REVIEW

published: 12 September 2019

doi: 10.3389/fimmu.2019.02178

Tumors vs. Chronic Wounds: An

Immune Cell’s Perspective
Yichao Hua 1 and Gabriele Bergers 1,2*
1
Laboratory of Tumor Microenvironment and Therapeutic Resistance, Department of Oncology, VIB-Center for Cancer
Biology, KU Leuven, Leuven, Belgium, 2 Department of Neurological Surgery, UCSF Comprehensive Cancer Center, UCSF,
San Francisco, CA, United States

The wound repair program is tightly regulated and coordinated among different cell
constituents including epithelial cells, fibroblasts, immune cells and endothelial cells
following consecutive steps to ensure timely, and proper wound closure. Specifically,
innate and adaptive immune cells are pivotal participants that also closely interact
with the vasculature. Tumors are portrayed as wounds that do not heal because they
undergo continuous stromal remodeling and vascular growth with immunosuppressive
features to ensure tumor propagation; a stage that is reminiscent of the proliferative
resolution phase in wound repair. There is increasing evidence from mouse model
systems and clinical trials that targeting both the immune and vascular compartments
Edited by: is an attractive therapeutic approach to reawaken the inflammatory status in the “tumor
Wei Zheng,
wound” with the final goal to abrogate tumor cells and invigorate tissue homeostasis. In
Icahn School of Medicine at Mount
Sinai, United States this review, we compare the implication of immune cells and the vasculature in chronic
Reviewed by: wounds and tumor wounds to underscore the conceptual idea of transitioning tumors
Zoltan Vereb, into an inflammatory wound-like state with antiangiogenic immunotherapies to improve
University of Szeged, Hungary
Shentong Fang, beneficial effects in cancer patients.
Wihuri Research Institute, Finland
Keywords: myeloid cells, macrophages, neutrophils, endothelial cells, tumor vessels, wound repair,
*Correspondence: antiangiogenic immunotherapy
Gabriele Bergers
[email protected]
INTRODUCTION
Specialty section:
This article was submitted to Neoplastic conversion of cells into a malignant tumor with metastatic properties acquires not only
Cancer Immunity and Immunotherapy,
multiple intrinsic traits but also necessitates the participation of the tumor microenvironment
a section of the journal
with its diverse cellular and matrix constituents (1). Notably, innate immune cells, and specifically
Frontiers in Immunology
macrophages, are functionally involved in nearly every stage of the multistep cascade of
Received: 20 May 2019
tumorigenesis (2). There is also increasing evidence that neutrophils functionally contribute
Accepted: 29 August 2019
to distinct stages, which includes angiogenesis, escape of tumor dormancy, and metastatic
Published: 12 September 2019
seeding (3, 4). Of the many cancer hallmarks, the onset of tumor neovascularization, and escape
Citation:
of immunosurveillance are two environmental traits that are codependent. They encompass
Hua Y and Bergers G (2019) Tumors
vs. Chronic Wounds: An Immune
endothelial and mural cells constituting the vasculature as well as innate and adaptive immune cells
Cell’s Perspective. that partake in heterotypic interactions with one another (5). This crosstalk is not tumor-specific
Front. Immunol. 10:2178. but attributed to their traditional roles in tissue repair where immune cells also affect vascular
doi: 10.3389/fimmu.2019.02178 properties while endothelial cells direct immune cell trafficking and survival.

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Hua and Bergers Tumor vs. Chronic Wounds

IMMUNE CELLS IN WOUND HEALING neovascularization by directly secreting Vascular Endothelial

