ECM components recognize receptors on the cell surface, triggering
giogenesis and inflammation [5]. Hyaluronan (HA) is a widely ex-
pressed polymer of ECM and its metabolism is extremely important in
the regulation of receptor signaling and cell behavior in cancer [6].
Given these considerations, this review will analyze the different as-
pects of HA in reference to the hallmarks of cancer. In particular, the
following topics will be analyzed: sustaining of the proliferative sig-
naling, evasion of apoptosis, angiogenesis, activation of invasion and
metastases, reprogramming of energy metabolism and evasion of the
immune response (Fig. 1).
2. Hyaluronan (HA)
HA is a simple linear and unsulfated glycosaminoglycan (GAG)
composed by repeating units of N-acetylglucosamine (GlcNAc) and
glucuronic acid (GlcUA). HA is produced on the plasma membrane by a
family of three transmembrane hyaluronan synthases named HAS1,
HAS2 and HAS3 using the cytosolic UDP-GlcNAc and UDP-GlcUA as
precursors [7,8].

Abbreviations: 4-MU, 4-Methylumbelliferone; 4-MUG, 4-Methylumbelliferone glucuronide; ECM, extracellular matrix; ECs, endothelial cells; EMT, epithelial to
mesenchymal transition; GAG, glycosaminoglycan; GlcNAc, N-acetylglucosamine; GlcUA, glucuronic Acid; HA, hyaluronan; HAREHA, receptor for Endocytosis;
HAS2-AS1-, hyaluronan synthase 2 antisense 1; HASes, hyaluronan synthases; HIF-1α, hypoxia-inducible factor 1-alpha; HMWHA, high molecular weight HA;
HYALs, hyaluronidases; LECs, lymphatic endothelial cells; LMWHA, low molecular weight HA; LncRNA, long non coding RNA; LYVE-1, lymphatic vessel endothelial
receptor; RHAMM, receptor for HA-mediated motility; TGFβ, transforming growth factor beta; TLR, toll-like receptor; VEGF, vascular endothelial growth factor;
VEGFR, vascular endothelial growth factor receptor
⁎
Corresponding authors.
E-mail addresses: Davide.vigetti@uninsubria.it (D. Vigetti), alberto.passi@uninsubria.it (A. Passi).

https://doi.org/10.1016/j.semcancer.2019.07.007
Received 29 April 2019; Received in revised form 19 June 2019; Accepted 14 July 2019
1044-579X/ © 2019 Elsevier Ltd. All rights reserved.

Please cite this article as: Ilaria Caon, et al., Seminars in Cancer Biology, https://doi.org/10.1016/j.semcancer.2019.07.007
I. Caon, et al.
Fig. 1. Schematic summary of HA role in the hallmarks of cancer.
Although the three HASes have a similar structure and share high
homology in their amino acid sequence [9], the most important isoform
for the production of HA is HAS2. HAS2 expression is critical for animal
survival, especially during embryogenesis as a deficiency of this enzyme
results in embryonic lethality and failure of the endocardial cushion
formation, along with defects in the yolk sac and vasculogenesis
[10,11].
HAS2 mRNA expression is strictly related to HA production and it
can be controlled at transcriptional and post-transcriptional levels
[12–14], as well as by epigenetic mechanisms via the long non coding
RNA (lncRNA) hyaluronan synthase 2 antisense 1 (HAS2-AS1) [15].
Under physiological conditions, HA is produced as a negatively
charged polymer of high molecular weight (HMW HA), with a size up to
1,4 × 107 Da in the naked mole rat that displays exceptional longevity
and shows an unusual resistance to cancer [16]. However, under pa-
thological conditions, HA may be fragmented by the action of hyalur-
onidases (HYALs) or oxidative/nitrosative stress into low molecular
weight chains (LMW HA). It is widely recognized that the biophysical
functions of HA strictly depend on its molecular size [17]. For instance,
HMW HA has anti-angiogenic, anti-proliferative and im-
munosuppressive properties, whereas LMW HA is able to induce in-
flammation, angiogenesis, proliferation and has immune stimulatory
functions [17]. Furthermore, HA can be covalently linked to the heavy
chains of inter-alpha-trypsin inhibitor (IαI) by the tumor necrosis
factor-inducible gene 6 protein (TSG-6) [18], which is involved in im-
mune cells modulation [19].
As an integral component of ECM, HA provides a scaffold for cancer
and stromal cells, regulating the diffusion of signaling molecules and
cell behavior through the interactions with the main HA receptors as
CD44 and the receptor for hyaluronic acid-mediated motility
(RHAMM). The synthesis of HA, along with the over expression of
HASes, HYALs and HA receptors are crucial events that regulate the
onset and the progression of cancer [20]. An abnormal production of
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Seminars in Cancer Biology xxx (xxxx) xxx–xxx
HA by stromal and cancer cells occurs in a variety of tumors as breast
[21], colorectal [22], lung [23], hepatic [24], gastric [25] and pan-
creatic cancer [26] and it is strongly associated with tumor aggres-
siveness and an unfavorable disease outcome.
However, contradictory observations have been made in clinical
and experimental studies, suggesting that HA may regulate tumor
progression in opposite ways in a context-dependent manner. For in-
stance, reduced levels of HA in patients affected by oral squamous cell
carcinoma correlated with poor survival [27] and, similarly, a de-
creased expression of CD44 and HA was associated to a poor prognosis
in patients with stage I melanoma [28].
Besides HA production, the expression of HASes is a critical aspect
during carcinogenesis. A vast number of studies have demonstrated that
HAS2 overexpression by cancer and stromal cells is associated with
tumor aggressiveness and a poor prognosis [29]. For instance, an in-
creased expression of HAS2 correlates with tumor progression and
metastasis in breast [30], oral [31], endometrial cancer [32] and as-
trocytomas [33]. Moreover, HAS2-AS1 and HAS2 have been demon-
strated to promote epithelial to mesenchymal transition (EMT), a highly
dynamic process by which epithelial cells can convert into a me-
senchymal phenotype promoting tumor progression and metastatic
expansion [34–36]. The majority of the published studies have focused
on HAS2, as it is the most important and finely regulated isoform
among the three HASes [37]. However, emerging evidences have de-
monstrated that also HAS3 and HAS1 play a role in a variety of cancers
[38–42].
3. Sustaining proliferative signaling
One of the most investigated hallmarks of tumor transformation and
progression is the acquired proliferative capability of cells that escapes
growth regulation. The mechanisms by which the tumor cells establish
their de-regulated ability to proliferate are active at different levels: by
I. Caon, et al.
enhancing proliferation itself and/or by inhibiting the proliferative
suppression control of the surrounding environment. In this context, the
function of ECM in presenting and/or sequestering growth factors to
cell receptors may contribute to cell fate. HA is a major component of
the extracellular microenvironment that can actively contribute to in-
duce proliferative signaling pathways.
HA accumulates in the stroma of several tumors, usually with poor
prognosis [43]. HA is the recognized ligand of a number of surface
receptors found in different cell types, both in physiological and pa-
thological conditions, i.e. CD44, RHAMM, the lymphatic vessel en-
dothelial hyaluronan receptor 1 (LYVE-1), the HA receptor for en-
docytosis (HARE) and the toll like receptor 4 (TLR4) [44]. The
engagement of one or more of its binding partners accounts for the
perturbation of the tissue homeostasis eventually unbalancing cell
motility, proliferation, apoptosis and tissue remodeling. The HA sig-
naling pathways and biological effects strongly depend on the mole-
cular size of the polymer [17]. The peculiar mechanism underlying HA
stimulation is the feedback loop generated by the activity of the HA
metabolic enzymes (HA synthases and hyaluronidases), which can be
induced or repressed and in turn generate new HA fragments. The latter
may as well amplify or dampen the triggering signal, modulating tumor
progression.
The most prominent receptor of HA is CD44. CD44 is a type I
transmembrane glycoprotein ubiquitously expressed on cell surfaces,
responsible for the communication and the adhesion between adjacent
cells and between cells and ECM. The receptor broadens the potentiality
of HA signaling in several contexts and especially in tumor progression
[45].
One of the targets of CD44 engagement by HA is the activation of
RhoGTPase signaling, which acts through different effectors to control
cytoskeletal organization, chemoresistance, cell growth and prolifera-
tion. Rho activation induces PI3K which triggers the serine/threonine
kinases (Akt) and, in turn, the phosphorylation of substrates involved in
cell proliferation, survival and motility [46]. Continuous activation of
the Akt signaling in breast cancer cells have been shown to be induced
by CD44 through a positive feedback loop that involves HAS2 and HA
production, with the final effect of overcome apoptosis and sustain cell
survival [47].
Another effector of PI3K/Akt is the mammalian target of rapamycin
(mTOR) pathway. mTOR is known to phosphorylate various substrates
that promote cell proliferation and metabolism [48]. Recently, an in-
creased attention has been payed to the role of tumor-derived micro-
vesicles. These vesicles shedded by tumor cells membranes contain a
variety of intracellular material (small proteins, RNA, miRNA, lncRNA)
and interestingly, can display HA on their membrane [49]. The delivery
of this material to target cells is a mechanism by which tumor cells
communicate with the environment influencing tissues and cell fate. In
this light, HA carried by microvesicles derived by tumor cells can sti-
mulate proliferative pathways in the target cell population and tissues
[50].
The HA/CD44 interaction also activates Cdc42 signaling. This
pathway plays a significant role in actin remodeling, cytoskeletal re-
arrangement and cell growth, especially through activation of ERK 1/2,
which has been already shown to be activated by HA/CD44 [51]. For
instance, the HA-CD44 interaction with the protein IQGAP1 activates
ERK2 phosphorylation and subsequently the estrogen receptor α in
ovarian tumor cells, [52], contributing to tumor progression.
The proliferative activity is not the only one sustained by HA/CD44
mediated signaling. As previously highlighted, cancer progression is
also supported by abnormal cell growth. HA promoted interaction of
CD44 with Vav2 protein, a member of the Vav family of oncoproteins,
sustains Rac1 and Ras activation, with the outcome of increasing
ovarian tumor cell growth and migration [53].
The enhanced survival potential of tumor cells is realized by the
combination of increased proliferation and growth and activation of
mechanisms to escape growth suppression and cell death. HA/CD44
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Seminars in Cancer Biology xxx (xxxx) xxx–xxx
binding takes part in the anti-apoptosis and chemoresistance of breast
tumor cells with a mechanism involving protein kinase C (PKC) and the
production of miR-21 [54].
RHAMM is another well-known HA binding partner on the cell
surface. RHAMM signals to kinases, calmodulin and cytoskeletal pro-
teins, primarily modifying adhesion and cell motility in response to HA
binding [55]. Like CD44, RHAMM is expressed in several cell lines,
including tumor cells where it was firstly described [56]. Its presence
has been suggested as a biomarker in different types of tumor and its
inhibition correlates with lower proliferation rate in colorectal cancer
[57]. RHAMM implication in proliferative signaling is underlined by
the fact that this receptor has been described as a cell cycle protein,
being involved in G2/M progression [58] and could therefore be con-
sidered as a promising therapeutic target.
HARE binds not only HA but also other glycosaminoglycans and it
triggers as well ERK1/2 and the nuclear factor kappa-light-chain-en-
hancer of activated B cells (NF-kB) [59]. Although no specific tumor-
related proliferative signaling has been described so far, its blocking
with a specific antibody inhibits the formation of lymph nodes metas-
tasis in prostate cancer [60].
LYVE-1 is highly homologous to CD44 and is mainly expressed in
lymphatics. Its binding to LMW HA promotes proliferation of lymphatic
endothelial cells [61]. Interestingly, a shedded ectodomain LYVE-1
originating from tumor associated M2 macrophages can act as a decoy
receptor for HA, reducing the proliferation in melanoma cells [62]. This
ability can be further explored as a potential therapeutic use of a HA
receptor in melanoma.
HAS2-AS1 natural antisense is a new player in the modulation of HA
signaling. HAS2-AS1 is expressed in normal and tumor cell lines and
displays a variety of effects, including cell proliferation inhibition
[63,64] and increased invasiveness [65]. The effect of this lncRNA
appears to be different in dependence on the cell line, acting via sta-
bilizing or neutralizing HAS2 transcript [15,66]. The role of HAS2-AS1
in sponging endogenous miRNAs in tumor cells may add new in-
formation in the modulation of proliferative, apoptotic and migratory
capacity in cancer.
4. Evasion of apoptosis
In addition to increased proliferative ability, cancer cells accomplish
their uncontrolled growth by escaping the signaling circuity regulating
cell death and apoptosis. In this light, HA and the related pathways
appear to be suitable candidates for the regulation of such processes as
well. Indeed, inhibition of lung cancer cell growth both in vitro and in
vivo can be realized by the targeting of CD44/RHAMM signaling [67]
and the use of drugs interfering with this axis may disclose new ther-
apeutic approaches.
