MHE worksheet for physicians

About MHE
Exostoses / Osteochondromas.
An Exostosis/Osteochondroma is a benign tumor that contains both bone and cartilage and usually
occurs near the end of long bones. Multiple Exostoses/Osteochondromas is where people develop these
tumors in multiple locations throughout the body.

The severity of MHE / MO/ HME varies from family to family and patient to patient. The number and size
of exostoses / osteochondroma's vary widely. Exostoses / osteochondroma’s can cause numerous
problems, including: compression of peripheral nerves or blood vessels; irritation of tendons and muscles
resulting in pain and loss of motion; skeletal deformity; short stature; limb length discrepancy; chronic pain
and fatigue; early onset arthritis. Problems associated include:

 Chronic Pain
 Inflammation, Bursa formation and resulting bursitis
 Irritation of a nearby nerve (weakness, numbness)
 Blood vessel aneurysm from pressure of the blood vessel by the Exostoses / Osteochondroma
 Angular deformity and Limb length discrepancy (Bowing of the limbs, Gait and Posture )
 Neurological problems (can also be associated with spinal tumors)
 Loss in range of motion (ROM)
 Higher prevalence to scarring (surgery related)

Heparan Sulfate Deficiency

Zak et al 2002, Lasselin et al 2006, Jones et al. 2012 conclude MHE patients have defective heparan
sulfate (HS) biosynthesis, a complex polysaccharide used in nearly every cell of the body (Multhaupt and
Couchman, 2012). Whitlock and Iozzo, 2005, have identified various diseases related to the lack of
heparan sulfate. Other MHE patients have reported symptoms, and researchers have confirmed links to
problems such as:

Severe gastric problems (hyperemesis and bleeding ulcers) HS has been implicated in many gastric
issues, including:
o Ascencio et al. 1993 and Chmiela et al. 1995 determined that H. Pylori binds HS, as one cause
of ulcers. If binding HS causes ulcers, then an absence of HS could also cause gastric distress.
o Weihua et al. 2002 concluded that heparanase1 might play an important role in the development
of invasion and metastasis of the gastric cancer
o Theoharides et al 1999 posits a relationship between HS and cyclic vomiting syndrome.
Kidney stones and other problems (See Van den Born et al. 1993)
Neurological deficiencies (Asperger’s Syndrome, language deficiencies) (See Fumitoshi et al. 2012)
Vertigo, hyperacusis
Lung issues (Nackerts et al. 1997, Broughten-Head et al. 2007, Haeger S.M. et al 2016, Miller et al.
2009)
Migraines
Wound healing (Zhongjun Zhou et al. 2004.)

1
Heparanase is an endoglycosidase which cleaves heparan sulfate (HS) and hence participaes in degradation and remodeling of the
extracellular matrix (ECM). Vlodavestky et al 2007.
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References with abstracts

Ascencio, F. L. Å. Fransson and T. WadstrÖum, 1993. Affinity of the gastric pathogen Helicobacter pylori for the N-sulphated
glycosaminoglycan heparan sulphate J Med Microbiol April 1993 vol. 38 no. 4 240-244
http://jmm.sgmjournals.org/content/38/4/240.short

Summary. Binding of 125I-heparan sulphate was a common property of Helicobacter pylori strains isolated from patients with
gastroduodenal ulcer diseases. Binding was (i) saturable; (ii) reversible by the addition of unlabelled heparan sulphate and
heparin; (iii) inhibited by unlabelled heparan sulphate, heparin, and heparin oligosaccharides but not by other
glycosaminoglycans of comparable size (chondroitin sulphate and dermatan sulphate) or by highly glycosylated glycoproteins
(hog gastric mucin and fetuin); (iv) reduced by heat treatment (80°C, 10 min) and exposure of the bacteria to pronase E,
proteinase K, trypsin and chymotrypsin, but unaffected by treatment with pepsin and neuraminidase; and (v) time-, pH-, and
ionic strength-dependent. Scatchard plot analysis of the binding data indicated the presence of one class of high-affinity
receptor (Kd = 9×10-9M) for heparan sulphate