Growth Factor (VEGF), Transforming Growth Factor β1 (TGF-
Acute wound healing, being extensively studied in the skin β1), and IL8 as well as other factors including metalloproteinases
and gut, follows a well-coordinated multistep process that (24). During wound healing, the generation of a new vascular
constitutes inflammation, proliferation and remodeling phases network is predominantly caused by sprouting by which new
to restore tissue homeostasis, regain function, and protect from vessel growth is initiated from activated preexisting capillary
infection (6–9) (Figure 1, upper panel). Following immediate endothelial cells. In addition, but to a much lesser extent,
hemostasis to impede bleeding, and as a first defense mechanism, bone marrow-derived hematopoietic precursors, and even
neutrophils, and then CCR2+ monocytes and macrophages dendritic cells and monocytes, can also be recruited to the
are recruited to the wound and activated by proinflammatory growing vasculature where they differentiate into endothelial
cytokines (e.g., TNFα, IL1) and chemokines (e.g., CXCL- cells (25–29).
1,5,8; CCL-2) -secreting epithelial cells and fibroblasts and Expanding vascular sprouts exist of proliferating endothelial
cellular contents (e.g., DNA, RNA, uric acid, metabolites, stalk cells and migrating tip cells at the leading edge which
HMGB1) from dying cells that serve as danger signals follow a gradient of proangiogenic factors produced by various
(DAMPs) (10, 11). During this inflammation period, neutrophils cells including keratinocytes and stromal cells. Tip cells of
secrete reactive oxygen species (ROS), nitric oxide (NO), different sprouts connect by anastomosis under the chaperon
and antimicrobial proteins (AMPs) and deploy web-like of macrophages, followed by maturation of the new vessel to
extracellular traps (NETs) in order to phagocytose and kill enable blood flow (30). The entire process is tightly regulated by
contaminating microorganisms (12, 13). Neutrophils also several proangiogenic factors (e.g., VEGF, PIGF, FGF, IL8) as well
produce TNFα, IL1β, IL-6, CXCL2/8 as well as MCP-1 as antiangiogenic factors (e.g., Sprouty2, pigment epithelium-
(monocyte attracting protein-1) that recruit macrophages, T derived factor (PEDF), CXCL10) displaying a fine balance of both
cells as well as additional neutrophils to the wound thus vascular growth and remodeling until vessels become covered
amplifying a Th1 proinflammatory response. Inflammatory with pericytes, form a basement membrane and mature (24, 31,
macrophages predominantly serve as scavengers removing 32). Although the implication of macrophages has been well-
dead cells and cellular debris. They also produce similar established in the distinct steps of wound healing, the role of
cytokines, including IL-12/23 as well as IFNγ that recruit neutrophils in the later stages, specifically in angiogenesis has not
T-cells and natural killer cells (NK), and stimulate their been appreciated until recently. Like macrophages, neutrophils
proinflammatory responses (14, 15). In addition, endothelial can polarize from an immunostimulating N1 phenotype to an
cells in dermal venules upregulate the lymphocyte adhesion immunosuppressive N2 status in which they, like macrophages,
molecules V-CAM-1, I-CAM-1, E- and P-selectins, which produce VEGF and MMPs and other angiogenic factors (3, 33).
regulate lymphocyte rolling and tethering, and thus augment For example, neutrophil-produced VEGF appears to be crucial
lymphocyte infiltration into the wound (7, 16). Consequently, in the healing process of an injured cornea in mice because
T cells in the wound produce interleukin (IL)-17, IL-22, and antibody-mediated neutrophil depletion substantially impaired
tumor necrosis factor a (TNFα), which further intensifies the neovascularization (34). Also, dendritic cell expansion in the
defense response of the immune system (Figure 1, upper panel). skin can enhance wound healing by DC-produced factors that
In addition, plasmacytoid dendritic cells (pDC) infiltrate the promote re-epithelialization, angiogenesis, granulation tissue
wound and recognize nucleic acids from injured cells leading formation, growth factor production (35). Finally, during the
to the production of type I interferons (17). Further, dermal last phase of wound repair, the immune cell composition
conventional dendritic cell type 1 (cDC1s) can cross-present reverses back to normal levels, and the extracellular matrix
antigens (6, 18, 19) to facilitate T cell function, and control in the wound undergoes further remodeling to properly
the generation of commensal-specific CD8+ IL-17+ T cells in close the wound, a process that can persist for weeks to
the skin (20). As soon as neutrophils complete their mission, months (8, 9).
they undergo apoptosis and are removed by macrophages (21).
This phagocytotic activity instigates the transition to an anti-
inflammatory Th2-like phenotype in macrophages and ends the TUMORS ARE NON-HEALING WOUNDS
inflammatory period (21). The conversion from a “Th1” to BUT DIFFER FROM CHRONIC WOUNDS
“Th2” state is indeed an essential and critical step to impede
inflammation and necessary to initiate the proliferative and While the acute wound healing cascade is tightly regulated
resolution phase for efficient wound repair (Figure 1, upper and coordinated, chronic wounds (like in diabetes or ulcers)
panel) (22). If the wound repair cannot proceed beyond the develop when the repair process is trapped, most commonly
inflammation phase, it will generate a chronic wound with barrier in the inflammatory response phase being unable to trigger the
defects (8, 9, 23). During the proliferative resolution phase, repair program in macrophages to move to the next phase.
granulation tissue fills the wound with connective tissue, and Consequently, an excessive immune response develops that
keratinocytes, fibroblasts, and endothelial cells expand to enable leads to further tissue damage rather than tissue restoration
a proper wound closure. Therefore, anti-inflammatory Th2- (23). In the late 80s, Harold Dvorak compared tumors to
like “repair” macrophages activate fibroblasts that in turn incite wounds that never heal (36). The difference to chronic wounds,
keratinocyte proliferation and migration and together promote however, is that “tumor wounds” avoid the inflammatory phase