HA link to apoptosis regulation was shown in aortic smooth muscle
cells, where the inhibition of HA synthases causes an increment in
apoptotic cells upon the stimulation with 4-methylumbelliferone (4-
MU) [68]. 4-MU is a coumarin derivative able to selectively inhibit HA
synthesis at least in two different ways. First, 4-MU can deplete the
availability of the substrate UDP-GlcUA, acting as a competitive sub-
strate for the enzyme UDP-glucuronosyltransferase (UGT). Second, 4-
MU is able to reduce the expression of HAS2 and HAS3 [69], as well as
the mRNA for UDP-glucose pyro-phosphorylase and dehydrogenase
[70]. Supporting this finding, the 4-MU treatment decreased malig-
nancy of peripheral nerve sheath tumors [71], pancreatic [72] and
bladder cancer [73], enhancing cell apoptosis.
Interestingly, there are evidences that the pathway involving p53
and mitochondrial apoptosis may be the target of HA signaling both in
normal [74] and cancer cells [75], the latter through a reduction of
CD44 positive cell population. Although in some studies the direct role
of HA is yet not described in the detail, the involvement of the main HA
receptor is a clear hint towards the importance of the molecule in the
process. The use of 4-MU as an inhibitor of HA synthesis and the
I. Caon, et al.
concomitant induction of apoptosis, appears as a reliable therapeutic
tool in the treatment of different types of cancer.
Recently, long-non coding RNA and microRNA have gained in-
creasing attention in the modulation of cancer biology. As already
mentioned the expression of HAS2-AS1 is enhanced in cancer cells and
its roles in coordinating not only HA metabolism and signaling path-
ways but also a series of other pathways through the action of miRNAs,
has to be taken into account.
New insights into the molecular pathways sustaining cell apoptosis
and drug resistance in cancer cells will come from the investigation of
the role played by non-coding RNAs and miRNAs [76].
5. Angiogenesis and lymphangiogenesis
The vast request of metabolites and oxygen of cancer cells implies
an increased supply by the vascular system, which therefore must be
reorganized to improve cancer progression. It is well-known that hy-
poxic tissue conditions at the beginning of the cancer growth trigger
local angiogenesis [77], as well as lymphangiogenesis [78]. The hy-
poxic response is essentially mediated by the hypoxia inducible factor-
1alpha (HIF-1α), induced under conditions of low oxygen via NF-kB
[79]. In cancer angiogenesis, hypoxic tumor cells (especially those
surrounding the necrotic core) release growth factors, such as the
vascular epithelial growth factor (VEGF) that stimulates the formation
of new blood vessels from pre-existing normal endothelial cells (ECs).
This process involves both ECs proliferation and enhanced vascular
permeability. New blood-vessels formation also occurs through the re-
cruitment of bone marrow–derived endothelial progenitor cells or
through mesenchymal or hematopoietic stem cells, which migrate from
the systemic circulation into the tumors [80,81].
Although the vasculature is pivotal in cancer development, the re-
sulted tumor vessels are usually disorganized, leaky and low per-
forming, causing an inefficient delivery of drugs and loss of therapy
efficacy [77]. The aim of recent preclinical and clinical studies is to
adjust the appropriate dosage of anti-angiogenic treatment that can
lead to a normalization of the tumor vasculature. Recent results pointed
out that survival benefits might be related to improved rather than
impaired tumor perfusion, as reported in lung cancer [82,83] or in
triple negative breast cancer trials [84].
The remodeling of ECM is a critical event contributing to the
spreading of the ECs and pericytes for the formation of new blood and
lymphatic vessels [85,86]. HA accumulation increases tumor interstitial
fluid pressure, compresses tumor blood vessels, and thus decreases drug
delivery. The exact mechanism by which HA accumulates in tumor
stroma has not yet been fully understood, since there is a balance be-
tween its synthesis due to HASes, its degradation (by HYALs) and its
turnover (HARE or LYVE-1 mediated) [87]. A PEGylated human re-
combinant PH20 Hyal (PEGPH20) increases tumor perfusion, vascular
permeability, and drug delivery [88], through the re-expansion of blood
vessels and an increased permeability of inter endothelial gap junctions.
These changes would be critical for the delivery of the chemotherapy
drugs to the tumoral site [88].
The presence of LMW HA in tumor microenvironment stimulates
angiogenesis via the expression of angiogenic factors like VEGF-A,
VEGF receptor 1 (VEGRF1) and HA binding protein-1 (HABP1) [89].
Interestingly, a combined treatment with doxorubicin and LMW HA
increased ECs migration and the formation of vessel-like structures. HA
can affect polyanions binding on the surface of the membranes, as it
happens in breast cancer cells, where the addition of LMW HA causes
the release of fibroblast growth factor-2 (FGF-2) from the heparan
sulfate (HS) proteoglycans which in turn increased migration and vessel
formation in ECs, independently from VEGF [90,91]. Furthermore,
LMW HA plays the critical function to stimulate the expression of ma-
trix metalloproteinases (MMPs) which favor tumor cell invasion and
angiogenesis [92].
Both tumor and stromal cells produce growth factors that promote
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Seminars in Cancer Biology xxx (xxxx) xxx–xxx
lymphangiogenesis from initial lymphatics, as well as the enlargement
of initial and collecting lymphatic vessels in and around solid tumors. In
both angiogenesis and lymphangiogenesis, ECs and pericytes represent
a critical target for the control of cancer growth and drugs penetration.
In gliomas, the use of Ibrutinib potently disrupted tumor vascular
pericytes, enhancing the delivery of drugs into the tumor to inhibit
malignant growth [93]. The study of glioblastoma multiforme indicates
CD44 as one of the main cancer markers and the receptor responsible
for contacting the target pericytes [94]. However, as also pericytes
express CD44, we cannot exclude that both glioblastoma cells and
pericytes can bind HA, which may be a connecting net wrapping the
nervous cells of the brain (as it happens in the rat myenteric plexus
[95]).
The enlargement of collecting lymphatics can involve remodeling of
these vessels by smooth muscle cells. Lymphangiogenic factors such as
VEGF-C and VEGF-D can induce the metastatic spread of tumor in
mouse models of cancer [96]. Experimental and clinic-pathological
studies have shown that lymphatic vessels undergo dynamic changes
that facilitate metastasis [96]. The receptor LYVE-1 is generally ex-
pressed on lymphatic endothelial cells (LECs) of small lymphatic vessels
but not on LECs from collecting lymphatics. The detection of LYVE-1
has been routinely used to identify lymphatic vessels in cancer [97].
The interaction between HA and LYVE‐1 stimulates the migration of
LECs [61,98]. Interestingly, the blocking of the interaction between HA
and LYVE-1 using a specific anti‐LYVE‐1 monoclonal antibody reduced
the number of lymphatic vessels in primary tumors as well as the tumor
volume in vivo [99]. To confirm the hypothesis of HA as therapeutic
target, many studies demonstrated the presence of small fragments of
HA (sHA) in interstitial tumor fluid. Pathophysiological concentrations
of sHA induce LECs proliferation and stimulate lymphangiogenesis via
VEGF-C and FGF-2 engaging LYVE-1, but not by CD44 or TLR-4 [100].
The role of HA in the stimulation of angiogenesis is highlighted by
the use of 4-MU which dramatically inhibits the growth of new vessels
in different cancer models and decreases tumor development and me-
tastasis [101,102]. The effect of HA inhibition on vessels is complex.
Indeed, the treatment with 4-MU of a model of atherosclerosis induced
by high fat diet in ApoE KO mice increased plaque formation [103]. On
the other hand, the administration of 4-MU in a model of restenosis
obtained by endothelial injury reduced neointima formation [104].
6. Activation of invasion and metastases
The invasion and metastasis of cancer cells are closely related to
poor prognosis and patient survival. Several studies have demonstrated
that modification of the ECM components affects adhesion and pene-
tration of primary tumor cells to metastasize to target [20]. Specifically,
HA, as well as its receptor CD44, correlate with metastasis of cancer
cells, such as breast, prostate and ovarian. Thus, various studies focus
on the enzymes involved in the metabolism of HA, its molecular weight,
receptors, and other intracellular or extracellular factors that enhance
its synthesis.
Metastasis of breast cancer has been described by two major models:
one suggests the evolution of a clonal selection of the initial primary
tumor cells that undergo multiple changes, including the potential to
metastasize to distant organs. The second model suggests that only a
cancer stem cell (CSCs) can metastasize and form new tumors to a
distant organ [105,106]. Delamination of tumor cells from the primary
tumor is associated by induction of EMT. As reported before, increased
HA in breast tumors supports EMT by enhancing the expression of the
zinc finger E-box-binding homeobox 1 (ZEB1), in cooperation with
CD44 standard isoform (CD44 s), which in turn activates HAS2 ex-
pression [34]. Increase of HAS2 activity is associated to a high pro-
duction of HA in these cells and, thus, to the regulation of ZEB1 in an
autocrine manner. HAS2 expression, but not the extracellular HA, has
also a regulatory role in transforming growth factorβ (TGFβ)-induced
EMT [107], as it was demonstrated that depletion of HAS2 in normal
I. Caon, et al.
Fig. 2. Schematic representation of the metabolic reprogramming in cancer cells and HA synthesis.
F6P: Fructose-6-phosphate; 3PG: 3-phosphoglycerate; A-CoA: acetyl-CoA; GlcNAc: N-Acetyl-Glucosamine; PDH: pyruvate dehydrogenase; A-KG: α-ketoglutarate;
OAA: oxalatoacetate; PPP: Pentose phosphate pathway; NAD-ME: NAD-malic enzyme; ACC: Acetyl-CoA carboxylase; UGDH: UDP-Glucose 6-dehydrogenase; UDP-
GlcUA: UDP-Glucuronic acid; HAS: hyaluronic acid synthase; MDH: Malate dehydrogenase; ER: endoplasmic reticulum.
murine mammary epithelial cells inhibited significantly the TGFβ-in-
duced EMT by decreasing the expression of the EMT markers fi-
bronectin, snail 1 and ZEB1.
The role of HAS2 in tumor progression and metastasis is noticed also
in oral cancer invasion, promoted by cancer-associated fibroblasts
(CAFs) [31]. In comparison to normal fibroblasts, CAFs show higher
expression levels not only of HAS2 but also of MMP1, with lower levels
of the tissue inhibitor of metalloproteinase 1 (TIMP1). In the same
work, it was found that HAS2 expression was consistent with α-SMA-
positive myofibroblasts in the stroma of oral squamous cell carcinoma,
and these were significantly correlated with advanced clinical stages
and cervical lymph node metastasis.
Tumor cell invasion and chemoresistance in cancer stem cells from
head to neck were also observed in HA-rich matrices [108]. In details,
in CSCs HA up-regulates histone methyltransferase DOT1L that in turn
stimulates miR-10b expression in an HA/CD44-mediated manner,
which results in the overexpression of RhoGTPases and survival pro-
teins. This process enhances the CSCs properties leading to tumor cell
invasion and cisplatin resistance.
The striking effect of HA on tumor progression is highly associated
with the molecular weight and the interactions with other proteins in
the ECM. Schmaus et al., showed that small HA oligosaccharides were
detected in a subset of interstitial tumor fluids but not in healthy tis-
sues. This increased amount of small HA was associated with lymphatic
vessel invasion by tumor cells and formation of lymph node metastasis
[109].
7. Reprogramming of energy metabolism
Isolated cancer cells from a variety of tumors and many tumor cell
lines are able to synthesize HA as well as to express HASes and all the
enzymes required for UDP-sugars production. Although ATP is not re-
quired for the reaction of HASes, HA synthesis is a demanding energy
process, which could remove substrates and indirectly ATP for other
critical biosynthesis. Further, probably because HA appeared relatively
late during tetrapod evolution, it has no critical functions for cell sur-
vival. This is not true for other GAGs as HS. Indeed HS, working as a co-
receptor for growth factors, caused dramatic cell death when its
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Seminars in Cancer Biology xxx (xxxx) xxx–xxx
synthesis was impaired.
Therefore, it is logical to wonder why a tumor cell would synthesize
HA. Cancers cells have a dramatic alteration in their metabolism.