Benoist-Lasselina, Catherine Emmanuel de Margerieb, Linda Gibbsa, Sarah Cormierc, Caroline Silvec, Gisèle Nicolasd, Martine
LeMerrera, Jean-Francois Mallete, Arnold Munnicha, Jacky Bonaventurea, Louise Zylberbergb, Laurence Legeai-Malleta,
2006. Defective chondrocyte proliferation and differentiation in osteochondromas of MHE patients. Bone, Volume 39, Issue
1, July 2006, Pages 17–26. http://www.thebonejournal.com/article/S8756-3282(05)00540-5/fulltext
Abstract

Multiple hereditary exostoses (MHE) is an autosomal dominant skeletal disorder caused by mutations in one of the two EXT
genes and characterized by multiple osteochondromas that generally arise near the ends of growing long bones. Defective
endochondral ossification is likely to be involved in the formation of osteochondromas. In order to investigate potential changes
in chondrocyte proliferation and/or differentiation during this process, osteochondroma samples from MHE patients were
obtained and used for genetic, morphological, immunohistological, and in situ hybridization studies. The expression patterns of
IHH (Indian hedgehog) and FGFR3 (Fibroblast Growth Factor Receptor 3) were similar with transcripts expressed throughout
osteochondromas. Expression of PTHR1 (Parathyroid Hormone Receptor 1) transcripts was restricted to a narrow zone of
prehypertrophic chondrocytes. Numerous cells forming osteochondromas although resembling prehypertrophic chondrocytes,
stained positively with an anti-proliferating cell nuclear antigen (PCNA) antibody. In addition, ectopic expression of collagen type
I and abnormal presence of osteocalcin (OC), osteopontin (OP), and bone sialoprotein (BSP) were observed in the cartilaginous
osteochondromas. These data indicate that most chondrocytes involved in the growth of osteochondromas can proliferate, and
that some of them exhibit bone-forming cell characteristics. We conclude that in MHE, defective heparan sulfate biosynthesis
caused by EXT mutations maintains the proliferative capacity of chondrocytes and promotes phenotypic modification to bone-
forming cells.

Broughton-Head, V.K, et al. 2007. Unfractionated heparin reduces the elasticity of sputum from patients with cystic fibrosis.
AMerican Journal of Physiology. Unfractionated heparin reduces the elasticity of sputum from patients with cystic fibrosis |
Lung Cellular and Molecular Physiology http://ajplung.physiology.org/content/293/5/L1240.short

Mucus obstruction of the airway in patients with cystic fibrosis (CF) reduces lung function, invites infection, and limits delivery of
inhaled drugs including gene therapy vectors to target cells. Not all patients respond to presently available mucolytics, and new
approaches are needed. Our objectives were to investigate the in vitro effects of unfractionated heparin (UFH) on the
morphology and rheology of sputum and the effect of UFH on diffusion of 200-nm nanospheres through sputum from adult CF
patients. . . .Thus the mucoactive properties of UFH indicate its potential as a new therapeutic approach in patients with cystic
fibrosis.

Chmiela, M. et al. 1995. The role of heparan sulphate-binding activity of Helicobacter pylori bacteria in their adhesion to
murine macrophages. http://onlinelibrary.wiley.com/doi/10.1111/j.1699-0463.1995.tb01133.x/full

