Journal of Pathology

J Pathol 2013; 230: 241248 INVITED REVIEW

Published online in Wiley Online Library
(wileyonlinelibrary.com) DOI: 10.1002/path.4188

Tumour necrosis factor and cancer

John P Waters,1 Jordan S Pober2 and John R Bradley1,*
1
Department of Medicine, University of Cambridge, Addenbrookes Hospital, Cambridge, UK
2 Yale University School of Medicine, New Haven, CT, USA

*Correspondence to: JR Bradley, Box 118, Addenbrookes Hospital, Cambridge CB2 0QQ, UK. e-mail: jrb1000@cam.ac.uk

Abstract
Tumour necrosis factor (TNF) was originally described as a circulating factor that can induce haemorrhagic
necrosis of tumours. It is now clear that TNF has many different functions in cancer biology. In addition to causing
the death of cancer cells, TNF can activate cancer cell survival and proliferation pathways, trigger inflammatory
cell infiltration of tumours and promote angiogenesis and tumour cell migration and invasion. These effects can
be explained by the diverse cellular responses TNF can initiate through distinct signal transduction pathways,
opening the way for more selective targeting of TNF signalling in cancer therapy.
Copyright 2013 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

Keywords: tumour necrosis factor; cancer; signal transduction; cell death; inflammation; cell survival; angiogenesis

Received 3 February 2013; Revised 15 February 2013; Accepted 23 February 2013

Conflict of interest. JSP and JRB are co-inventors on a patent entitled Selective modulation of tumour necrosis factor receptors in therapy.