“Normal” resting/quiescent cells live in a well-regulated environment
(i.e., proper growth factors and hormones signaling) in which nutrients
are often limiting substrates [110]. These cells should maximize ATP
availability by using glycolysis, tricarboxylic acid cycle (TCA) and the
aerobic mitochondrial oxidative phosphorylation [111]. Although the
metabolic reprogramming typical of cancer cells can be the secondary
effect of aberrant proliferative signaling, the metabolism of tumor cells
is not focused on increasing ATP availability. In fact, in order to sustain
rapid cell growth and division, proliferating cells need to maximize the
synthesis of macromolecules, increasing nucleotides, proteins, lipids
and glycans [112]. Therefore, rather than ATP, cancers cells need
carbon skeletons, nitrogen and cytosolic NADPH for anabolic reactions.
With this last concept in mind and considering the limited availability
of oxygen in tumors, it is clear that the mitochondria in cancer cells do
not work to produce ATP but to supply the cells with substrates for
biosynthesis. For example, mitochondrial pyruvate dehydrogenase is
the only reaction to produce acetyl-CoA, therefore TCA is used to
produce citrate that, in turn, is translocated to the cytoplasm, and then
reconverted in acetyl-CoA and oxaloacetate or pyruvate and NADPH.
Other important examples of mitochondrial substrates used in anabolic
reactions are oxaloacetate and alpha-ketoglutarate. Transamination
reactions convert these latter compounds into aspartate and glutamate
that are in turn exported outside the mitochondrion for nucleotides and
amino acids biosynthesis. Further, the anabolic role of mitochondria is
highlighted in glutaminolysis, probably one of the well characterized
mechanisms through which cancer cells recover precursors.
In cancer, the metabolism of glucose is very peculiar as firstly ob-
served by Otto Warburg [113]. Glucose is shunted to glycolysis with the
aim to recover pyruvate and 3-phosphoglycerate to sustain serine bio-
synthesis. Moreover, fructose 6-phosphate is required for glucosamine
and N-acetylglucosamine production via the hexosamine biosynthetic
pathway. Further, fructose 6-phosphate and glyceraldehyde 3-phos-
phate are used to synthesize ribose 5-phosphate necessary for all nu-
cleotide biosynthesis by transketolase and transaldolase catalyzed re-
actions (non oxidative phase of the pentose pathway).
I. Caon, et al.
Glycogen metabolism is very efficient in cancerous cells and glucose
is rapidly converted in UDP-glucose. The latter intermediate is also the
substrate of the enzyme UDP-glucose 6-dehydrogenase (UGDH), which
is the only reaction able to produce UDP-GlcUA. Interestingly, UDP-
GlcUA is a critical factor for GAG synthesis, detoxification reactions,
and hormones turnover. UDP-GlcUA is also converted in UPD-Xilose,
the first sugar of the linker region used to bind GAGs to the core protein
(Fig. 2).
Although it is not clear whether or not the synthesis of HA by cancer
cells is the cause of cell transformation or a secondary effect of the
tumorigenic process, as one of the main points that regulate HA
synthesis is the substrate availability, it is not surprising that cancer
cells, with such massive availability of anabolic precursors, produce
HA.
This complex reprogramming of cell biochemistry also involves al-
terations in cell metabolism. UDP-GlcNAc is elevated in many tumors
allowing the complex biosynthesis of GAGs as well as N- and O-glycans.
Further, UDP-GlcNAc has a crucial role in protein O-GlcNAcylation
within the nucleus, mitochondria and cytosol. In fact, UDP-GlcNAc is
the substrate of O-GlcNAc transferase (OGT), which has a central role in
the regulation of metabolism in response to nutrients availability.
Moreover, OGT is able to regulate glycolysis and mitochondrial flux
[114]. The synthesis of HA is enhanced by O-GlcNAcylation of HAS2 via
its stabilization in the plasma membrane allowing an efficient HA
production. Further, O-GlcNAcylation of the Nf-kB subunit p65 has a
critical function in the induction of HAS2 transcription. Mechan-
istically, this regulation involved HAS2-AS1 that is able to modify the
chromatin structure around HAS2 promoter allowing its efficient
transcription and HA deposition [15]. HAS2-AS1 is also directly regu-
lated by HIF-1α. In oral squamous cell carcinoma hypoxia-induced EMT
of transformed cells is sustained by HAS2 upregulation due to the
epigenetic action of HAS2-AS1 [65].
Another master regulator of cell metabolism is adenosine mono-
phosphate activated protein kinase (AMPK). During nutrient depriva-
tion or energetic stress conditions, the low ATP/AMP ratio activates
AMPK that is able to phosphorylate a multitude of enzymes in order to
elevate ATP production and to inhibit ATP consuming reactions. LKB1
is the upstream activator of AMPK and in many cancers LKB1 is mu-
tated, suggesting its regulatory function as a tumor suppressor [115].
Therefore, AMPK pathway is blocked in many malignancies and the
activation of AMPK is a well-known proposed method to reduce tumor
growth. This evidence is supported by the effects of the anti-diabetic
drug metformin (a potent activator of AMPK pathway), which reduces
the risk of cancer and cancer-related mortality in patients with type 2
diabetes [116]. Interestingly, the synthesis of HA is under the control of
AMPK and the activation of AMPK inhibits HA production via phos-
phorylation of HAS2 [117].
Further, the catabolism of HA is very active in cancers which can
produce i) short fragments of HA with peculiar signaling and in-
flammatory properties [118] and ii) the lysosomal recycling of HA
components that could sustain the tumor reprogrammed metabolism. It
is recently demonstrated that an active HA catabolism is able to reg-
ulate the glucose transporter 1 (GLUT1) on cancer cell membrane via
RHAMM [119].
8. Evasion of the immune response
In the last years, the concept of immune surveillance in cancer has
gained more and more importance. According to the theory of immune
surveillance, the immune system actively participates in resisting or
eradicating the formation and the progression of incipient cancer, late-
stage tumors and micro metastases. This long-standing theory proposes
that cells and tissues are constantly under the control of the immune
system, which operates as a barrier to tumor formation and progression,
recognizing and eliminating the majority of early cancer cells [2]. Ex-
periments conducted in vivo demonstrated that the onset and the
6
Seminars in Cancer Biology xxx (xxxx) xxx–xxx
growth of tumors in immunodeficient mice were more frequent and
faster than in immunocompetent control animals. Moreover, defi-
ciencies in the development or in the function of CD8+ cytotoxic
lymphocytes, CD4+ Th1 helper T cells or Natural Killer (NK) cells in-
creased tumor incidence, and the simultaneous lack of function of both
T cells and NK cells caused a more susceptible phenotype to cancer
development. These results clearly demonstrate that both the innate
and the adaptive immune response contribute significantly to immune
surveillance and thus to tumor eradication [120].
Experiments with immune deficient mice introduced the concept of
immunoediting. During this process, the immune system routinely
eliminates and shapes malignant diseases selecting only weak and im-
munogenic variants, which escape from immune surveillance and
generate solid tumors. In this way, cancer cells can enter a slow-cycling
state and remain latent for a long time, while new variants of malignant
clones emerge increasing resistance to immune pressure [121].
Several escape mechanisms have been described, such as the lack of
tumor-antigen recognition, the resistance to cell death and the pro-
duction of immunosuppressive molecules by tumor cells. The common
denominator at the base of such processes is the role of the ECM that
allows the interaction between specific ligands and receptors, the dif-
fusion of signaling molecules and the recruitment of immune cells. HA
is a potent modulator of the immune system [122,123], affecting ad-
hesion, migration and activation of immune cells expressing HA re-
ceptors. Activated T lymphocytes express high levels of CD44, which is
able to bind HA both in vivo and in vitro models, whereas naïve T
lymphocytes express CD44 but are unable to bind HA [124,125]. As T
cell activation proceeds, HA binding increases, as well as the ability of T
cells to roll under flow on HA substrate suggesting that HA could be
important for T cell migration and extravasation [126].
Although the immunomodulatory mechanism of HA during tumor
development still need to be investigated, some researchers have de-
monstrated that HA can frequently act as a barrier surrounding tumor
cells and limiting the accessibility by the immune system. The group of
Singha et al. showed that an HA-rich tumor microenvironment ob-
structed tumor access to NK immune cells and limited the exposure of
tumor cells to chemotherapeutic agents as monoclonal antibodies.
Interestingly, the depletion of HA by the use of a PEGylated re-
combinant hyaluronidase promoted NK cells access to the tumor and
enhanced the antibody-dependent cell-mediated cytotoxicity [127].
Remarkably, experiments conducted in vivo demonstrated that a high
pericellular density of HA contributed to the resistance to monoclonal
antibody therapy masking ErB2 receptor to trastuzumab [128,129]. The
concept of HA working as an exclusion barrier has been well described
also by the group of Wight, who showed that HA within the pericellular
matrix of lung fibroblast and synoviocytes inhibits T lymphocytes mi-
gration, preventing them from directly contact fibroblast surface [130].
Growing evidences have demonstrated that malignant tumors are
infiltrated with tumor-associated macrophages (TAMs) that can stimu-
late tumoral cell proliferation, migration, angiogenesis and micro-
environment remodeling [131]. Macrophages polarize into two dif-
ferent sub-classes identified as M1 and M2. M1 macrophages function in
host defense against microbial products and fulfil anti-tumor immunity,
while M2 macrophages are widely recognized as anti-inflammatory and
pro-tumor cells (TAMs). Within the tumor microenvironment, TAMs
have an immunosuppressive function, preventing tumor cell attack by
NK and T cells during tumor progression and after recovery from
chemo- or immunotherapy [132]. HA has frequently been implicated in
monocytes/macrophages trafficking and activation. Several studies re-
ported that an increased number of TAMs correlated with HA accu-
mulation in tumors and that TAMs preferentially infiltrate rich-HA tu-
mors, enhancing tumor vascularization and growth [133–135]. Cancer-
derived HA is able to stimulate TAMs formation in a mouse model of
breast cancer, suppressing killing capacity and promoting tumor pro-
gression [136,137]. Interestingly, the upregulation of HAS2 in CSCs is
critical for the interaction between TAMs and CSCs, enhancing CSCs
I. Caon, et al.
self-renewal [138].
The polarization of macrophages depends on several signals from
the surrounding microenvironment. HA molecular weight is a critical
modulator of macrophages activation, influencing macrophages che-
motaxis [139], gene expression, enzyme activity, and cytokine pro-
duction [140]. HA oligosaccharides induce the activation of im-
munosuppressive macrophages. This finding is consistent with the fact
that HA oligosaccharides can interact with CD44 and TLR4, inhibiting
the production of inflammatory cytokines as TNFα and IL-12 and sti-
mulating the synthesis of anti-inflammatory molecules as IL-10
[141,142]. Another study showed that HA fragments of intermediate
length, along with HAS2 upregulation in tumor cells, induced mono-
cytes dysfunction, whereas HMW-HA or HA monomer had little or no
effect [142]. According to the same study, the exposure of monocytes to
HA fragments released from tumor cells induced the formation of an
immunosuppressive (M2) phenotype, creating favorable conditions for
tumor progression. HA fragments can also accelerate the elimination of
pro-inflammatory neutrophils by promoting their apoptosis in a TLR4
dependent manner [143]. Therefore, the activation of M2 macrophages
with respect to M1 within the tumor microenvironment is critical to
establish a milieu that tolerates tumor growths and metastasis by set-
ting immunosuppressive mechanism.
Besides macrophages, HA can also regulate the maturation of den-
dritic cells (DCs) in a TLR4 dependent manner. [144–146]. DCs are a
class of antigen presenting cells that, when activated, migrate to the
draining lymph nodes where they present the antigen to naïve T cells.
While mature DCs are able to induce anti-tumoral immunity, antigen
presentation by immature DCs results in tolerance and fails to induce T
cells response [147]. The exposure of DCs to HA fragments was found to
increase the expression of activation markers as MHC class II, CD80,
CD86 and CD40, promoting DCs activation [148]. Many studies de-
monstrated that DCs stimulation occurs preferably under the exposure
of DCs to HA oligosaccharides, rather than HMW HA [122,145,149].
Interestingly, the treatment with LMW HA of DCs derived from patients
with colorectal carcinoma improved the maturation state of DCs, in-
creasing their ability to migrate and enhancing mixed leucocyte reac-
tion activity in vivo [150]. According to the same study, LMW HA would
enhance the immunogenic properties of DCs favoring their migration
towards lymph nodes rather than tumor site, as demonstrated in vitro
experiments by the reduced attraction to human tumor derived super-
natants and in vivo by an increased amount of DCs in nude mice lymph
nodes.
Given these considerations, it is clear that the immunological role of
HA in cancer progression is controversial and requires more insights.