The aim of this study was to determine the role of heparan sulphate (HS)-binding activity of Helicobacter pylori microbes in their
adhesion to and ingestion by inflammatory peritoneal macrophages. Two H. pylori strains expressing sialic acid-specific
haemagglutinins but differing in the expression of heparan sulphate-binding capacity were chosen for investigation. The
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attachment to an ingestion by macrophages of the H. pylori bacteria were estimated by ELISA using anti-H. pylori antibodies.
The adhesion of both H. pylori strains could be inhibited by pretreatment of the bacteria with heparin (H), HS or fetuin, as well as
by preincubation of the macrophages with heparinase or neuraminidase. However, detailed analysis of the data on the
inhibition of bacterial adhesion to macrophages led to the conclusion that the attachment of H. pylori 25 bacteria, which
expressed a high heparan sulphate binding, was mainly determined by HS-binding structures. In contrast, the adhesion to
macrophages of H. pylori bacteria 17874 microbes, which expressed a weak heparan sulphate binding, was more dependent on
the exhibition of sialic acid-dependent haemagglutinins. The described variation in H. pylori bacterial surface structures
mediating their adhesion to macrophages could suggest a similar variation in bacterial adhesion to stomach mucosa and maybe
in the pathogenicity of H. pylori strains

Fumitoshi Irie, Hedieh Badie-Mahdavi, and Yu Yamaguchi, 2012. Autism-like socio-communicative deficits and stereotypies in
mice lacking heparan sulfate. PNAS 2012 109 (13) 5052-5056;  March 27, 2012 vol. 109 no. 13
http://www.pnas.org/content/109/13/5052.short

Heparan sulfate regulates diverse cell-surface signaling events, and its roles in the development of the nervous system recently
have been increasingly uncovered by studies using genetic models carrying mutations of genes encoding enzymes for its
synthesis. On the other hand, the role of heparan sulfate in the physiological function of the adult brain has been poorly
characterized, despite several pieces of evidence suggesting its role in the regulation of synaptic function. To address this issue,
we eliminated heparan sulfate from postnatal neurons by conditionally inactivating Ext1, the gene encoding an enzyme essential
for heparan sulfate synthesis. Resultant conditional mutant mice show no detectable morphological defects in the
cytoarchitecture of the brain. Remarkably, these mutant mice recapitulate almost the full range of autistic symptoms, including
impairments in social interaction, expression of stereotyped, repetitive behavior, and impairments in ultrasonic vocalization, as
well as some associated features. Mapping of neuronal activation by c-Fos immunohistochemistry demonstrates that neuronal
activation in response to social stimulation is attenuated in the amygdala in these mice. Electrophysiology in amygdala
pyramidal neurons shows an attenuation of excitatory synaptic transmission, presumably because of the reduction in the level of
synaptically localized AMPA-type glutamate receptors. Our results demonstrate that heparan sulfate is critical for normal
functioning of glutamatergic synapses and that its deficiency mediates socio-communicative deficits and stereotypies
characteristic for autism.

Haeger S.M. et al. 2016. Heparan Sulfate in the Developing, Healthy, and Injured Lung. American Journal of Respiratory Cell
and Molecular Biology. 
http://www.atsjournals.org/doi/abs/10.1165/rcmb.2016-0043TR
The focus of this Translational Review is to highlight the importance of a specific glycan polymer—the glycosaminoglycan
heparan sulfate (HS)—on lung health and disease. We demonstrate how HS contributes to lung physiology and pathophysiology
via its actions as both a structural constituent of the lung parenchyma as well as a regulator of cellular signaling. By highlighting
current uncertainties in HS biology, we identify opportunities for future high-impact pulmonary and critical care translational
investigations.

Jones K.B. et al. 2014. Multiple hereditary exostoses (MHE): elucidating the pathogenesis of a rare skeletal disorder through
interdisciplinary research.. Connect Tissue Res. 2014 Apr;55(2):80-8. doi: 10.3109/03008207.2013.867957. Epub 2014 Feb 1
https://www.ncbi.nlm.nih.gov/pubmed/24409815#
MHE is largely caused by autosomal dominant mutations in EXT1 or EXT2, genes encoding Golgi-associated glycosyltransferases
responsible for heparan sulfate (HS) synthesis. HS chains are key constituents of cell surface- and extracellular matrix-associated
proteoglycans, which are known regulators of skeletal development.