Introduction which include local and systemic pro-inflammatory

Tumour necrosis factor (TNF, also known as TNF)
was originally identified as a glycoprotein found
in the serum of bacillus CalmetteGuerin (BCG)-
infected mice treated with endotoxin (also known
as lipopolysaccharide, or LPS) that could induce
haemorrhagic necrosis of sarcomas that had been
transplanted subcutaneously into mice, seemingly
without injury to healthy tissues [1,2]. A cDNA
encoding human tumour necrosis factor was cloned
in 1984, and recombinant human TNF was shown
to induce the haemorrhagic necrosis of transplanted
methylcholanthrene (MethA)-induced sarcomas in
syngeneic mice [3]. Similar effects were noted in
response to a T lymphocyte-derived, structurally
related protein called lymphotoxin (LT or LT-, briefly
known as TNF); both LT and TNF bind to the same
receptors and we will restrict our discussion in this
review to the more well-studied TNF (also known
as TNF) molecule. TNF was subsequently found to
mediate widespread systemic effects. When admin-
istered to rats in quantities similar to those produced
endogenously in response to endotoxin, TNF was
found to cause shock and tissue injury [4]. TNF was
also identified as a humoral mediator of cachexia, the
syndrome of anorexia, weight loss, anaemia and pro-
tein wasting that complicates cancer as well as chronic
infections and inflammation [5,6]. Early clinical trials
of TNF as a treatment for cancer were limited by these
toxicities [79]. However, subsequent elucidation of
the pathways that signal the complex actions of TNF,
Copyright 2013 Pathological Society of Great Britain and Ireland.
Published by John Wiley & Sons, Ltd. www.pathsoc.org.uk
effects, as well as cell death, survival, differentiation,
proliferation and migration, has renewed interest in
TNF as both a target and therapy in cancer.
Biological effects of TNF
TNF is synthesized primarily by immune cells (espe-
cially macrophages, dendritic cells lymphocytes and
mast cells) as a 34 kDa type II transmembrane pro-
tein (with an external C-terminus and cytoplasmic
N-terminus) that functions both as a homotrimeric form
expressed on the surface of TNF-producing cells, and
as a soluble homotrimer formed by the C-terminal
17 kDa portions of the membrane version that is
released from the cell surface by TNF-converting
enzyme (TACE; a metalloproteinase also known as
ADAMS 17). Cellular responses to TNF are medi-
ated through two distinct receptors, designated TNFR1
(also known as the p55 TNF receptor and designated
CD120a) and TNFR2 (also known as the p75 TNF
receptor and designated CD120b). The expression of
each receptor is highly and independently regulated on
the surface of cells. The intracellular domains of TNF
receptors are devoid of any intrinsic kinase or other
enzymatic activities, and signal by recruiting cytoso-
lic adaptor proteins to their intracellular domains. The
ability of each TNF receptor to interact with both iden-
tical and unrelated downstream signalling molecules
explains their shared and distinctive functions.
Broadly, TNF can activate pathways leading to three
different cellular responses [10]: cell survival and
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242
proliferation; transcription of pro-inflammatory genes;
and cell death. TNFR1 is able to signal each of these
biological effects. Ligand-occupied TNFR1 recruits
adaptor molecules that create a signalling complex
capable of activating various mitogen-activated pro-
tein kinase kinase kinases (MAP3Ks). Recruitment
and activation of the MAP3Ks mitogen-activated
protein kinase kinase kinase 3 (MAP3K3, also known
as MAPK/ERK kinase kinase 3, MEKK3) [11]
and transforming growth factor- (TGF)-activated
kinase (TAK1) [12] leads to phosphorylation and
activation of the inhibitor of B (IB) kinase (IKK)
complex, which, in turn, leads to activation of
the transcription factor NF-B [13] and transcrip-
tion of both pro-inflammatory and survival genes.
TNFR1 can also initiate pro-inflammatory, survival
and cell death signals by activating apoptosis sig-
nalling kinase 1 (ASK1), a MAP3K that initiates
a kinase cascade culminating in activation of the
downstream signalling molecules c-Jun N-terminal
kinase (JNK) and p38 mitogen-activated protein
kinase. These kinases, in turn, activate various
forms of the heterodimeric transcription factor AP-1.
Through less well-defined pathways TNFR1 can
also activate the rasrafMEK1ERK1,2 [14] and
phosphatidylinositol 3-kinasephosphatidylinositol
tris-phosphate-dependent kinaseAkt (also known
as protein kinase B) pathways, both of which can
promote cell survival and proliferation. Alternatively,
TNFR1 can initiate the formation of a death-inducing
signalling complex (DISC) that can trigger cell death
through apoptosis [15] or through necroptosis [16],
the latter being a form of programmed cell death
characterized by cell swelling and lysis (onchosis).
In most normal cells, death is prevented by TNF-
induced de novo synthesis of inhibitors of JNK and
of DISC-mediated cell death. Many tumour cell lines
are deficient in such proteins, enabling TNF to cause
apoptosis or necroptosis in vitro.
In some cell types, TNFR2 can also initiate phos-
phorylation of IKK leading to nuclear translocation
of NF-B through a similar pathway to TNFR1, but
distinct TNFR2 signal transduction pathways have
also been described. Specifically TNFR2 can activate
endothelial/epithelial tyrosine kinase (Etk), a mem-
ber of the Brutons tyrosine kinase (Btk) non-receptor
tyrosine kinase family implicated in cell adhesion,
migration, proliferation and survival [17]. In endothe-
lial cells, TNFR2-mediated activation of Etk mediates
tyrosine phosphorylation of the intracellular regions
of VEGFR2, resulting in a VEGF-independent, pro-