What is certain is that the interaction of HA between the different
components of the immune system can have opposite functions in terms
of immune activation or suppression and that the presence of HA of
different molecular weight differently stimulates immune surveillance
9. Concluding remarks
In the last decade, the study of cancer biology has confirmed the
ECM as an essential player able to support the survival, growth and
invasion of cancer cells. As a significant component of ECM, HA has
emerged as a critical factor at various stages of carcinogenesis, from the
initiation to the metastatic process and the resistance to che-
motherapies. The activation of signaling pathways related to cancer
cells proliferation, angiogenesis and motility is the result of the inter-
action with different HA receptors, able to trigger different responses
according to the size of the interacting HA chains. In most of the cases,
HA functions as a barrier around tumoral cells, masking the accessi-
bility to specific targets for monoclonal antibodies and therapeutic
agents. Moreover, the HA-enriched pericellular matrix could also be
able to cover specific epitopes avoiding the surveillance of the immune
system. HA can also trigger the formation of new blood and lymphatic
vessels that are required to sustain cancer progression and to mediate
7
Seminars in Cancer Biology xxx (xxxx) xxx–xxx
tumoral cells metastasis. Considering the pleiotropic effect of HA during
tumorigenesis, the inhibition of its synthesis and metabolism could be
adopted as a strategy against many types of tumors [151]. Interestingly,
4-MU is able to inhibit tumor growth through the induction of apoptosis
in canine mammary tumor cells [152] and prostate cancer [153]. In
another study, the use of 4-MU in mice affected by colorectal carcinoma
treated with a combined immunotherapy increased the number of T
cells at tumor site, resulting in a potent inhibition of tumor growth and,
in 75% of mice, in a complete tumor regression when 4-MU was ad-
ministrated in combination with the immunotherapy [154]. Recently,
also the 4-methylumbelliferyl glucuronide (4-MUG) has been found to
inhibit HA synthesis [155]. Interestingly, 4-MUG shows an increased
water solubility with respect to 4-MU, making such compound a better
agent for therapeutic treatments. Nevertheless, the use of 4-MU should
be carefully balanced since it can cause a defective glycocalyx forma-
tion with damage of endothelium [103].
Another strategy to inhibit cancer progression could be the selective
silencing of HAS2, as demonstrated by Heldin and collaborators.
According to this study, the selective silencing of HAS2 was able to
suppress the malignant phenotype of invasive breast cancer cells, af-
fecting HA production and cell migration [156]. Moreover, the abro-
gation of other enzymes needed for UDP-sugar biosynthesis (i.e.,
UGDH) reduced cancer cells growth and motility, likely altering the
signaling through several receptors as CD44 and RHAMM, but also
regulating the structure of ECM and microenvironment around the tu-
mors. Promising targets of cancer control are also the metabolic sensors
AMPK and OGT, addressing the research in a control limited to the
tumor mass, therefore to a new way of administering inhibitory drugs.
Besides the canonical pharmacological and genetics approaches to
inhibit HA metabolism, the discovery of thousands of different non
coding RNAs could be a promising issue to regulate HA-dependent
carcinogenesis. Recent studies have found that miRNAs and lncRNAs
are closely related to tumorigenesis and can act as oncogenes or tumor
suppressor genes to influence the occurrence and development of
tumor. HA-CD44 interaction promotes miR-302 expression, with re-
percussion on the chemoresistance of breast cancer stem cells [157]. On
the other hand, HAS2 expression can be negatively regulated by
miRNAs as miR-26b, promoting apoptosis via caspase 3 and CD44
[158]. Moreover, the lncRNA HAS2-AS1 mediates cell proliferation,
invasion and migration in glioma [64], becoming a suitable target for
cancer gene therapy.
An intriguing approach in HA related carcinogenesis could be the
targeting of HA-coated extracellular vesicles. Indeed, a recent study
described that HA is present all around extracellular vesicles that are
able to transport HA through tissues and body fluids, establishing new
interactions with molecules and receptors involved in invasion and
metastasis of cancer cells [49].
Considering the heterogeneous and widespread effects of HA in the
onset and progression of cancer, the study of the mechanisms related
the regulation of HA synthesis could be a promising and challenging
issue to develop new therapeutic strategies.
Declaration of Competing Interest
The authors declare no conflict of interest with the content of the
present review.
Aknowledgments
Ar.P is a PhD student of the “Life Science and Biotechnology” course
at Università degli Studi dell’Insubria.BB is supported by the Università
degli Studi dell’Insubria as postdoc fellows (assegno di ricerca junior).
IC is financially supported by Matex Lab. This work was partially sup-
ported by RS Regione Lombardia, University of Insubria FAR (MV, EK,
DV and AP) and by the EU H2020 Marie Skłodowska-Curie Grant
645,756 “GLYCANC” (to AP).
I. Caon, et al.
References
[1] D. Hanahan, R.A. Weinberg, The hallmarks of cancer, Cell. 100 (2000) 57–70.
[2] D. Hanahan, R.A. Weinberg, Hallmarks of cancer: the next generation, Cell. 144
(2011) 646–674, https://doi.org/10.1016/j.cell.2011.02.013.
[3] N.K. Karamanos, Z. Piperigkou, A.D. Theocharis, H. Watanabe, M. Franchi,
S. Baud, S. Brézillon, M. Götte, A. Passi, D. Vigetti, S. Ricard-Blum,
R.D. Sanderson, T. Neill, R.V. Iozzo, Proteoglycan chemical diversity drives mul-
tifunctional cell regulation and therapeutics, Chem. Rev. 118 (2018) 9152–9232,
https://doi.org/10.1021/acs.chemrev.8b00354.
[4] Z. Werb, P. Lu, The role of stroma in tumor development, Cancer J. 21 (2015)
250–253, https://doi.org/10.1097/PPO.0000000000000127.
[5] S.-H. Kim, J. Turnbull, S. Guimond, Extracellular matrix and cell signalling: the
dynamic cooperation of integrin, proteoglycan and growth factor receptor, J.
Endocrinol. 209 (2011) 139–151, https://doi.org/10.1530/JOE-10-0377.
[6] D. Nikitovic, M. Tzardi, A. Berdiaki, A. Tsatsakis, G.N. Tzanakakis, Cancer mi-
croenvironment and inflammation: role of hyaluronan, Front. Immunol. 6 (2015)
169, https://doi.org/10.3389/fimmu.2015.00169.
[7] D. Vigetti, M. Viola, E. Karousou, G. De Luca, A. Passi, Metabolic control of hya-
luronan synthases, Matrix Biol. 35 (2014) 8–13, https://doi.org/10.1016/J.
MATBIO.2013.10.002.
[8] M. Viola, D. Vigetti, E. Karousou, M.L. D’Angelo, I. Caon, P. Moretto, G. De Luca,
A. Passi, Biology and biotechnology of hyaluronan, Glycoconj. J. 32 (2015),
https://doi.org/10.1007/s10719-015-9586-6.
[9] A.P. Spicer, J.A. McDonald, Characterization and molecular evolution of a verte-
brate hyaluronan synthase gene family, J. Biol. Chem. 273 (1998) 1923–1932,
https://doi.org/10.1074/JBC.273.4.1923.
[10] A.P. Spicer, J.Y.L. Tien, Hyaluronan and morphogenesis. Birth Defects Res, C.
Embryo Today. 72 (2004) 89–108, https://doi.org/10.1002/bdrc.20006.
[11] T.D. Camenisch, A.P. Spicer, T. Brehm-Gibson, J. Biesterfeldt, M. Lou Augustine,
A. Calabro, S. Kubalak, S.E. Klewer, J.A. McDonald, Disruption of hyaluronan
synthase-2 abrogates normal cardiac morphogenesis and hyaluronan-mediated
transformation of epithelium to mesenchyme, J. Clin. Invest. 106 (2000) 349–360,
https://doi.org/10.1172/JCI10272.
[12] P. Moretto, E. Karousou, M. Viola, I. Caon, M.L. D’Angelo, G. De Luca, A. Passi,
D. Vigetti, Regulation of hyaluronan synthesis in vascular diseases and diabetes, J.
Diabetes Res. (2015), https://doi.org/10.1155/2015/167283 2015.
[13] E. Karousou, M. Kamiryo, S.S. Skandalis, A. Ruusala, T. Asteriou, A. Passi,
H. Yamashita, U. Hellman, C.-H. Heldin, P. Heldin, The activity of hyaluronan
synthase 2 is regulated by dimerization and ubiquitination, J. Biol. Chem. 285
(2010) 23647–23654, https://doi.org/10.1074/jbc.M110.127050.
[14] V.C. Hascall, A. Wang, M. Tammi, S. Oikari, R. Tammi, A. Passi, D. Vigetti,
R.W. Hanson, G.W. Hart, The dynamic metabolism of hyaluronan regulates the
cytosolic concentration of UDP-GlcNAc, Matrix Biol. 35 (2014) 14–17, https://doi.
org/10.1016/j.matbio.2014.01.014.
[15] D. Vigetti, S. Deleonibus, P. Moretto, T. Bowen, J.W. Fischer, M. Grandoch,
A. Oberhuber, D.C. Love, J.A. Hanover, R. Cinquetti, E. Karousou, M. Viola,
M.L. D’Angelo, V.C. Hascall, G. De Luca, A. Passi, Natural antisense transcript for
hyaluronan synthase 2 (HAS2-AS1) induces transcription of HAS2 via protein O-
GlcNAcylation, J. Biol. Chem. 289 (2014) 28816–28826, https://doi.org/10.
1074/jbc.M114.597401.
[16] X. Tian, J. Azpurua, C. Hine, A. Vaidya, M. Myakishev-Rempel, J. Ablaeva, Z. Mao,
E. Nevo, V. Gorbunova, A. Seluanov, High-molecular-mass hyaluronan mediates
the cancer resistance of the naked mole rat, Nature. 499 (2013) 346–349, https://
doi.org/10.1038/nature12234.
[17] A.G. Tavianatou, I. Caon, M. Franchi, Z. Piperigkou, D. Galesso, N.K. Karamanos,
Hyaluronan: molecular size‐dependent signaling and biological functions in in-
flammation and cancer, FEBS J. (2019), https://doi.org/10.1111/febs.14777 febs.
14777.
[18] M.S. Rugg, A.C. Willis, D. Mukhopadhyay, V.C. Hascall, E. Fries, C. Fülöp,
C.M. Milner, A.J. Day, Characterization of complexes formed between TSG-6 and
Inter-α-inhibitor that act as intermediates in the covalent transfer of heavy chains
onto hyaluronan, J. Biol. Chem. 280 (2005) 25674–25686, https://doi.org/10.
1074/jbc.M501332200.
[19] A.J. Day, C.M. Milner, TSG-6: a multifunctional protein with anti-inflammatory
and tissue-protective properties, Matrix Biol. (2018), https://doi.org/10.1016/J.
MATBIO.2018.01.011.
[20] E. Karousou, S. Misra, S. Ghatak, K. Dobra, M. Götte, D. Vigetti, A. Passi,
N.K. Karamanos, S.S. Skandalis, Roles and targeting of the HAS/hyaluronan/CD44
molecular system in cancer, Matrix Biol. 59 (2017) 3–22, https://doi.org/10.
1016/j.matbio.2016.10.001.
[21] P. Auvinen, R. Tammi, J. Parkkinen, M. Tammi, U. ÅGren, R. Johansson,
P. Hirvikoski, M. Eskelinen, V.-M. Kosma, Hyaluronan in Peritumoral Stroma and
malignant cells associates with breast Cancer Spreading and predicts survival, Am.
J. Pathol. 156 (2000) 529–536, https://doi.org/10.1016/S0002-9440(10)
64757-8.
[22] H.-R. Kim, M.A. Wheeler, C.M. Wilson, J. Iida, D. Eng, M.A. Simpson,
J.B. McCarthy, K.M. Bullard, Hyaluronan facilitates invasion of colon carcinoma
cells in vitro via interaction with CD44, Cancer Res. 64 (2004) 4569–4576,
https://doi.org/10.1158/0008-5472.CAN-04-0202.
[23] R. Pirinen, R. Tammi, M. Tammi, P. Hirvikoski, J.J. Parkkinen, R. Johansson,
J. Böhm, S. Hollmén, V.M. Kosma, Prognostic value of hyaluronan expression in
non-small-cell lung cancer: increased stromal expression indicates unfavorable
outcome in patients with adenocarcinoma, Int. J. Cancer 95 (2001) 12–17.
[24] J.-H. Li, Y.-C. Wang, C.-D. Qin, R.-R. Yao, R. Zhang, Y. Wang, X.-Y. Xie, L. Zhang,
8
Seminars in Cancer Biology xxx (xxxx) xxx–xxx
Y.-H. Wang, Z.-G. Ren, Over expression of hyaluronan promotes progression of
HCC via CD44-mediated pyruvate kinase M2 nuclear translocation, Am. J. Cancer
Res. 6 (2016) 509–521.