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Hua and Bergers Tumor vs. Chronic Wounds

FIGURE 1 | Tumors hijack the wound repair program: Chronic wound vs. tumor wound. Usually wound healing is manifested in several sequential steps after injury
referred to as inflammation, proliferation-resolution, and remodeling phase. Immune cells are key regulators in the wound repair program. In the inflammation phase,
neutrophils kill microbes and macrophages phagocytose apoptosing neutrophils, while skin-resident or infiltrating T cells produce IL-17, IL-22, and TNF α to amplify
the host defense response. During the proliferation phase, macrophages switch to an anti-inflammatory phenotype (Msupp ). Msupp macrophages, Nsupp neutrophils
(or tumor-associated neutrophil, TANs), Tregs and other immunosuppressive cells may help to attenuate the inflammation response and facilitate resolution and tissue
remodeling. Chronic wounds get trapped in the inflammation phase, exacerbate inflammation and thus, hinder tissue repair. Tumors, on the other hand, hijack the
proliferative/remodeling program and provide signals that create a continuous angiogenic and immunosuppressive environment enabling tumors to grow and escape
immune surveillance. Therefore, tumors remain in the proliferative phase upon the onset of angiogenesis. Antiangiogenic immunotherapies induce an inflammation
program in tumors that reawakens and boosts an anti-tumor response. The ultimate goal is to create a homeostatic situation in which tumor cells are eliminated and a
normal tissue architecture is achieved. CAF, Cancer-associated fibroblast; CTL, cytotoxic T lymphocyte; DC, dendritic cell; DCreg, regulatory DC; ECM, extracellular
matrix; MDSC, myeloid-derived suppressor cells; Mono, monocyte; Mstim , immunostimulatory macrophage (M1-like); Msupp , immunosuppressive macrophage
(M2-like); Nstim , immunostimulatory neutrophil (N1-like); Nsupp , immunosuppressive neutrophil (TAN); pDC, plasmacytoid DC; Th, T helper cell; Treg, regulatory T cell.

to escape immunosurveillance, and hijack the proliferative to expand its tumor vasculature accommodating the needs of
resolution program of the wound repair to induce a vascular-rich a growing tumor (Figure 1, lower panel) (38). Notably, the
stroma with immunosuppressive and angiogenesis-promoting process of angiogenesis in wounds and tumors is regulated
cell constituents conducive to tumor propagation (Figure 1) by similar factors, but in contrast to the tight regulation of
(36). Similar to the processes in the resolution phase of angiogenesis in acute wounds, the production of angiogenesis-
wounds, tumors instigate several remodeling processes that promoting and inhibiting molecules in tumors is imbalanced
include increased vascular permeability, the onset of angiogenesis (39, 40). Tumors continue to stimulate neovascularization, which
and deposition of an extravascular fibrin-enriched provisional results in an expanding tumor vasculature with an abnormal
stroma which is replaced by a vascular connective granulation phenotype displaying hyperdilated tumor vessels with poor
tissue causing desmoplasia in certain tumor types (37). pericyte coverage and leaky and sluggish blood flow (41).
Concomitantly, tumors polarize innate immune cells from an Subsequently, a hypoxic and acidic environment in tumors with
immunostimulating to an immunosuppressive and angiogenic increased interstitial pressure evolves that further elevates the
state and thus, not only escape immunosurveillance but also production of proangiogenic factors and thus exacerbates a
take advantage of myeloid-produced angiogenic factors that help proangiogenic response (40, 42).

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Hua and Bergers Tumor vs. Chronic Wounds