angiogenic response involving activation of Akt [18].
TNF responses in tumours
Based on the original Carswell et al . findings and
the susceptibility of many tumour cell lines to killing
in vitro, TNF was initially viewed as a magic bullet
Copyright 2013 Pathological Society of Great Britain and Ireland.
Published by John Wiley & Sons, Ltd. www.pathsoc.org.uk
JP Waters et al
that would kill tumour cells while sparing nor-
mal tissues. However, such differences between the
responses of normal and tumour cells could not fully
explain TNF actions in vivo because TNF appeared
capable of destroying implanted tumours, such as
Meth A sarcoma, in which the tumour cells did not
have TNF receptors and were unresponsive to TNF
in vitro. Tumour killing in this case was mediated
by a Shwartzman-like neutrophil-mediated destruction
and thrombosis of tumour blood vessels, and TNF
has been shown to be an important mediator of the
priming phase of the Shwartzman reaction [19]. The
tumour cells secreted molecules, such as VEGF-A,
that sensitized local endothelial cells to TNF actions
[20]. However, it has also been observed that TNF is
synthesized and secreted by malignant epithelial cells
derived from a number of tumour cell types [2123]
and, instead of resulting in tumour cell death, TNF
may act as an autocrine survival signal for cancer cells,
promote tumour cell migration and invasion and regu-
late infiltration of tumour-promoting macrophages into
the tumour microenvironment. Each of these various
responses has been analysed in molecular detail.
TNF and cancer cell death
The identification of different pathways through which
cell death can occur (Figure 1) has provided insights
into the mechanisms through which cancer cells evade
death, and identified targets for therapy. Furthermore,
different forms of cell death elicit distinct immunolog-
ical and inflammatory responses to tumour cells that
can influence tumour progression.
Apoptosis is characterized by programmed or con-
trolled cell shrinkage with plasma membrane vesic-
ulation, nuclear condensation and DNA fragmenta-
tion. These morphological changes are associated with
the exposure of molecules, including phosphatidylser-
ine [24] and calreticulin [25], on the surface of the
dying cells, often allowing them to be recognized
and engulfed by neighbouring phagocytic cells with-
out eliciting an inflammatory response. Apoptotic death
is caused by cleavage of critical cellular proteins by
a family of structurally-related intracellular proteases
known as active cysteinyl aspartyl-directed proteases,
or caspases. Within minutes of binding TNF, TNFR1
assembles signalling complex I, also called a sig-
nalosome, which contains three principal cytosolic
components: an adaptor protein called TNF receptor-
associated death domain protein (TRADD), a ser-
ine/threonine kinase called receptor interacting protein
kinase (RIPK)-1, and an E3 ubiquitin ligase called
TNF receptor-associated factor (TRAF) 2 (sometimes
TRAF2 can be replaced by TRAF 5). Several hours
after its formation, signalling complex 1 recruits an
adaptor protein known as Fas-associated death domain
protein (FADD), forming a DISC (also known as com-
plex 2) [15]. The DISC can recruit and promote auto-
catalytic activation of pro-caspases 8 and 10 (also
known as FLICE and FLICE 2, respectively); activated
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TNF and cancer
caspases 8 and 10 then proteolytically activate other,
so-called effector caspases, such as caspases 3 and 6.
Nuclear fragmentation is caused by effector caspase-
mediated cleavage of nuclear lamins, while DNA frag-
mentation into nucleosomes is triggered by effector
caspasemediated cleavage of a protein called inhibitor
of caspase-activated DNAse (iCAD), liberating and
activating CAD. Small molecule inhibitors of cas-
pases are capable of protecting cells from apoptotic
cell death. In contrast, necrotic cell death is charac-
terized by uncontrolled cellular and nuclear swelling
in response to injury, which leads to cell lysis and
is often accompanied by inflammation. Necroptosis is
a caspase-independent form of cell death which, like
apoptosis, is programmed, but results in cell swelling
and lysis as seen in necrosis. The TNF DISC can initi-
ate this response through RIPK-1-mediated recruitment
and activation of the structurally related protein RIPK-
3 [16,26,27]. Necroptosis in response to TNF is primar-
ily observed in cells that lack FADD or pro-caspase 8,
but can sometimes be revealed by blocking caspase
activation. Autophagy is an energy-requiring process
in which intralysosomal proteolysis of cell organelles
can promote survival of cells starved of nutrients, but
autophagy can also progress to cell death. Autophagic
vacuoles (autophagosomes) are formed when por-
tions of the cytoplasm, including organelles such as
mitochondria, endoplasmic reticulum and peroxisomes
(but not the nucleus), are surrounded by a sequester-
ing membrane, principally derived from ribosome-free
regions of the rough endoplasmic reticulum. These
double membrane-bound structures then fuse with lyso-
somes to form autolysosomes with protein-degradative
capacity. TNF can also induce autophagy, which can
be a precursor to both apoptotic and necrotic cell death
[28]. All of these forms of cell death are found in
tumours.
The mode of cell death in tumours is an impor-
tant determinant of the local immune and inflamma-
tory response. Whilst apoptosis is often characterized
by the absence of an inflammatory infiltrate (apart
from the phagocytic cells that clear the apoptotic cell
debris), necrotic cell death is typically accompanied by
inflammation [29] and prevention of necroptosis can
limit the inflammatory response [30]. In addition to its