[25] L.P. Setälä, M.I. Tammi, R.H. Tammi, M.J. Eskelinen, P.K. Lipponen, U.M. Agren,
J. Parkkinen, E.M. Alhava, V.M. Kosma, Hyaluronan expression in gastric cancer
cells is associated with local and nodal spread and reduced survival rate, Br. J.
Cancer 79 (1999) 1133–1138, https://doi.org/10.1038/sj.bjc.6690180.
[26] N. Sato, S. Kohi, K. Hirata, M. Goggins, Role of hyaluronan in pancreatic cancer
biology and therapy: once again in the spotlight, Cancer Sci. 107 (2016) 569–575,
https://doi.org/10.1111/cas.12913.
[27] A. Kosunen, K. Ropponen, J. Kellokoski, M. Pukkila, J. Virtaniemi, H. Valtonen,
E. Kumpulainen, R. Johansson, R. Tammi, M. Tammi, J. Nuutinen, V.-M. Kosma,
Reduced expression of hyaluronan is a strong indicator of poor survival in oral
squamous cell carcinoma, Oral Oncol. 40 (2004) 257–263.
[28] J.M. Karjalainen, R.H. Tammi, M.I. Tammi, M.J. Eskelinen, U.M. Ågren,
J.J. Parkkinen, E.M. Alhava, V.-M. Kosma, Reduced Level of CD44 and Hyaluronan
Associated with Unfavorable Prognosis in Clinical Stage I Cutaneous Melanoma,
Am. J. Pathol. 157 (2000) 957–965, https://doi.org/10.1016/S0002-9440(10)
64608-1.
[29] A. Passi, D. Vigetti, S. Buraschi, R.V. Iozzo, Dissecting the role of hyaluronan
synthases in the tumor microenvironment, FEBS J. (2019) febs.14847, https://doi.
org/10.1111/febs.14847.
[30] P. Li, T. Xiang, H. Li, Q. Li, B. Yang, J. Huang, X. Zhang, Y. Shi, J. Tan, G. Ren,
Hyaluronan synthase 2 overexpression is correlated with the tumorigenesis and
metastasis of human breast cancer, Int. J. Clin. Exp. Pathol. 8 (2015)
12101–12114.
[31] Z. Zhang, D. Tao, P. Zhang, X. Liu, Y. Zhang, J. Cheng, H. Yuan, L. Liu, H. Jiang,
Hyaluronan synthase 2 expressed by cancer-associated fibroblasts promotes oral
cancer invasion, J. Exp. Clin. Cancer Res. 35 (2016) 181, https://doi.org/10.1186/
s13046-016-0458-0.
[32] T.K. Nykopp, K. Rilla, M.I. Tammi, R.H. Tammi, R. Sironen, K. Hämäläinen, V.-
M. Kosma, S. Heinonen, M. Anttila, Hyaluronan synthases (HAS1-3) and hyalur-
onidases (HYAL1-2) in the accumulation of hyaluronan in endometrioid en-
dometrial carcinoma, BMC Cancer 10 (2010) 512, https://doi.org/10.1186/1471-
2407-10-512.
[33] M. Valkonen, H. Haapasalo, K. Rilla, K. Tyynelä-Korhonen, Y. Soini, S. Pasonen-
Seppänen, Elevated expression of hyaluronan synthase 2 associates with decreased
survival in diffusely infiltrating astrocytomas, BMC Cancer 18 (2018) 664, https://
doi.org/10.1186/s12885-018-4569-1.
[34] B.-T. Preca, K. Bajdak, K. Mock, W. Lehmann, V. Sundararajan, P. Bronsert,
A. Matzge-Ogi, V. Orian-Rousseau, S. Brabletz, T. Brabletz, J. Maurer,
M.P. Stemmler, A novel ZEB1/HAS2 positive feedback loop promotes EMT in
breast cancer, Oncotarget. 8 (2017) 11530–11543, https://doi.org/10.18632/
oncotarget.14563.
[35] A. Moustakas, P. Heldin, TGFβ and matrix-regulated epithelial to mesenchymal
transition, Biochim. Biophys. Acta - Gen. Subj. 1840 (2014) 2621–2634, https://
doi.org/10.1016/j.bbagen.2014.02.004.
[36] C. Kolliopoulos, C.Y. Lin, C.H. Heldin, A. Moustakas, P. Heldin, Has2 natural an-
tisense RNA and Hmga2 promote Has2 expression during TGFβ-induced EMT in
breast cancer, Matrix Biol. 80 (2019) 29–45, https://doi.org/10.1016/j.matbio.
2018.09.002.
[37] R.H. Tammi, A.G. Passi, K. Rilla, E. Karousou, D. Vigetti, K. Makkonen,
M.I. Tammi, Transcriptional and post-translational regulation of hyaluronan
synthesis, FEBS J. 278 (2011) 1419–1428, https://doi.org/10.1111/j.1742-4658.
2011.08070.x.
[38] A. Kultti, C. Zhao, N.C. Singha, S. Zimmerman, R.J. Osgood, R. Symons, P. Jiang,
X. Li, C.B. Thompson, J.R. Infante, M.A. Jacobetz, D.A. Tuveson, G.I. Frost,
H.M. Shepard, Z. Huang, Accumulation of extracellular hyaluronan by hyaluronan
synthase 3 promotes tumor growth and modulates the pancreatic Cancer micro-
environment, Biomed Res. Int. 2014 (2014) 1–15, https://doi.org/10.1155/2014/
817613.
[39] K. Tofuku, M. Yokouchi, T. Murayama, S. Minami, S. Komiya, HAS3-related
hyaluronan enhances biological activities necessary for metastasis of osteosarcoma
cells, Int. J. Oncol. 29 (2006) 175–183.
[40] A.J. Deen, U.T. Arasu, S. Pasonen-Seppänen, A. Hassinen, P. Takabe,
S. Wojciechowski, R. Kärnä, K. Rilla, S. Kellokumpu, R. Tammi, M. Tammi,
S. Oikari, UDP-sugar substrates of HAS3 regulate its O-GlcNAcylation, in-
tracellular traffic, extracellular shedding and correlate with melanoma progres-
sion, Cell. Mol. Life Sci. 73 (2016) 3183–3204, https://doi.org/10.1007/s00018-
016-2158-5.
[41] P. Auvinen, K. Rilla, R. Tumelius, M. Tammi, R. Sironen, Y. Soini, V.-M. Kosma,
A. Mannermaa, J. Viikari, R. Tammi, Hyaluronan synthases (HAS1–3) in stromal
and malignant cells correlate with breast cancer grade and predict patient sur-
vival, Breast Cancer Res. Treat. 143 (2014) 277–286, https://doi.org/10.1007/
s10549-013-2804-7.
[42] A. Ghosh, H. Kuppusamy, L.M. Pilarski, Aberrant splice variants of HAS1
(Hyaluronan synthase 1) multimerize with and modulate normally spliced HAS1
protein, J. Biol. Chem. 284 (2009) 18840–18850, https://doi.org/10.1074/jbc.
M109.013813.
[43] R.H. Tammi, A. Kultti, V.-M. Kosma, R. Pirinen, P. Auvinen, M.I. Tammi,
Hyaluronan in human tumors: pathobiological and prognostic messages from cell-
associated and stromal hyaluronan, Semin. Cancer Biol. 18 (2008) 288–295,
https://doi.org/10.1016/j.semcancer.2008.03.005.
[44] D. Vigetti, E. Karousou, M. Viola, S. Deleonibus, G. De Luca, A. Passi, Hyaluronan:
biosynthesis and signaling, Biochim. Biophys. Acta - Gen. Subj. 1840 (2014)
2452–2459, https://doi.org/10.1016/j.bbagen.2014.02.001.
I. Caon, et al.
[45] I. Morath, T.N. Hartmann, V. Orian-Rousseau, CD44: more than a mere stem cell
marker, Int. J. Biochem. Cell Biol. 81 (2016) 166–173, https://doi.org/10.1016/J.
BIOCEL.2016.09.009.
[46] B.D. Manning, A. Toker, AKT/PKB signaling: navigating the network, Cell. 169
(2017) 381–405, https://doi.org/10.1016/j.cell.2017.04.001.
[47] S. Liu, C. Cheng, Akt signaling is sustained by a CD44 splice isoform-mediated
positive feedback loop, Cancer Res. 77 (2017) 3791–3801, https://doi.org/10.
1158/0008-5472.CAN-16-2545.
[48] C.C. Dibble, L.C. Cantley, Regulation of mTORC1 by PI3K signaling, Trends Cell
Biol. 25 (2015) 545–555, https://doi.org/10.1016/j.tcb.2015.06.002.
[49] K. Rilla, H. Siiskonen, M. Tammi, R. Tammi, Hyaluronan-coated extracellular
vesicles—a novel link between hyaluronan and cancer, Adv. Cancer Res. 123
(2014) 121–148, https://doi.org/10.1016/B978-0-12-800092-2.00005-8.
[50] M. Lenart, M. Rutkowska-Zapala, M. Baj-Krzyworzeka, R. Szatanek,
K. Węglarczyk, T. Smallie, L. Ziegler-Heitbrock, M. Zembala, M. Siedlar,
Hyaluronan carried by tumor-derived microvesicles induces IL-10 production in
classical (CD14++CD16-) monocytes via PI3K/Akt/mTOR-dependent signalling
pathway, Immunobiology. 222 (2017) 1–10, https://doi.org/10.1016/j.imbio.
2015.06.019.
[51] D. Vigetti, M. Viola, E. Karousou, M. Rizzi, P. Moretto, A. Genasetti, M. Clerici,
V.C. Hascall, G. De Luca, A. Passi, Hyaluronan-CD44-ERK1/2 regulate human
aortic smooth muscle cell motility during aging, J. Biol. Chem. 283 (2008)
4448–4458, https://doi.org/10.1074/jbc.M709051200.
[52] L.Y.W. Bourguignon, E. Gilad, K. Rothman, K. Peyrollier, Hyaluronan-CD44 in-
teraction with IQGAP1 promotes Cdc42 and ERK signaling, leading to actin
binding, Elk-1/estrogen receptor transcriptional activation, and ovarian cancer
progression, J. Biol. Chem. 280 (2005) 11961–11972, https://doi.org/10.1074/
jbc.M411985200.
[53] L.Y.W. Bourguignon, H. Zhu, B. Zhou, F. Diedrich, P.A. Singleton, M.C. Hung,
Hyaluronan promotes CD44v3-Vav2 interaction with Grb2-p185HER2 and in-
duces Rac1 and ras signaling during ovarian tumor cell migration and growth, J.
Biol. Chem. 276 (2001) 48679–48692, https://doi.org/10.1074/jbc.M106759200.
[54] L.Y.W. Bourguignon, C.C. Spevak, G. Wong, W. Xia, E. Gilad, Hyaluronan-CD44
interaction with protein kinase C(epsilon) promotes oncogenic signaling by the
stem cell marker Nanog and the Production of microRNA-21, leading to down-
regulation of the tumor suppressor protein PDCD4, anti-apoptosis, and che-
motherapy resistance in breast tumor cells, J. Biol. Chem. 284 (2009)
26533–26546, https://doi.org/10.1074/jbc.M109.027466.
[55] D. Vigetti, E. Karousou, M. Viola, S. Deleonibus, G. De Luca, A. Passi, Hyaluronan:
biosynthesis and signaling, Biochim. Biophys. Acta - Gen. Subj. 1840 (2014)
2452–2459, https://doi.org/10.1016/j.bbagen.2014.02.001.
[56] C. Hardwick, K. Hoare, R. Owens, H.P. Hohn, M. Hook, D. Moore, V. Cripps,
L. Austen, D.M. Nance, E.A. Turley, Molecular cloning of a novel hyaluronan re-
ceptor that mediates tumor cell motility, J. Cell Biol. 117 (1992) 1343–1350,
https://doi.org/10.1083/JCB.117.6.1343.
[57] V. Mele, L. Sokol, V.H. Kölzer, D. Pfaff, M.G. Muraro, I. Keller, Z. Stefan,
I. Centeno, L.M. Terracciano, H. Dawson, I. Zlobec, G. Iezzi, A. Lugli, The hya-
luronan-mediated motility receptor RHAMM promotes growth, invasiveness and
dissemination of colorectal cancer, Oncotarget. 8 (2017) 70617–70629, https://
doi.org/10.18632/oncotarget.19904.