INNATE IMMUNE CELLS PROMOTE secretion of proangiogenic cytokines in tumor cells, specifically
ANGIOGENESIS VEGF, which is the most prominent angiogenic factor being
highly expressed in a variety of different tumor types (66). This
Like in wounds, myeloid cells present a prominent population makes tumor cells the major source of VEGF and raises the
in tumors where they can make up to 30% of the entire question as to why myeloid cells also induce VEGF in response to
population dependent on tumor type and stage (5, 43–45). As hypoxia (67–70). As it is well-established that VEGF contributes
soon as myeloid cells reach the tumor, some of the immature to tumorigenesis (71), Stockmann et al. made a surprising
innate immune cells will differentiate into tumor-associated observation that myeloid cell-specific VEGF deletion in mice
macrophages (TAMs) and neutrophils while others remain enhanced the development of spontaneous mammary PYMT
in an immature stage resembling monocytic myeloid-derived tumors and tumors of several subcutaneous isograft models (53).
suppressor cells (M-MDSCs) and immature DCs or granulocytic Interestingly, VEGF depletion in macrophages promoted tumor
MDSCs (G-MDSCs) (46). In addition, the presence of regulatory vessel normalization and thus enhanced the exposure of tumors
(reg) DCs has also been described which suppress T cell to chemotherapeutic cytotoxicity (53). This is an important
activation and proliferation and enable Treg differentiation and study that supports the notion that not only total VEGF levels
expansion (47–49). but also the location of VEGF within the tumor regulate
Importantly, however, the cytokine milieu to which myeloid vascular characteristics. It appears that likely perivascular
cells are exposed, and the specific tumor microenvironment macrophages secrete VEGF to fine-tune angiogenic properties
in which they reside will dictate which phenotype these of blood vessels by closely interacting with endothelial cells.
plastic cells will display. IFNγ, TNFα, and IL-12 promote an Congruent with these observation of location-dependent effects
immunostimulatory polarization in innate immune cells while of VEGF, myeloid cell-produced VEGF has also been shown to
TGF-β, IL-4, IL-10, and CSF-1 are prominent factors that skew promote the intravasation of tumor cells into the blood stream
macrophages and neutrophils toward an immunosuppressive by enhancing vascular permeability (72). Besides producing
and angiogenic phenotype, and promote Treg proliferation (3, VEGF, myeloid cells regulate VEGF bioavailability by releasing
50, 51). matrix metalloproteinase MMP-9 to liberate sequestered VEGF
Thus, although macrophages and neutrophils have the ability from the extracellular matrix. This enables VEGF binding to
to inhibit angiogenesis and attack whatever they consider and activation of VEGFR2 on endothelial cells at sites of
foreign, in tumors, they commonly promote an escape of neovascularization (59, 73) (Figure 2). Another example of
immunosurveillance, and new vessel formation. There is strong location-dependent regulation and function of TAM activity
evidence of the functional significance of TAMs in tumor has been described for semaphorin 3A (Sema 3A). Sema 3A is
angiogenesis in multiple systems. One of the first seminal induced by hypoxia and was found to recruit macrophages by
studies demonstrating the relevance of TAM-directed tumor binding to neuropilin-1 (Nrp-1) and PlexinA1/A4 co-receptors
angiogenesis was achieved in the mammary virus-polyoma and signaling through VEGFR1. As soon as macrophages
middle T- antigen (PyMT) breast tumor model, and then localized in low-oxygen conditions, expression of Nrp-1,
confirmed in other tumor model systems (52–54). Thereby, but not PlexinA1/A4, was repressed in macrophages, which
macrophages were depleted in tumors by genetically or trapped macrophages in these hypoxic areas where they
pharmacologically impairing CSF1-CSF1R signaling, which is facilitated angiogenic and immunosuppressive properties (63).
essential for macrophage differentiation and survival, or by Congruently, genetic deletion of Nrp-1 in macrophages was
broad elimination of myeloid cells with clodronate liposomes. sufficient to impair TAM recruitment and accumulation in
As a result, macrophage-deficiency in these various murine hypoxic regions, resulting in impaired neovascularization,
tumor models reduced angiogenic activity (52, 54–56). Again, improved antitumor immunity and consequently, delayed tumor
however, the pro-angiogenic capacity of TAMs is dependent on growth (63). TIE2-expressing macrophages (TEMs) have highly
the cytokine milieu, which in part is triggered by a hypoxic angiogenic characteristics which, like TAMs, correlate with
and acidic microenvironment (40, 57). These conditions induce vascular density in various murine and human tumors (74,
the secretion of chemotactic factors such as VEGF, colony- 75). TEMs are preferentially found in close association with
stimulating factor 1-3 (CSF1-3), the CX chemokines CXCL12 blood vessels being recruited by angiopoietin 2 (ANGPT2)-
(aka SDF1a) and CX3CL1, the CC-chemokines CCL2, CCL5, secreting endothelial cells. ANGPT2 promotes angiogenesis in an
CCL22, interleukin IL6, semaphoring 3A and others that recruit autocrine manner by binding to the TIE2 receptor on endothelial
immune cells to the tumor where they become programmed cells and mediates interactions between endothelial cells and
to facilitate angiogenesis by secreting proangiogenic factors TEMs to support vessel sprouting and macrophage -directed
(40, 43, 46, 54, 58–63) (Figure 2). In this pro-tumor state, anastomosis (30, 46, 76). Albeit TEMs compose a minor subset of
myeloid cells represent a crucial source of angiogenic factors TAMs, they have been found to be highly relevant in promoting
producing VEGF, fibroblast growth factor 2 (FGF2), CXCL8 tumor angiogenesis because TEM depletion experiments using
(CXC-chemokine ligand 8), WNT7B, and BV8. In addition, antibody-mediated neutralization of the Tie2 ligand Ang2 or Tie2
they produce PDGF-B, PIGF, Neuropilin-1, IL-6, and several promoter-driven thymidine kinase both reduced angiogenesis
proteinases, including matrix metalloproteinases (MMPs) and and tumor propagation in mammary, pancreatic neuroendocrine
cathepsins, which also have pro-angiogenic properties (64, 65) and brain tumor mouse models (76, 77). Besides macrophages,
(Figure 2). Certainly, hypoxia via HIF-1α also augments the neutrophils have now also been recognized to be important