Miller, A.C. et al. 2009. Influence of Nebulized Unfractionated Heparin and N-Acetylcysteine in Acute Lung Injury After Smoke
Inhalation Injury. Journal of BUrn Care and Research, Influence of Nebulized Unfractionated Heparin and N-Acetylcy... :
Journal of Burn Care & Research

To determine whether the combination of aerosolized unfractionated heparin and N-acetylcystine reduces 28-days mortality and
lung injury scores (LISs) in adult patients with smoke inhalation injury requiring mechanical ventilation. The study was a single-
center retrospective study with historical control. . . . Survival for the control vs experimental group was 0.5714 ± 0.1497 vs
0.9375 ± 0.0605, respectively, (risk ratio −0.0055; 95% confidence interval −0.0314-0.0204; hazard ratio 1.003; number needed
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to treat 2.7). The use of aerosolized unfractionated heparin and N−acetylcystine attenuates lung injury and the progression of
acute respiratory distress syndrome in ventilated adult patients with acute lung injury following smoke inhalation.

Multhaupt, H.A.B. and J.R. Couchman, 2012. Heparan Sulfate Biosynthesis,J Histochem Cytochem. 2012 Dec; 60(12): 908–
915. : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3527879/
Heparan sulfate is perhaps the most complex polysaccharide known from animals. The basic repeating disaccharide is
extensively modified by sulfation and uronic acid epimerization. Despite this, the fine structure of heparan sulfate is remarkably
consistent with a particular cell type. This suggests that the synthesis of heparan sulfate is tightly controlled. Although genomics
has identified the enzymes involved in glycosaminoglycan synthesis in a number of vertebrates and invertebrates, the regulation
of the process is not understood. Moreover, the localization of the various enzymes in the Golgi apparatus has not been carried
out in a detailed way using high-resolution microscopy. We have begun this process, using well-known markers for the various
Golgi compartments, coupled with the use of characterized antibodies and cDNA expression

Nackaerts, K. et al. 1997. Heparan Sulfate Proteoglycan Expression In Human Lung-Cancer Cells. Int. J. Cancer (Pred. Oncol.):
74, 335–345 (1997) r 1997 Wiley-Liss, Inc.
https://www.researchgate.net/profile/Maurits_Demedts/publication/13997415_Heparan_sulfate_proteoglycan_expression
_in_human_lung-cancer_cells/links/5600565108aeafc8ac8c7374.pdf
Heparan sulfate (HS) functions as a co-factor in several signal-transduction systems that affect cellular growth, differ- entiation,
adhesion and motility. HS, therefore, may also play a role in the malignant transformation of cells, tumor growth, cell
invasiveness and the formation of tumor metastases. To explore this hypothesis, we analyzed the expression of HS and heparan
sulfate proteoglycan (HSPG) in histological sections of human lung-cancer tissues and assayed for the presence of HSPGs in
extracts of human lung-cancer cell lines, using a panel of native HS-, D-HS- and HSPG (syndecan, glypican, CD44 and perlecan)
core protein–specific monoclonal antibod- ies. Compared to normal epithelia, non-small-cell lung carcinomas, particularly poorly
differentiated tumors, often ex- pressed reduced amounts of the major cell surface–associated HSPGs (most consistently of
syndecan-1). CD44 or CD44- variant proteins, in contrast, were found on all tumor cells, irrespective of their differentiation.
Perlecan, a matrix- associated HSPG found in the basement membrane of nor- mal bronchial epithelium, was consistently
undetectable in invasive bronchogenic carcinomas. Staining reactions for native HS were consistently reduced in squamous-cell
lung carcinomas, in the cells in contact with the stroma and in the less differentiated areas of these tumors. Reactions for D-HS,
however, were not reduced, suggesting a structural change in the HS of these tumor cells. Poorly differentiated adenocarci-
nomas, in contrast, yielded strong HS and D-HS reactions. Marked differences in HSPG expression also were observed among
various non-small-cell lung carcinoma cell lines. Our results suggest that poorly differentiated lung tumors have markedly
altered patterns of HSPG expression, which may contribute to their invasive phenotype. Int. J. Cancer 74:335– 345, 1997.