[58] Y.-T. Chen, Z. Chen, Y.-C.N. Du, Y.-T. Chen, Z. Chen, Y.-C. Nancy Du, Y.-T. Chen,
Z. Chen, Y.-C.N. Du, Immunohistochemical analysis of RHAMM expression in
normal and neoplastic human tissues: a cell cycle protein with distinctive ex-
pression in mitotic cells and testicular germ cells, Oncotarget. 9 (2018)
20941–20952, https://doi.org/10.18632/oncotarget.24939.
[59] M.S. Pandey, C.M. Miller, E.N. Harris, P.H. Weigel, Activation of ERK and NF-κB
during HARE-Mediated heparin uptake require only one of the four endocytic
motifs, PLoS One 11 (2016) e0154124, , https://doi.org/10.1371/journal.pone.
0154124.
[60] M.A. Simpson, J.A. Weigel, P.H. Weigel, Systemic blockade of the hyaluronan
receptor for endocytosis prevents lymph node metastasis of prostate cancer, Int. J.
Cancer 131 (2012) E836–E840, https://doi.org/10.1002/ijc.27427.
[61] M. Wu, Y. Du, Y. Liu, Y. He, C. Yang, W. Wang, F. Gao, Low molecular weight
hyaluronan induces lymphangiogenesis through LYVE-1-Mediated signaling
pathways, PLoS One 9 (2014) e92857, , https://doi.org/10.1371/journal.pone.
0092857.
[62] C. Dollt, K. Becker, J. Michel, S. Melchers, C.-A. Weis, K. Schledzewski, A. Krewer,
L. Kloss, C. Gebhardt, J. Utikal, A. Schmieder, C. Dollt, K. Becker, J. Michel,
S. Melchers, C.-A. Weis, K. Schledzewski, A. Krewer, L. Kloss, C. Gebhardt,
J. Utikal, A. Schmieder, C. Dollt, K. Becker, J. Michel, S. Melchers, C.-A. Weis,
K. Schledzewski, A. Krewer, L. Kloss, C. Gebhardt, J. Utikal, A. Schmieder, The
shedded ectodomain of Lyve-1 expressed on M2-like tumor-associated macro-
phages inhibits melanoma cell proliferation, Oncotarget. 8 (2017)
103682–103692, https://doi.org/10.18632/oncotarget.21771.
[63] H. Chao, A.P. Spicer, Natural antisense mRNAs to hyaluronan synthase 2 inhibit
hyaluronan biosynthesis and cell proliferation, J. Biol. Chem. 280 (2005)
27513–27522, https://doi.org/10.1074/jbc.M411544200.
[64] Z. Zhao, T. Liang, S. Feng, Silencing of HAS2-AS1 mediates PI3K/AKT signaling
pathway to inhibit cell proliferation, migration, and invasion in glioma, J. Cell.
Biochem. (2019), https://doi.org/10.1002/jcb.28430 (in press).
[65] G. Zhu, S. Wang, J. Chen, Z. Wang, X. Liang, X. Wang, J. Jiang, J. Lang, L. Li, Long
noncoding RNA HAS2-AS1 mediates hypoxia-induced invasiveness of oral squa-
mous cell carcinoma, Mol. Carcinog. (2017) 1–46, https://doi.org/10.1002/mc.
22674.
[66] Y. Yung, L. Ophir, G.M. Yerushalmi, M. Baum, A. Hourvitz, E. Maman, HAS2-AS1
is a novel LH/hCG target gene regulating HAS2 expression and enhancing cumulus
9
Seminars in Cancer Biology xxx (xxxx) xxx–xxx
cells migration, J. Ovarian Res. 12 (2019) 21, https://doi.org/10.1186/s13048-
019-0495-3.
[67] J.M. Song, K. Molla, A. Anandharaj, I. Cornax, M.G.O. Sullivan, A.R. Kirtane,
J. Panyam, F. Kassie, Triptolide suppresses the in vitro and in vivo growth of lung
cancer cells by targeting hyaluronan-CD44/RHAMM signaling, Oncotarget. 8
(2017) 26927–26940, https://doi.org/10.18632/oncotarget.15879.
[68] D. Vigetti, M. Rizzi, P. Moretto, S. Deleonibus, J.M. Dreyfuss, E. Karousou,
M. Viola, M. Clerici, V.C. Hascall, M.F. Ramoni, G. De Luca, A. Passi,
Glycosaminoglycans and glucose prevent apoptosis in 4-methylumbelliferone-
treated human aortic smooth muscle cells, J. Biol. Chem. 286 (2011)
34497–34503, https://doi.org/10.1074/jbc.M111.266312.
[69] A. Kultti, S. Pasonen-Seppänen, M. Jauhiainen, K.J. Rilla, R. Kärnä, E. Pyöriä,
R.H. Tammi, M.I. Tammi, 4-Methylumbelliferone inhibits hyaluronan synthesis by
depletion of cellular UDP-glucuronic acid and downregulation of hyaluronan
synthase 2 and 3, Exp. Cell Res. 315 (2009) 1914–1923, https://doi.org/10.1016/
j.yexcr.2009.03.002.
[70] D. Vigetti, M. Rizzi, M. Viola, E. Karousou, A. Genasetti, M. Clerici, B. Bartolini,
V.C. Hascall, G. De Luca, A. Passi, The effects of 4-methylumbelliferone on hya-
luronan synthesis, MMP2 activity, proliferation, and motility of human aortic
smooth muscle cells, Glycobiology. 19 (2009) 537–546, https://doi.org/10.1093/
glycob/cwp022.
[71] K. Ikuta, T. Ota, L. Zhuo, H. Urakawa, E. Kozawa, S. Hamada, K. Kimata,
N. Ishiguro, Y. Nishida, Antitumor effects of 4-methylumbelliferone, a hyaluronan
synthesis inhibitor, on malignant peripheral nerve sheath tumor, Int. J. Cancer 140
(2017) 469–479, https://doi.org/10.1002/ijc.30460.
[72] H. Nagase, D. Kudo, A. Suto, E. Yoshida, S. Suto, M. Negishi, I. Kakizaki,
K. Hakamada, 4-Methylumbelliferone Suppresses Hyaluronan Synthesis and
Tumor Progression in SCID Mice Intra-abdominally Inoculated With Pancreatic
Cancer Cells, Pancreas. 46 (2017) 190–197, https://doi.org/10.1097/MPA.
0000000000000741.
[73] D.S. Morera, M.S. Hennig, A. Talukder, S.D. Lokeshwar, J. Wang, M. Garcia-Roig,
N. Ortiz, T.J. Yates, L.E. Lopez, G. Kallifatidis, M.W. Kramer, A.R. Jordan,
A.S. Merseburger, M. Manoharan, M.S. Soloway, M.K. Terris, V.B. Lokeshwar,
Hyaluronic acid family in bladder cancer: potential prognostic biomarkers and
therapeutic targets, Br. J. Cancer 117 (2017) 1507–1517, https://doi.org/10.
1038/bjc.2017.318.
[74] Y.-J. Lee, S.A. Kim, S.-H. Lee, Hyaluronan suppresses lidocaine-induced apoptosis
of human chondrocytes in vitro by inhibiting the p53-dependent mitochondrial
apoptotic pathway, Acta Pharmacol. Sin. 37 (2016) 664–673, https://doi.org/10.
1038/aps.2015.151.
[75] S. Kumar, J.R. Inigo, R. Kumar, A.K. Chaudhary, J. O’Malley, S. Balachandar,
J. Wang, K. Attwood, N. Yadav, S. Hochwald, X. Wang, D. Chandra, Nimbolide
reduces CD44 positive cell population and induces mitochondrial apoptosis in
pancreatic cancer cells, Cancer Lett. 413 (2018) 82–93, https://doi.org/10.1016/j.
canlet.2017.10.029.
[76] L.Y.W. Bourguignon, Matrix hyaluronan promotes specific MicroRNA upregula-
tion leading to drug resistance and tumor progression, Int. J. Mol. Sci. 17 (2016)
517, https://doi.org/10.3390/ijms17040517.
[77] R.R. Ramjiawan, A.W. Griffioen, D.G. Duda, Anti-angiogenesis for cancer re-
visited: Is there a role for combinations with immunotherapy? Angiogenesis. 20
(2017) 185–204, https://doi.org/10.1007/s10456-017-9552-y.
[78] R.-C. Ji, Hypoxia and lymphangiogenesis in tumor microenvironment and me-
tastasis, Cancer Lett. 346 (2014) 6–16, https://doi.org/10.1016/j.canlet.2013.12.
001.
[79] B.H. Jiang, J.Z. Zheng, S.W. Leung, R. Roe, G.L. Semenza, Transactivation and
inhibitory domains of hypoxia-inducible factor 1alpha. Modulation of transcrip-
tional activity by oxygen tension, J. Biol. Chem. 272 (1997) 19253–19260,
https://doi.org/10.1074/JBC.272.31.19253.
[80] M. Marçola, C.E. Rodrigues, Endothelial progenitor cells in tumor angiogenesis:
another brick in the wall, Stem Cells Int. 2015 (2015), https://doi.org/10.1155/
2015/832649.
[81] S. Das, P.A. Marsden, Angiogenesis in glioblastoma, N. Engl. J. Med. 369 (2013)
1561–1563, https://doi.org/10.1056/NEJMcibr1309402.
[82] J. Ciccolini, S. Benzekry, B. Lacarelle, D. Barbolosi, F. Barlési, Improving efficacy
of the combination between antiangiogenic and chemotherapy: Time for mathe-
matical modeling support, Proc. Natl. Acad. Sci. U. S. A. 112 (2015) E3453,
https://doi.org/10.1073/pnas.1506689112.
[83] R.S. Heist, D.G. Duda, D.V. Sahani, M. Ancukiewicz, P. Fidias, L.V. Sequist,
J.S. Temel, A.T. Shaw, N.A. Pennell, J.W. Neal, L. Gandhi, T.J. Lynch,
J.A. Engelman, R.K. Jain, Improved tumor vascularization after anti-VEGF therapy
with carboplatin and nab-paclitaxel associates with survival in lung cancer, Proc.
Natl. Acad. Sci. U. S. A. 112 (2015) 1547–1552, https://doi.org/10.1073/pnas.
1424024112.
[84] R. Bell, J. Brown, M. Parmar, M. Toi, T. Suter, G.G. Steger, X. Pivot, J. Mackey,
C. Jackisch, R. Dent, P. Hall, N. Xu, L. Morales, L. Provencher, R. Hegg,
L. Vanlemmens, A. Kirsch, A. Schneeweiss, N. Masuda, F. Overkamp, D. Cameron,
Final efficacy and updated safety results of the randomized phase III BEATRICE
trial evaluating adjuvant bevacizumab-containing therapy in triple-negative early
breast cancer, Ann. Oncol. 28 (2016), https://doi.org/10.1093/annonc/mdw665
mdw665.
[85] V. Poltavets, M. Kochetkova, S.M. Pitson, M.S. Samuel, The role of the extra-
cellular matrix and its molecular and cellular regulators in Cancer cell plasticity,
Front. Oncol. 8 (2018) 431, https://doi.org/10.3389/fonc.2018.00431.
[86] H. Kobayashi, P.C. Lin, Angiogenesis links chronic inflammation with Cancer,
Methods Mol. Biol. (2009) 185–191, https://doi.org/10.1007/978-1-59745-447-
6_8.
I. Caon, et al.
[87] R.-L. Wu, L. Huang, H.-C. Zhao, X.-P. Geng, Hyaluronic acid in digestive cancers, J.
Cancer Res. Clin. Oncol. 143 (2017) 1–16, https://doi.org/10.1007/s00432-016-
2213-5.
[88] M.A. Jacobetz, D.S. Chan, A. Neesse, T.E. Bapiro, N. Cook, K.K. Frese, C. Feig,
T. Nakagawa, M.E. Caldwell, H.I. Zecchini, M.P. Lolkema, P. Jiang, A. Kultti,
C.B. Thompson, D.C. Maneval, D.I. Jodrell, G.I. Frost, H.M. Shepard, J.N. Skepper,
D.A. Tuveson, Hyaluronan impairs vascular function and drug delivery in a mouse
model of pancreatic cancer, Gut. 62 (2013) 112–120, https://doi.org/10.1136/
gutjnl-2012-302529.
[89] S. Ghose, S. Biswas, K. Datta, R.K. Tyagi, Dynamic Hyaluronan drives liver en-
dothelial cells towards angiogenesis, BMC Cancer 18 (2018) 648, https://doi.org/
10.1186/s12885-018-4532-1.