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Hua and Bergers Tumor vs. Chronic Wounds

FIGURE 2 | Regulatory network of the tumor immune microenvironment. The tumor microenvironment facilitates cross-talks between immunosuppressive
macrophages, MDSCs, Nsupp , Tregs and CD4+ Th2 cells that promotes angiogenesis, immunosuppression, and tumor progression. During the course of
antiangiogenic and/or immunotherapy, myeloid cells including macrophages can switch to an inflammatory phenotype, and cooperate with CD8+ CTLs and CD4+
Th1 cells to generate an anti-tumor response and promote vessel pruning and normalization. Ang2, angiopoietin 2; CAF, Cancer-associated fibroblast; CTL, cytotoxic
T lymphocyte; DC, dendritic cell; DCreg, regulatory DC; FGF, Fibroblast growth factor; IFN, interferon; IL, interleukin; M-CSF, Macrophage colony-stimulating factor;
MDSC, myeloid-derived suppressor cells; MMP, Matrix metalloproteinases; Mstim , immunostimulatory macrophage (M1-like); Msupp , immunosuppressive
macrophage (M2-like); Nstim , immunostimulatory neutrophil (N1-like); Nsupp , immunosuppressive neutrophil (TAN); PDGF, Platelet-derived growth factor; PlGF,
Placental growth factor; TAN, Tumor-associated neutrophil; TGF-β, Transforming growth factor beta; Th, T helper cell; Treg, regulatory T cell; VEGFA, Vascular
endothelial growth factor A. Cells in orange or red color represent immunostimulation/type 1 immunity/anti-angiogenic status, while cells in green/blue represent
immunosuppression/type 2 immunity/pro-angiogenic status.

mediators of tumorigenesis but the TAN-dependent mechanisms reflected in TANs (3). In support, cytokine-driven polarization
of tumor progression are not fully understood (3, 4, 78). G- of neutrophils in murine models of cancer have provided
CSF mediates neutrophil proliferation and differentiation by evidence that the cytokine TGF-β and type I interferons are key
binding to CSF3R and activating downstream Janus kinase effectors of neutrophil polarization. TGF-β skews neutrophils
(JAK)–signal transducer and activator of transcription 3 (STAT3) toward an N2 phenotype. It blocks neutrophil production of
pathways. CXCL chemokines including CXCL8 as well as IL- ROS, reactive nitrogen intermediates, and IL-1β and impedes
1β, IL17, and IL-6 predominantly mediate the recruitment neutrophil degranulation in response to LPS. Conversely, TGF-
of neutrophils to tumors (3, 79–81) (Figure 2). In contrast β inhibition or the presence of type I interferons polarize
to injuries, where neutrophils are the first cells to enter the neutrophils to an N1 phenotype while inhibiting type I interferon
wound to fight contaminants and then undergo efferocytosis, signaling unleashes N2 properties in neutrophils (82). N2
neutrophils in tumors (TAN) do not appear to apoptose but conversion, similar to M2 macrophage polarization, may in
like macrophages become polarized to an immunosuppressive part be caused by hypoxia, which has been shown to delay
and angiogenic phenotype. These observations of phenotypic neutrophil apoptosis (83). Mechanistically, hypoxia induced
neutrophil modulation have led to the notion that the functional neutrophil survival through HIF-1α-dependent NF-κB activity
plasticity seen in other immune cells, such as TAMs, may also be under low-oxygen tension in a PHD3-dependent manner (57,

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Hua and Bergers Tumor vs. Chronic Wounds