Russel A.L. and M.F.McCarty, 2000 Glucosamine for migraine prophylaxis? Medical Hypotheses. Volume 55, Issue 3,
September 2000, Pages 195-198. http://www.sciencedirect.com/science/article/pii/S0306987799910125

Following a fortuitous observation that migraine headaches ceased in a patient receiving glucosamine therapy for osteoarthritis,
a further ten patients with migraine or migraine-like vascular headaches, refractory to established preventive or abortive
therapies, have been treated with daily oral glucosamine. After a lag of 4–6 weeks, a substantial reduction in headache
frequency and/or intensity has been noted; in some cases, the benefit appears to be dose-dependent. Since glucosamine can be
a rate-limiting precursor for mucopolysaccharide synthesis, it is germane to note previous reports that heparin and pentosan
polysulfate may have migraine-preventive activity. There is reason to suspect that mast cells are central mediators of the
neurogenic inflammation associated with migraine and cluster headaches. The heparin produced by mast cells may function to
provide feedback down-regulation of mast cell activation, and exerts a range of other anti-inflammatory effects. We postulate
that supplemental glucosamine can boost mast cell heparin synthesis – perhaps correcting a functional heparin deficiency –
thereby preventing or ameliorating the neurogenic inflammation that mediates pain in vascular headache. Whether or not this
idea has validity, a controlled study of glucosamine for migraine prophylaxis appears to be warranted.

Theoharides TC et al. 1999. Stress-induced rat intestinal mast cell intragranular activation and inhibitory effect of sulfated
proteoglycans. Digestive Diseases and Sciences [1999, 44(8 Suppl):87S-93S]. http://europepmc.org/abstract/med/10490045

Cyclic vomiting syndrome is characterized by sudden episodes of vomiting and abdominal pain. It occurs primarily in children, is
exacerbated by stress, and is often considered a migraine equivalent. Migraines have been linked to mast cells, which are often
found close to neurons where they are activated by neuropeptides. We investigated the ultrastructural appearance of rat ileal
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brush border and mast cells following acute stress by immobilization. The effect of sulfated proteoglycans heparin and
chondroitin sulfate was also tested on mast cell histamine secretion. Ileal brush border appeared intact in control animals, but
was shorter and exhibited intercellular gaps after 30 min of acute immobilization stress. Mast cell activation in control rats was
minimal, while stress induced obvious signs of activation as judged from disappearance of secretory granule electron dense
contents. However, these intragranular changes were not accompanied by typical degranulation through exocytosis. Treatment
of purified homogeneic rat peritoneal mast cells with 10(-4) M heparin or chondroitin sulfate 30 min prior to stimulation with 0.5
microg/ml compound 48/80 decreased histamine release by over 70% and 50% (P < 0.05), respectively. These results suggest the
possible usefulness of chondroitin sulfate in conditions such as cyclic vomiting syndrome.

van den Born J, van den Heuvel LP, Bakker MA, Veerkamp JH, Assmann KJ, Weening JJ, Berden JH., 1993. Distribution of GBM
heparan sulfate proteoglycan core protein and side chains in human glomerular diseases. Kidney Int. 1993 Feb;43(2):454-63.
http://www.ncbi.nlm.nih.gov/pubmed/8441243