[90] D.L. Vitale, F.M. Spinelli, D. Del Dago, A. Icardi, G. Demarchi, I. Caon, M. García,
M.F. Bolontrade, A. Passi, C. Cristina, L. Alaniz, D.L. Vitale, F.M. Spinelli, D. Del
Dago, A. Icardi, G. Demarchi, I. Caon, M. García, M.F. Bolontrade, A. Passi,
C. Cristina, L. Alaniz, D.L. Vitale, F.M. Spinelli, D. Del Dago, A. Icardi,
G. Demarchi, I. Caon, M. García, M.F. Bolontrade, A. Passi, C. Cristina, L. Alaniz,
Co-treatment of tumor cells with hyaluronan plus doxorubicin affects endothelial
cell behavior independently of VEGF expression, Oncotarget. 9 (2018)
36585–36602, https://doi.org/10.18632/oncotarget.26379.
[91] L. Ma, L. Dong, P. Chang, CD44v6 engages in colorectal cancer progression, Cell
Death Dis. 10 (2019) 30, https://doi.org/10.1038/s41419-018-1265-7.
[92] C. Fieber, Hyaluronan-oligosaccharide-induced transcription of metalloproteases,
J. Cell. Sci. 117 (2003) 359–367, https://doi.org/10.1242/jcs.00831.
[93] W. Zhou, C. Chen, Y. Shi, Q. Wu, R.C. Gimple, X. Fang, Z. Huang, K. Zhai, S.Q. Ke,
Y.-F. Ping, H. Feng, J.N. Rich, J.S. Yu, S. Bao, X.-W. Bian, Targeting glioma stem
cell-derived pericytes disrupts the blood-tumor barrier and improves chemother-
apeutic efficacy, Cell Stem Cell 21 (2017) 591–603, https://doi.org/10.1016/j.
stem.2017.10.002 e4.
[94] E.M. Caspani, P.H. Crossley, C. Redondo-Garcia, S. Martinez, Glioblastoma: a
pathogenic crosstalk between tumor cells and pericytes, PLoS One 9 (2014)
e101402, , https://doi.org/10.1371/journal.pone.0101402.
[95] V. Filpa, M. Bistoletti, I. Caon, E. Moro, A. Grimaldi, P. Moretto, A. Baj,
M.C. Giron, E. Karousou, M. Viola, F. Crema, G. Frigo, A. Passi, C. Giaroni,
D. Vigetti, Changes in hyaluronan deposition in the rat myenteric plexus after
experimentally-induced colitis, Sci. Rep. 7 (2017) 17644, https://doi.org/10.
1038/s41598-017-18020-7.
[96] S.A. Stacker, S.P. Williams, T. Karnezis, R. Shayan, S.B. Fox, M.G. Achen,
Lymphangiogenesis and lymphatic vessel remodelling in cancer, Nat. Rev. Cancer
14 (2014) 159–172, https://doi.org/10.1038/nrc3677.
[97] E. Caravà, C. Marcozzi, B. Bartolini, M. Reguzzoni, P. Moretto, I. Caon,
E. Karousou, A. Passi, M. Viola, Method for Studying ECM Expression: In Situ RT-
PCR, (2019), pp. 21–31, https://doi.org/10.1007/978-1-4939-9133-4_2.
[98] H. Nishida-Fukuda, R. Araki, M. Shudou, H. Okazaki, Y. Tomono, H. Nakayama,
S. Fukuda, T. Sakaue, Y. Shirakata, K. Sayama, K. Hashimoto, M. Detmar,
S. Higashiyama, S. Hirakawa, Ectodomain shedding of lymphatic vessel en-
dothelial hyaluronan receptor 1 (LYVE-1) is induced by vascular endothelial
growth factor a (VEGF-A), J. Biol. Chem. 291 (2016) 10490–10500, https://doi.
org/10.1074/jbc.M115.683201.
[99] Y. Hara, R. Torii, S. Ueda, E. Kurimoto, E. Ueda, H. Okura, Y. Tatano, H. Yagi,
Y. Ohno, T. Tanaka, K. Masuko, T. Masuko, Inhibition of tumor formation and
metastasis by a monoclonal antibody against lymphatic vessel endothelial hya-
luronan receptor 1, Cancer Sci. 109 (2018) 3171–3182, https://doi.org/10.1111/
cas.13755.
[100] J. Bauer, M. Rothley, A. Schmaus, L. Quagliata, M. Ehret, M. Biskup, V. Orian-
Rousseau, D.G. Jackson, R.J. Pettis, A. Harvey, S. Bräse, W. Thiele, J.P. Sleeman,
TGFβ counteracts LYVE-1-mediated induction of lymphangiogenesis by small
hyaluronan oligosaccharides, J. Mol. Med. 96 (2018) 199–209, https://doi.org/
10.1007/s00109-017-1615-4.
[101] J.A. García-Vilas, A.R. Quesada, M.Á. Medina, 4-methylumbelliferone inhibits
angiogenesis in vitro and in vivo, J. Agric. Food Chem. 61 (2013) 4063–4071,
https://doi.org/10.1021/jf303062h.
[102] F. Piccioni, E. Fiore, J. Bayo, C. Atorrasagasti, E. Peixoto, M. Rizzo, M. Malvicini,
I. Tirado-González, M.G. García, L. Alaniz, G. Mazzolini, 4-Methylumbelliferone
inhibits hepatocellular carcinoma growth by decreasing IL-6 production and an-
giogenesis, Glycobiology. 25 (2015) 825–835, https://doi.org/10.1093/glycob/
cwv023.
[103] N. Nagy, T. Freudenberger, A. Melchior-Becker, K. Röck, M. ter Braak, H. Jastrow,
M. Kinzig, S. Lucke, T. Suvorava, G. Kojda, A.A. Weber, F. Sörgel, B. Levkau,
S. Ergün, J.W. Fischer, Inhibition of hyaluronan synthesis accelerates murine
atherosclerosis, Circulation 122 (2010) 2313–2322, https://doi.org/10.1161/
CIRCULATIONAHA.110.972653.
[104] Y. Kashima, M. Takahashi, Y. Shiba, N. Itano, A. Izawa, J. Koyama, J. Nakayama,
S. Taniguchi, K. Kimata, U. Ikeda, Crucial role of hyaluronan in neointimal for-
mation after vascular injury, PLoS One 8 (2013) e58760, , https://doi.org/10.
1371/journal.pone.0058760.
[105] B. Weigelt, J.L. Peterse, L.J. van’t Veer, Breast cancer metastasis: markers and
models, Nat. Rev. Cancer 5 (2005) 591–602, https://doi.org/10.1038/nrc1670.
[106] T.A. Werfel, D.L. Elion, B. Rahman, D.J. Hicks, V. Sanchez, P.I. Gonzales-Ericsson,
M.J. Nixon, J.L. James, J.M. Balko, P.A. Scherle, H.K. Koblish, R.S. Cook,
Treatment-induced tumor cell apoptosis and secondary necrosis drive tumor
progression in the residual tumor microenvironment through MerTK and IDO1,
Cancer Res. 79 (2019) 171–182, https://doi.org/10.1158/0008-5472.CAN-18-
1106.
[107] H. Porsch, B. Bernert, M. Mehić, A.D. Theocharis, C.-H. Heldin, P. Heldin, Efficient
TGFβ-induced epithelial-mesenchymal transition depends on hyaluronan synthase
10
Seminars in Cancer Biology xxx (xxxx) xxx–xxx
HAS2, Oncogene. 32 (2013) 4355–4365, https://doi.org/10.1038/onc.2012.475.
[108] L.Y.W. Bourguignon, G. Wong, M. Shiina, Up-regulation of histone methyl-
transferase, DOT1L, by matrix hyaluronan promotes MicroRNA-10 expression
leading to tumor cell invasion and Chemoresistance in Cancer stem cells from head
and neck squamous cell carcinoma, J. Biol. Chem. 291 (2016) 10571–10585,
https://doi.org/10.1074/jbc.M115.700021.
[109] A. Schmaus, S. Klusmeier, M. Rothley, A. Dimmler, B. Sipos, G. Faller, W. Thiele,
H. Allgayer, P. Hohenberger, S. Post, J.P. Sleeman, Accumulation of small hya-
luronan oligosaccharides in tumour interstitial fluid correlates with lymphatic
invasion and lymph node metastasis, Br. J. Cancer 111 (3) (2014) 559–567,
https://doi.org/10.1038/bjc.2014.
[110] J.C. Rathmell, M.G. Vander Heiden, M.H. Harris, K.A. Frauwirth, C.B. Thompson,
In the absence of extrinsic signals, nutrient utilization by lymphocytes is in-
sufficient to maintain either cell size or viability, Mol. Cell 6 (2000) 683–692.
[111] M.G. Vander Heiden, L.C. Cantley, C.B. Thompson, Understanding the warburg
effect: the metabolic requirements of cell proliferation, Science 324 (80) (2009)
1029–1033, https://doi.org/10.1126/science.1160809.
[112] P.S. Ward, C.B. Thompson, Metabolic reprogramming: a Cancer hallmark even
warburg did not anticipate, Cancer Cell 21 (2012) 297–308, https://doi.org/10.
1016/j.ccr.2012.02.014.
[113] J. Kim, C.V. Dang, Cancer’s molecular sweet tooth and the warburg effect: figure 1,
Cancer Res. 66 (2006) 8927–8930, https://doi.org/10.1158/0008-5472.CAN-06-
1501.
[114] C.M. Ferrer, T.P. Lynch, V.L. Sodi, J.N. Falcone, L.P. Schwab, D.L. Peacock,
D.J. Vocadlo, T.N. Seagroves, M.J. Reginato, O-GlcNAcylation regulates Cancer
metabolism and survival stress signaling via regulation of the HIF-1 pathway, Mol.
Cell 54 (2014) 820–831, https://doi.org/10.1016/j.molcel.2014.04.026.
[115] D.R. Alessi, K. Sakamoto, J.R. Bayascas, LKB1-dependent signaling pathways,
Annu. Rev. Biochem. 75 (2006) 137–163, https://doi.org/10.1146/annurev.
biochem.75.103004.142702.
[116] S.L. Bowker, S.R. Majumdar, P. Veugelers, J.A. Johnson, Increased cancer-related
mortality for patients with type 2 diabetes who use sulfonylureas or insulin,
Diabetes Care 29 (2006) 254–258.
[117] D. Vigetti, M. Clerici, S. Deleonibus, E. Karousou, M. Viola, P. Moretto, P. Heldin,
V.C. Hascall, G. De Luca, A. Passi, Hyaluronan Synthesis Is Inhibited by Adenosine
Monophosphate-activated Protein Kinase through the Regulation of HAS2 Activity
in Human Aortic Smooth Muscle Cells, J. Biol. Chem. 286 (2011) 7917–7924,
https://doi.org/10.1074/jbc.M110.193656.
[118] M. Wu, M. Cao, Y. He, Y. Liu, C. Yang, Y. Du, W. Wang, F. Gao, A novel role of low
molecular weight hyaluronan in breast cancer metastasis, FASEB J. 29 (2015)
1290–1298, https://doi.org/10.1096/fj.14-259978.
[119] W.J. Sullivan, P.J. Mullen, E.W. Schmid, A. Flores, M. Momcilovic, M.S. Sharpley,
D. Jelinek, A.E. Whiteley, M.B. Maxwell, B.R. Wilde, U. Banerjee, H.A. Coller,
D.B. Shackelford, D. Braas, D.E. Ayer, T.Q. de Aguiar Vallim, W.E. Lowry,
H.R. Christofk, Extracellular matrix remodeling regulates glucose metabolism
through TXNIP destabilization, Cell. 175 (2018) 117–132, https://doi.org/10.
1016/j.cell.2018.08.017 e21.
[120] R. Kim, M. Emi, K. Tanabe, Cancer immunoediting from immune surveillance to
immune escape, Immunology. 121 (2007) 1–14, https://doi.org/10.1111/j.1365-
2567.2007.02587.x.
[121] Y.A. Fouad, C. Aanei, Revisiting the hallmarks of cancer, Am. J. Cancer Res. 7
(2017) 1016–1036.
[122] M.E. Mummert, Immunologic roles of hyaluronan, Immunol. Res. 31 (2005)
189–206, https://doi.org/10.1385/IR:31:3:189.
[123] D. Jiang, J. Liang, P.W. Noble, Hyaluronan as an immune regulator in human
diseases, Physiol. Rev. 91 (2011) 221–264, https://doi.org/10.1152/physrev.
00052.2009.
[124] N. Maeshima, G.F.T. Poon, M. Dosanjh, J. Felberg, S.S.M. Lee, J.L. Cross,
D. Birkenhead, P. Johnson, Hyaluronan binding identifies the most proliferative
activated and memory T cells, Eur. J. Immunol. 41 (2011) 1108–1119, https://doi.
org/10.1002/eji.201040870.