84). Like TAMs, TANs produce similar proangiogenic factors pancreatic neuroendocrine tumors. Therapeutic targeting of
and proteases like VEGF, FGF, BV8, and MMP9, which is in either population caused enhanced infiltration of the other
part regulated by STAT3 signaling (81, 85–87). The angiogenic myeloid cell population compensating for the loss of neutrophils
expression profile appears to be very conserved because in and macrophages, respectively, which created an oscillating
zebrafish, transcriptomic profiling of liver tumor-associated pattern of distinct immune-cell populations to facilitate adequate
neutrophils revealed up-regulation of similar gene transcripts neovascularization (87).
promoting angiogenesis (88). VEGF is the prominent angiogenic Finally, innate lymphoid cells (ILCs) represent a recently
factor that neutrophils, like TAMs, not only express and secrete identified heterogeneous family of mononuclear hematopoietic
but they also carry it in granules which are released upon cells. Based on their lymphoid morphology, surface antigens,
TNF stimulation (89). TANs, like TAMs, provide another transcription factor expression, and cytokine productions (TH1,
quick route of VEGF accessibility to activate endothelial cells TH2, and TH17-like), ILCs have been classified into three
by releasing MMP-9 to release sequestered VEGF from the major groups, termed ILC1, ILC2, and ILC3 (96). ILC3s elicit
extracellular matrix (ECM) (90, 91). Indeed, this neutrophil- tumorigenic and angiogenic properties in part by secreting IL-17
dependent mechanism was critical to instigate the angiogenic (79, 97, 98). Notably, a subset of ILC1s share features with Natural
switch in the dysplastic stage of pancreatic islets in the Rip1Tag2 killer (NK) cells, which are bone marrow-derived large granular
endogenous pancreatic neuroendocrine tumor model because effector lymphocytes. Cancer infiltrating NK cells have been
not only MMP-9 inhibition but also neutrophil depletion was shown to release angiogenic factors and immunosuppressive
sufficient to diminish the angiogenic switch (73, 90). Further, cytokines like VEGF, PlGF, and IL-8, similar to proangiogenic NK
GM-CSF stimulated tumor-associated neutrophils to produce cells found in the developing endometrium (99). CD56+ CD16−
the angiogenic factor Bv8 in several murine tumor models, NK cells from peripheral blood of patients with non-small cell
which in turn attracted more neutrophils, thus, providing a lung cancer (NSCLC), especially squamous cell carcinoma (SCC)
forward loop for neutrophil recruitment and activation (92). subtype, produce higher levels of VEGF, IL-8, and PlGF than
Consequently, pharmacological or genetic blockade of CSF3, those from healthy donors (100)
CSF3R, or BV8 decreased the number of TANs and inhibited
tumor angiogenesis and growth (81). It is notable that in addition
to the identification of intratumoral neutrophils, three distinct ADAPTIVE IMMUNE CELLS REGULATE
neutrophil populations have recently been described in the ANGIOGENESIS
blood circulation, both in mice and in patients with advanced
cancer (93). High- density neutrophils are reminiscent of cancer- While adaptive immune cells are predominantly associated with
killing N1 neutrophils while mature LDNs are not cytotoxic immune surveillance, there is increasing evidence that they
and display impaired functionality and immunosuppressive also regulate angiogenesis, although their exact functions in
properties. The third population consists of morphologically this process are just beginning to be revealed. In tumors, T-
immature LDNs which show characteristics of granulocytic cells, due to their heterogeneous nature, appear to negatively
myeloid-derived immunosuppressive cells (MDSCs). They are or positively regulate tumor angiogenesis. Conditioned medium
also observed in tumors, and thus suggest the other circulating from Th2 and Th17 T-cells contained factors that enhanced
neutrophil populations may be present in tumors as well (93). angiogenesis in vitro in an endothelial sprouting assay and in
MDSCs are immature myeloid cells of granulocytic (G-MDSC) a murine model of ischemia when released from an injectable
or monocytic (M-MDSC) origin, first discovered in tumors, alginate biomaterial. In contrast, Th1 conditioned medium
that not only strongly suppress CD4 and CD8 T cells but induced regression of vascular tubes in vitro and was inefficient
also convey angiogenic features (43, 94, 95). MDSCs, as well to instigate angiogenesis in vivo (101). In several mouse tumor
as reg-DCs, secrete proangiogenic factors similar to M2-like model systems, CD8+ T-cells and CD4+ T-helper 1 cells have
TAMs and N2-like TANs, such as VEGF, FGF2, BV8, and been shown to secrete IFNγ, which blocks vascular growth
MMP9 (79). Tumor -produced CSF3, IL-1β, and IL-6 activate and triggers TAMs and TANs to produce the angiostatic
STAT3 in MDSCs which leads to their expansion but hinders chemokines CXCL 9,10, and 11 (3, 102, 103). In contrast,
MDSC maturation into macrophages or neutrophils. Notably, Treg cells suppress INFγ -expressing CD4+ Th1 cells and
the proangiogenic expression profile of MDSCs conceivably secrete VEGF via hypoxia-induced CCL28, that both promote
overlaps with those of TAMs and TANs (85, 87, 94). Indeed, an angiogenic tumor environment (104). The importance of
it has become apparent from several studies that the different VEGF production by T-cells was recently underscored by
innate immune cell populations produce several but similar the finding that genetic deletion of VEGF in CD8+ T-cells
angiogenic molecules to facilitate neovascularization. Given enhanced tumorigenesis while it also exhibited hallmarks of
the functional redundancy in their angiogenic properties, it is tumor vessel normalization, with typical features of increased
conceivable that myeloid cells can compensate for the lack of pericyte coverage of tumor blood vessels and decreased vessel
other myeloid cell constituents to regulate tumor angiogenesis. tortuosity (105). Interestingly, the overall level of hypoxia was
Indeed, neutrophils can compensate for macrophages to support decreased consistently with better perfusion, a phenotype that
tumor angiogenesis in tumor-bearing CCR2-knockout mice was also observed when VEGF was deleted in TAMs (53).
(91). Further, neutrophils and macrophages are implicated in The lower numbers of infiltrating T-cells in tumors of VEGF
adaptive resistance to anti-angiogenic therapy in the Rip1Tag2 mutant mice suggests that VEGF secreted by CD8+ T cells