Abstract. Using monoclonal antibodies (mAbs) recognizing either the core protein or the heparan sulfate (HS) side chain of
human GBM heparan sulfate proteoglycan (HSPG), we investigated their glomerular distribution on cryostat sections of human
kidney tissues. The study involved 95 biopsies comprising twelve different glomerulopathies. Four normal kidney specimens
served as controls. A homogenous to linear staining of the GBM was observed in the normal kidney with anti-HSPG-core mAb
(JM-72) and anti-HS mAb (JM-403). In human glomerulopathies the major alteration was a segmental or total absence of GBM
staining with anti-HS mAb JM-403, which is most pronounced in lupus nephritis, membranous glomerulonephritis (GN), minimal
change disease and diabetic nephropathy, whereas the HSPG-core staining by mAb JM-72 was unaltered. In addition we found
HSPG-core protein in the mesangial matrix when this was increased in membranoproliferative GN Type I, Schönlein-Henoch GN,
IgA nephropathy, lupus nephritis, diabetic nephropathy and in focal glomerulosclerosis. Also staining with the anti-HS mAb JM-
403 became positive within the mesangium, although to a lesser extent. Furthermore, amyloid deposits in AL and AA
amyloidosis clearly stained with anti-HSPG-core mAb JM-72, and to a lesser degree with anti-HS mAb JM-403. Finally, in
membranous GN (stage II and III), the GBM staining with anti-HSPG-core mAb JM-72 became irregular or granular, probably
related to the formation of spikes. In conclusion, major alterations were observed in the glomerular distribution of HS and HSPG-
core in various human glomerulopathies. The mAbs can be useful to further delineate the significance of HSPG and HS for
glomerular diseases.

Vlodavestky, I. et al. 2007. Heparanase: Structure, Biological Functions, and Inhibition by Heparin-Derived Mimetics of
Heparan Sulfate. Current Pharmaceutical Design, Volume 13, Number 20, July 2007, pp. 2057-2073(17).
http://www.ingentaconnect.com/content/ben/cpd/2007/00000013/00000020/art00004

Abstract: Heparanase is an endoglycosidase which cleaves heparan sulfate (HS) and hence participates in degradation and
remodeling of the extracellular matrix (ECM). Heparanase is preferentially expressed in human tumors and its over-expression in
tumor cells confers an invasive phenotype in experimental animals. The enzyme also releases angiogenic factors from the ECM
and thereby induces an angiogenic response in vivo. Heparanase upregulation correlates with increased tumor vascularity and
poor postoperative survival of cancer patients. Heparanase is synthesized as a 65 kDa inactive precursor that undergoes
proteolytic cleavage, yielding 8 kDa and 50 kDa protein subunits that heterodimerize to form an active enzyme. Heparanase
exhibits also non-enzymatic activities, independent of its involvement in ECM degradation. Among these, are the enhancement
of Akt signaling, stimulation of PI3K- and p38-dependent endothelial cell migration, and up regulation of VEGF, all contributing
to its potent pro-angiogenic activity. Studies on relationships between structure and heparanase inhibition activity of
nonanticogulant heparins systematically differing in their O-sulfation patterns, degrees of N-acetylation, and glycol-splitting of
both pre-existing nonsulfated uronic acid residues (prevalently D-glucuronic) and/or those (Liduronic acid/L-galacturonic acid)
generated by graded 2-O-desulfation, have permitted to select effective inhibitors of the enzymatic activity of heparanase. N-
acetylated, glycol-split heparins emerged as especially strong inhibitors of heparanase, exerting little or no release of growth
factors from ECM. N-acetylated glycol-split species of heparin, as well as heparanase gene silencing inhibit tumor metastasis,
angiogenesis and inflammation in experimental animal models. These observations and the unexpected identification of a single
functional heparanase, suggest that the enzyme is a promising target for anti-cancer and anti-inflammatory drug development.