[125] J. Lesley, N. Howes, A. Perschl, R. Hyman, Hyaluronan binding function of CD44 is
transiently activated on T cells during an in vivo immune response, J. Exp. Med.
180 (1994) 383–387.
[126] S.S.M. Lee-Sayer, Y. Dong, A.A. Arif, M. Olsson, K.L. Brown, P. Johnson, D. Naor,
The Where, When, How, and Why of Hyaluronan Binding by Immune Cells,
(2015), https://doi.org/10.3389/fimmu.2015.00150.
[127] N.C. Singha, T. Nekoroski, C. Zhao, R. Symons, P. Jiang, G.I. Frost, Z. Huang,
H.M. Shepard, Tumor-associated hyaluronan limits efficacy of monoclonal anti-
body therapy, Mol. Cancer Ther. 14 (2015) 523–532, https://doi.org/10.1158/
1535-7163.MCT-14-0580.
[128] T. Váradi, T. Mersich, P. Auvinen, R. Tammi, M. Tammi, F. Salamon, I. Besznyák,
F. Jakab, Z. Baranyai, J. Szöllősi, P. Nagy, Binding of trastuzumab to ErbB2 is
inhibited by a high pericellular density of hyaluronan, J. Histochem. Cytochem. 60
(2012) 567–575, https://doi.org/10.1369/0022155412448070.
[129] Z. Pályi-Krekk, M. Barok, J. Isola, M. Tammi, J. Szöllo˝si, P. Nagy, Hyaluronan-
induced masking of ErbB2 and CD44-enhanced trastuzumab internalisation in
trastuzumab resistant breast cancer, Eur. J. Cancer 43 (2007) 2423–2433, https://
doi.org/10.1016/j.ejca.2007.08.018.
[130] S.P. Evanko, S. Potter-Perigo, P.L. Bollyky, G.T. Nepom, T.N. Wight, Hyaluronan
and versican in the control of human T-lymphocyte adhesion and migration,
Matrix Biol. 31 (2012) 90–100, https://doi.org/10.1016/j.matbio.2011.10.004.
[131] B.-Z. Qian, J.W. Pollard, Macrophage diversity enhances tumor progression and
metastasis, Cell. 141 (2010) 39–51, https://doi.org/10.1016/j.cell.2010.03.014.
[132] R. Noy, J.W. Pollard, Tumor-associated macrophages: from mechanisms to
therapy, Immunity. 41 (2014) 49–61, https://doi.org/10.1016/j.immuni.2014.06.
I. Caon, et al.
010.
[133] N. Kobayashi, S. Miyoshi, T. Mikami, H. Koyama, M. Kitazawa, M. Takeoka,
K. Sano, J. Amano, Z. Isogai, S. Niida, K. Oguri, M. Okayama, J.A. McDonald,
K. Kimata, S. Taniguchi, N. Itano, Hyaluronan deficiency in tumor stroma impairs
macrophage trafficking and tumor neovascularization, Cancer Res. 70 (2010)
7073–7083, https://doi.org/10.1158/0008-5472.CAN-09-4687.
[134] T. Chanmee, P. Ontong, N. Itano, Hyaluronan: a modulator of the tumor micro-
environment, Cancer Lett. 375 (2016) 20–30, https://doi.org/10.1016/j.canlet.
2016.02.031.
[135] S. Tiainen, R. Tumelius, K. Rilla, K. Hämäläinen, M. Tammi, R. Tammi, V.-
M. Kosma, S. Oikari, P. Auvinen, High numbers of macrophages, especially M2-
like (CD163-positive), correlate with hyaluronan accumulation and poor outcome
in breast cancer, Histopathology. 66 (2015) 873–883, https://doi.org/10.1111/
his.12607.
[136] G. Zhang, L. Guo, C. Yang, Y. Liu, Y. He, Y. Du, W. Wang, F. Gao, A novel role of
breast cancer-derived hyaluronan on inducement of M2-like tumor-associated
macrophages formation, Oncoimmunology. 5 (2016) e1172154, , https://doi.org/
10.1080/2162402X.2016.1172154.
[137] F.M. Spinelli, D.L. Vitale, A. Icardi, I. Caon, A. Brandone, P. Giannoni, V. Saturno,
A. Passi, M. García, I. Sevic, L. Alaniz, Hyaluronan preconditioning of monocytes/
macrophages affects their angiogenic behavior and regulation of TSG ‐6 expression
in a tumor type‐specific manner, FEBS J. (2019) febs.14871, https://doi.org/10.
1111/febs.14871.
[138] H. Okuda, A. Kobayashi, B. Xia, M. Watabe, S.K. Pai, S. Hirota, F. Xing, W. Liu,
P.R. Pandey, K. Fukuda, V. Modur, A. Ghosh, A. Wilber, K. Watabe, Hyaluronan
synthase HAS2 promotes tumor progression in bone by stimulating the interaction
of breast Cancer Stem-Like cells with macrophages and stromal cells, Cancer Res.
72 (2012) 537–547, https://doi.org/10.1158/0008-5472.CAN-11-1678.
[139] J.P. Foley, D. Lam, H. Jiang, J. Liao, N. Cheong, T.M. McDevitt, A. Zaman,
J.R. Wright, R.C. Savani, Toll-like receptor 2 (TLR2), transforming growth Factor-
β, hyaluronan (HA), and receptor for HA-mediated motility (RHAMM) are re-
quired for surfactant protein A-stimulated macrophage chemotaxis, J. Biol. Chem.
287 (2012) 37406–37419, https://doi.org/10.1074/jbc.M112.360982.
[140] J.E. Rayahin, J.S. Buhrman, Y. Zhang, T.J. Koh, R.A. Gemeinhart, High and low
molecular weight hyaluronic acid differentially influence macrophage activation,
ACS Biomater. Sci. Eng. 1 (2015) 481–493, https://doi.org/10.1021/
acsbiomaterials.5b00181.
[141] C. del Fresno, K. Otero, L. Gómez-García, M.C. González-León, L. Soler-Ranger,
P. Fuentes-Prior, P. Escoll, R. Baos, L. Caveda, F. García, F. Arnalich, E. López-
Collazo, Tumor cells deactivate human monocytes by up-regulating IL-1 receptor
associated kinase-M expression via CD44 and TLR4, J. Immunol. 174 (2005)
3032–3040.
[142] D.-M. Kuang, Y. Wu, N. Chen, J. Cheng, S.-M. Zhuang, L. Zheng, Tumor-derived
hyaluronan induces formation of immunosuppressive macrophages through tran-
sient early activation of monocytes, Blood. 110 (2007) 587–595, https://doi.org/
10.1182/blood-2007-01-068031.
[143] S.-W. Leu, L. Shi, C. Xu, Y. Zhao, B. Liu, Y. Li, A. Shiedlin, C. Xiang, H. Shen,
D.A. Quinn, C.A. Hales, H. Zhao, TLR4 through IFN- promotes low molecular mass
hyaluronan-induced neutrophil apoptosis, J. Immunol. 186 (2011) 556–562,
https://doi.org/10.4049/jimmunol.1001630.
[144] C. Termeer, J.P. Sleeman, J.C. Simon, Hyaluronan–magic glue for the regulation of
the immune response? Trends Immunol. 24 (2003) 112–114, https://doi.org/10.
1016/S1471-4906(03)00029-2.
[145] C. Termeer, F. Benedix, J. Sleeman, C. Fieber, U. Voith, T. Ahrens, K. Miyake,
M. Freudenberg, C. Galanos, J.C. Simon, Oligosaccharides of Hyaluronan activate
11
Seminars in Cancer Biology xxx (xxxx) xxx–xxx
dendritic cells via toll-like receptor 4, J. Exp. Med. 195 (2002) 99–111.
[146] Y. Do, P.S. Nagarkatti, M. Nagarkatti, Role of CD44 and hyaluronic acid (HA) in
activation of alloreactive and antigen-specific T cells by bone marrow-derived
dendritic cells, J. Immunother. 27 (n.d.) 1–12.
[147] A.K. Palucka, H. Ueno, J.W. Fay, J. Banchereau, Taming cancer by inducing im-
munity via dendritic cells, Immunol. Rev. 220 (2007) 129–150, https://doi.org/
10.1111/j.1600-065X.2007.00575.x.
[148] L. Alaniz, M. Garcia, M. Rizzo, F. Piccioni, G. Mazzolini, Altered hyaluronan
biosynthesis and cancer progression: an immunological perspective, Mini Rev.
Med. Chem. 9 (2009) 1538–1546.
[149] K.A. Scheibner, M.A. Lutz, S. Boodoo, M.J. Fenton, J.D. Powell, M.R. Horton,
Hyaluronan fragments act as an endogenous danger signal by engaging TLR2, J.
Immunol. 177 (2006) 1272–1281, https://doi.org/10.4049/JIMMUNOL.177.2.
1272.
[150] M. Rizzo, J. Bayo, F. Piccioni, M. Malvicini, E. Fiore, E. Peixoto, M.G. García,
J.B. Aquino, A. Gonzalez Campaña, G. Podestá, M. Terres, O. Andriani, L. Alaniz,
G. Mazzolini, Low molecular weight hyaluronan-pulsed human dendritic cells
showed increased migration capacity and induced resistance to tumor chemoat-
traction, PLoS One 9 (2014) e107944, , https://doi.org/10.1371/journal.pone.
0107944.
[151] N. Nagy, H.F. Kuipers, A.R. Frymoyer, H.D. Ishak, J.B. Bollyky, T.N. Wight,
P.L. Bollyky, 4-methylumbelliferone treatment and hyaluronan inhibition as a
therapeutic strategy in inflammation, autoimmunity, and Cancer, Front. Immunol.
6 (2015) 123, https://doi.org/10.3389/fimmu.2015.00123.
[152] T. SAITO, D. TAMURA, T. NAKAMURA, Y. MAKITA, H. ARIYAMA, K. KOMIYAMA,
T. YOSHIHARA, R. ASANO, 4-Methylumbelliferone leads to growth arrest and
apoptosis in canine mammary tumor cells, Oncol. Rep. 29 (2013) 335–342,
https://doi.org/10.3892/or.2012.2100.
[153] V.B. Lokeshwar, L.E. Lopez, D. Munoz, A. Chi, S.P. Shirodkar, S.D. Lokeshwar,
D.O. Escudero, N. Dhir, N. Altman, Antitumor activity of hyaluronic acid synthesis
inhibitor 4-Methylumbelliferone in prostate Cancer cells, Cancer Res. 70 (2010)
2613–2623, https://doi.org/10.1158/0008-5472.CAN-09-3185.
[154] M. Malvicini, E. Fiore, V. Ghiaccio, F. Piccioni, M. Rizzo, L. Olmedo Bonadeo,
M. García, M. Rodríguez, J. Bayo, E. Peixoto, C. Atorrasagasti, L. Alaniz, J. Aquino,
P. Matar, G. Mazzolini, Tumor microenvironment remodeling by 4-
Methylumbelliferone boosts the antitumor effect of combined immunotherapy in
murine colorectal carcinoma, Mol. Ther. 23 (2015) 1444–1455, https://doi.org/
10.1038/mt.2015.112.
[155] N. Nagy, I. Gurevich, H.F. Kuipers, S.M. Ruppert, P.L. Marshall, B.J. Xie, W. Sun,
A.V. Malkovskiy, J. Rajadas, M. Grandoch, J.W. Fischer, A.R. Frymoyer, G. Kaber,
P.L. Bollyky, 4-Methylumbelliferyl glucuronide contributes to hyaluronan synth-
esis inhibition, J. Biol. Chem. 294 (19) (2019) 7864–7877, https://doi.org/10.
1074/jbc.RA118.006166.
[156] Y. Li, L. Li, T.J. Brown, P. Heldin, Silencing of hyaluronan synthase 2 suppresses
the malignant phenotype of invasive breast cancer cells, Int. J. Cancer 120 (2007)
2557–2567, https://doi.org/10.1002/ijc.22550.
[157] L.Y.W. Bourguignon, G. Wong, C. Earle, L. Chen, Hyaluronan-CD44v3 interaction
with Oct4-Sox2-Nanog promotes miR-302 expression leading to self-renewal,
clonal formation, and cisplatin resistance in cancer stem cells from head and neck
squamous cell carcinoma, J. Biol. Chem. 287 (2012) 32800–32824, https://doi.
org/10.1074/jbc.M111.308528.
[158] J. Liu, F. Tu, W. Yao, X. Li, Z. Xie, H. Liu, Q. Li, Z. Pan, Conserved miR-26b
enhances ovarian granulosa cell apoptosis through HAS2-HA-CD44-Caspase-3
pathway by targeting HAS2, Sci. Rep. 6 (2016) 21197, https://doi.org/10.1038/
srep21197.