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Hua and Bergers Tumor vs. Chronic Wounds

may affect T cell homing through the endothelial barrier and innate immune cells concomitant with a drop of intratumoral
thus, its lack may be in part responsible for the augmented CD8 cells. Mechanistically, CXCL12 and IL6 induction
tumor growth (105). In support of these observations, human activated PI3Kγ signaling in intratumoral macrophages,
breast cancer tissues revealed an inverse correlation between neutrophils and MDSCs rendering them proangiogenic and
VEGF levels and CD8+ T cell infiltration, and congruently linked immunosuppressive. PI3K-activated myeloid cells negated the
T cell infiltration with the stage of vascularization (105). In antiangiogenic blockade and promoted tumor relapse (87).
further support, depletion of intratumoral CD4+ and CD8+ T- Further support stems from the observation that myeloid
cell in mouse tumor models generated a more dysfunctional PI3Kγ signaling inhibits NFκB while it promotes C/EBPβ
tumor vasculature with an increase in hypoxic areas. These activation, thereby inducing a transcriptional program that
effects could be reverted by CD8 influx and activity through favors immunosuppression (115). Importantly, therapeutic
checkpoint immunotherapy (anti-PD1 and/or anti-CTLA4), inhibition of myeloid PI3Kγ/δ was able to sustain the efficacy
or by adoptive TH1 transfer, both invigorating tumor vessel of antiangiogenic therapy. It polarized all myeloid cells to an
normalization and reducing hypoxia (106). While these data angiostatic and immunostimulatory phenotype and enhanced
provide evidence of T-cells in regulating vascular properties, the CD8 T cell infiltration and activity in tumors (87). Tumors
implication of B-cells remains somewhat elusive. Analysis of the relapsing from antiangiogenic therapy did not only convert
overall B-cell population in tumors revealed that B-cells can myeloid cells into a Th2 state, but they also enhanced the levels
secrete proangiogenic factors such as VEGF, FGF2, and MMP- of the negative immune checkpoint regulator PD-L1 in tumor
9 and that they are able to promote immunosuppressive and and stromal cells (116, 117). This displayed another mechanism
proangiogenic properties in macrophages in an IgG-dependent of escaping immune surveillance because PD-L1 binds PD-1 on
manner (107, 108). the surface of activated T-cells and thus blocks T-cell activity.
Similarly to antiangiogenic therapy combined with a myeloid
PI3K inhibitor, combined antiangiogenic (either anti-VEGF or
HEALING TUMOR WOUNDS anti-VEGF/Ang2 antibodies) and anti-PD-L1 immunotherapy
had superior beneficial effects than respective monotherapies
The studies described above support the proposition that tumors because the immunostimulating therapy blocked evasion
generate a cytokine and chemokine milieu that stimulates an from antiangiogenic therapy, while antiangiogenic-induced
immunosuppressive and angiogenic environment displaying vascular normalization enhanced cytotoxic T cell infiltration
characteristics of the proliferative resolution phase in the wound and activation (116, 117). Notably, successful antiangiogenic
repair process. Among the multifarious participants in this immunotherapy could not only normalize tumor vessels but also
“wound scenario” are immune cells and blood vessels, which generate high-endothelial venule (HEV)-like structures in some
are functionally interconnected by mediators and molecules tumors that further enhanced lymphocyte infiltration to eradicate
that commonly regulate both immunity and angiogenesis. tumor cells (117). Another example demonstrating the benefits
Strategies to impede neovascularization were first developed of antiangiogenic immunotherapy was demonstrated with the
with the intention to restrain tumor growth and “starve a combination of the angiokinase inhibitor axitinib and anti-
tumor to death” (109). Antiangiogenic therapy targeting the CTLA4 treatment. The drug combination provided extensive
VEGF-VEGFR and/or Ang-Tie2 pathway, however, has so far survival benefits in a mouse model of melanoma because it
only provided beneficial effects in a subset of patients eliciting increased effector T-cell influx and dendritic cell maturation,
progression-free but not overall survival (77, 110, 111) because and it reduced intratumoral MDSCs while the monotherapies
tumors find alternative strategies to adapt to the restrictions of failed (118). These observations resemble only a few examples
vascular growth and reinstate growth (112). A major resistance for the support of targeting both the vascular and immune
mechanism is prompted by treatment-induced hypoxia and cell compartment to elicit enduring effects. Besides immune
relies on recruiting distinct innate immune cells from the bone checkpoint inhibitors, there are certainly a variety of different
marrow to the tumor where they stimulate vascular growth in drugs that have been developed for targeting signaling pathways
a VEGF-independent manner (5, 57, 59, 77). Importantly, the in myeloid cells, including the inhibition of CSF1R, CXCR4,
seminal observation of “vessel normalization” in responding PI3Kγ/δ, CD47/SIRPα, and CCL2/CCR2 as well as the activation
tumors that pruned tumor vessels exhibited a more functional of CD40 and TLR7/9 (2, 119, 120) that could be combined with
morphology with proper pericyte alignment improving blood antiangiogenic therapies. From a mechanistic point of view, these
flow and oxygenation also revealed a more immunostimulating results reveal a communality, i.e., the attempt to transit tumors
environment with enhanced CD8 T cell influx (113, 114). from their proangiogenic and immunosuppressive phase into an
Congruent with these studies, angiokinase inhibitors and immunostimulatory and angiostatic state similar to those phases
anti-VEGFR antibodies facilitating vessel normalization in observed during wound repair (Figures 1, 2). However, while
responding Rip1Tag2 PNET tumors converted intratumoral the wound repair program transitions from an inflammatory
myeloid cells to an angiostatic and immunostimulating stage to a proliferative resolution phase in order to properly close
phenotype which was associated with an enhanced influx of the wound, antiangiogenic immunotherapy in tumors attempts
cytotoxic CD8 cells (87). Due to continuous vessel pruning, to do the opposite by awakening an inflammatory status in
however, hypoxic areas formed, leading to enhanced influx as the “tumor wound” to abrogate tumor cells and invigorate
well as proangiogenic and immunosuppressive polarization of tissue homeostasis.