Weihua T. et al. 2002. Heparanase: A Key Enzyme in Invasion and Metastasis of Gastric Carcinoma.Mod Pathol
2002;15(6):593–59. http://www.nature.com/modpathol/journal/v15/n6/abs/3880571a.html
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Abstract. Previous reports have shown that the biochemical activity of heparanase is significantly correlated with the invasion
and metastasis of malignant cells in vitro. Recently, it was found that the human heparanase gene was cloned and highly
expressed in malignant cell lines and human solid malignant tumors. In the present study, we investigated the heparanase
mRNA expression by using in situ hybridization in 116 paraffin-embedded tissues of primary gastric carcinomas. To explore its
clinicopathologic significance, it was detected in the various steps of tumor progression and then compared with prognostic
indicators. As a result, the heparanase expression was more prevalent in late-stage rather than early-stage carcinomas (P
< .0001) and was more frequent in tumors of large size (P = .0212). Expression also correlated with lymphatic (P = .0086) and
venous (P = .0171) invasion and with negative prognostic factors such as lymph nodal (P < .0001) and distant (P = .0221)
metastases. However, in a multivariate analysis, messenger RNA expression of heparanase was not an independent prognostic
factor. It was concluded that heparanase might play an important role in the development of invasion and metastasis of the
gastric cancer. It was indicated that patients with heparanase-positive gastric carcinoma would have a greater chance of
metastasis with a poor prognosis. Keywords: Extracellular matrix, Gastric cancer, Heparanase, Invasion, Metastasis, mRNA
expression, Prognostic indicator

Whitelock John M. and Renato V. Iozzo, 2005. Heparan Sulfate:  A Complex Polymer Charged with Biological Activity. Chem.
Rev., 2005, 105 (7), pp 2745–2764. http://pubs.acs.org/doi/pdf/10.1021/cr010213m

Abstract unavailable, but first page states . “HS is a complex and highly active biopolymer…” one section is on heparin
sulfate therapies, but I contacted the authors in 2013 and never heard back.

Zak, B.M., B.E. Crawford, and J.D. Esko, 2002. Hereditary multiple exostoses and heparan sulfate polymerization Biochimica
et Biophysica Acta (BBA) Volume 1573, Issue 3, 19 December 2002, Pages 346–355
http://www.sciencedirect.com/science/article/pii/S0304416502004026

Hereditary multiple exostoses (HME, OMIM 133700, 133701) results from mutations in EXT1 and EXT2, genes encoding the
copolymerase responsible for heparan sulfate (HS) biosynthesis. Members of this multigene family share the ability to transfer
N-acetylglucosamine to a variety of oligosaccharide acceptors. EXT1 and EXT2 encode the copolymerase, whereas the roles of
the other EXT family members (EXTL1, L2, and L3) are less clearly defined. Here, we provide an overview of HME, the EXT family
of proteins, and possible models for the relationship of altered HS biosynthesis to the ectopic bone growth characteristic of the
disease.

Zhongjun Zhou et al. 2004. Impaired Angiogenesis, Delayed Wound Healing and Retarded Tumor
Growth in Perlecan Heparan Sulfate-Deficient Mice. DOI: 10.1158/0008-5472.CAN-04-0810 Published
July 2004. http://cancerres.aacrjournals.org/content/64/14/4699.short. Abstract

Perlecan, a modular proteoglycan carrying primary heparan sulfate (HS) side chains, is a major
component of blood vessel basement membranes. It sequesters growth factors such as fibroblast
growth factor 2 (FGF-2) and regulates the ligand-receptor interactions on the cell surface, and thus it has
been implicated in the control of angiogenesis. Both stimulatory and inhibitory effects of perlecan on
FGF-2 signaling have been reported. To understand the in vivo function of HS carried by perlecan, the
perlecan gene heparan sulfate proteoglycan 2 (Hspg2) was mutated in mouse by gene targeting. The HS
at the NH2 terminus of perlecan was removed while the core protein remained intact. Perlecan HS-
deficient (Hspg2Δ3/Δ3) mice survived embryonic development and were apparently healthy as adults.
However, mutant mice exhibited significantly delayed wound healing, retarded FGF-2-induced tumor
growth, and defective angiogenesis. In the mouse corneal angiogenesis model, FGF-2-induced
neovascularization was significantly impaired in Hspg2Δ3/Δ3 mutant mice. Our results suggest that HS in
perlecan positively regulates the angiogenesis in vivo.
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