Frontiers in Immunology | www.frontiersin.org 7 September 2019 | Volume 10 | Article 2178

Hua and Bergers Tumor vs. Chronic Wounds

CONCLUSIONS the treatments arguing that these signatures could be utilized

as prospective biomarkers (121, 122). Similar to the results
Ongoing clinical trials that combine antiangiogenic agents obtained in preclinical tumor models described above, myeloid-
and immunotherapies like ICB or those targeting and driven inflammation in tumors appeared to be a resistance
modulating innate immune cells as well as strategies to mechanism to anti-PD-L1 monotherapy in mRCC which could
directly enhance infiltration and activation of CD8 T-cells be overturned by bevacizumab (87, 116, 117). These first clinical
validate the concept of enhancing an immunostimulating results are certainly promising and together with upcoming
environment in cancer. For example, several clinical trials are clinical trials, will be able to thoroughly assess the effectiveness
currently evaluating combined VEGF/VEGFR and PD-1/PD-L1 of antiangiogenic immunotherapies in improving and enduring
inhibitors for various cancer types including renal cell carcinoma, survival of cancer patients.
recurrent glioblastoma, ovarian cancer and colorectal cancer
(NCT03024437, NCT02659384, NCT02873962, NCT02017717). AUTHOR CONTRIBUTIONS
The clinical trial IMmotion150 (NCT01984242) in patients
with naïve renal cell cancer (mRCC) assessed the combination All authors listed have made a substantial, direct and intellectual
of anti-PD-L1 (atezolizumab) with or without bevacizumab, contribution to the work, and approved it for publication.
against the standard-of-care angiokinase inhibitor, sunitinib
(121). Combining anti-PD-L1 with bevacizumab was more FUNDING
efficacious than sunitinib in patients with PDL1-positive tumors.
Interestingly, the mutational rate and neoantigen burden of This work was supported by grants from the Flemish cancer
tumors did not correlate with progression-free survival (PFS), society Kom op tegen Kanker (2018/11321/2822 to YH), the
but angiogenesis and myeloid inflammatory gene expression Flemish government FWO (G0A0818N to GB), and the National
signatures associated strongly with PFS within and across Institute of Health NIH/NCI (R01CA201537 to GB).

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