pro-inflammatory effects, necrotic (or necroptotic) cell
death is thought to provoke a strong adaptive immune
response, whereas apoptotic cell death is thought to be
poorly immunogenic, and may promote tolerance [31].
However, exposure of calreticulin, an early marker of
apoptosis, can be an important determinant of whether
the death of a cancer cell is immunogenic by promot-
ing engulfment of dying cells by dendritic cells. Whilst
exposure of calreticulin alone does not appear to be
sufficient to elicit immunogenicity, when induced by
certain cyctotoxic agents, including anthracyclines and
ionizing radiation, calreticulin can induce anti-tumour
immunity [32,33]. On the other hand, the tumour
cell death induced by Shwartzman-like destruction of
tumour vessels is necrotic, and mice bearing Meth A
Copyright 2013 Pathological Society of Great Britain and Ireland.
Published by John Wiley & Sons, Ltd. www.pathsoc.org.uk
243
sarcoma implants that are destroyed by TNF develop
adaptive immune responses that render them resistant
to subsequent challenges by MethA sarcoma.
TNF and cancer-related inflammation
The risk of cancer is increased in chronic infections
and inflammatory diseases, settings in which sustained
TNF production is common, eg Helicobacter pylori is
associated with gastric cancer and gastric lymphoma
[34], hepatocellular carcinoma is associated with viral
hepatitis [35], inflammatory bowel disease is associ-
ated with colonic cancer [36] and rheumatoid arthritis
is associated with an increased risk of a number of
cancers, including lung cancer, Hodgkin lymphoma
and non-Hodgkin lymphoma [37,38]. In addition to
an inflammatory environment contributing to cancer,
inflammation can result from the activation of onco-
genes within cancer cells, leading to the dysregula-
tion of extrinsic and intrinsic pathways that can drive
the inflammatory changes that are seen in tumours
(Figure 2) [39]. A key component of this inflamma-
tory response is the recruitment of leukocytes. Leuko-
cytic infiltrates in tumours may include T cells, B
cells and/or tumour-associated macrophages (TAMs),
and TNF may regulate tumour growth by modulating
each of these leukocyte subsets. TNF mediates TNFR1-
dependent IL-17 production by CD4+ cells, leading to
myeloid cell recruitment into the tumour microenvi-
ronment and enhanced tumour progression [40]. TNF
can also promote differentiation of tumour-associated
myeloid cells into cells that express endothelial cell
markers, and although these cells may not be directly
incorporated into the tumour vasculature, they appear
to promote angiogenesis and tumour growth [41,42].
TAMs can display an immunosuppressive phenotype
that promotes tumour progression or, if NF-B is inhib-
ited in the tumour cells, become cytotoxic to tumour
cells [43]. TNF-induced VEGF production by TAMs
may also play an important role in tumour angiogenesis
and growth [44]. B cells may also be important effector
cells for TNF-mediated carcinogenesis; B cells may be
a significant source of TNF, and TNF may modulate
the activity of regulatory B cells in a way that represses
anti-tumour immunity [45].
TNF and cell proliferation, invasion and
angiogenesis
TNF can signal cell proliferation or cell survival
and differentiation (Figure 2) via TNFR1 by acti-
vation of the transcription factors NF-B, AP-1 and
(through the activation of ERK-1,2) Elk-1. In addition,
TNFR2 can regulate cellcell interactions and signal
cell migration and proliferation through phosphoryla-
tion of Etk, which can activate a phosphatidylinositol
3-kinase (PI3K)Akt growth and survival pathway.
In vascular endothelial cells this can result in Etk-
mediated crosstalk with vascular endothelial growth
factor receptor 2 (VEGFR2), resulting in enhanced
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244
angiogenesis [17,18]. Etk also mediates survival, pro-
liferation and invasion of breast cancer cells [4648].
In renal cell carcinoma, ligation of TNFR2 activates
Etk and VEGFR2 in tumour cells, promoting cell cycle
entry, suggesting that TNF acts selectively through
a TNFR2EtkVEGFR2 pathway as an autocrine
growth factor that contributes to tumour progression.
TNF as a target or therapy for cancer
TNF as a treatment for cancer
Although initial studies of TNF as a treatment for can-
cer were limited by systemic toxicity, local administra-
tion by isolated limb perfusion of TNF in combination
with the alkylating agent melphalan has proved to be an
effective treatment for metastatic melanoma and unre-
sectable soft tissue sarcomas [4951]. TNF has also
been reported to promote regression of unresectable
metastases from colorectal cancer when delivered in
combination with melphalan by isolated hepatic per-
fusion [52]. The predominant target of TNF delivered
directly into tumours by isolated perfusion appears to
be the tumour vasculature. Angiography has demon-
strated selective loss of tumour vessels [49], which is
thought to occur as a result of reduced v3-dependent
endothelial cell adhesion to underlying basement mem-
brane within the tumour vasculature [53]. The integrin
v3 is expressed during tumour angiogenesis, and
antagonists of v3 induce detachment and apopto-
sis of proliferative angiogenic endothelial cells, whilst
quiescent blood vessels are unaffected [54].The pro-
coagulant effects of TNF (reviewed in [10]) may also
be an important cause of tumour necrosis. Selective
TNF-induced expression of tissue factor on capillaries
can promote fibrin deposition and thrombus formation
within the tumour vasculature [20,55]
Anti-TNF treatment and cancer
Five drugs, adalibumab (Humira), infliximab (Rem-
icade), Enbrel (etanercept), certolizumab pegol
(Cimzia) and golimumab (Simponi), are currently
licensed as TNF-blocking agents and used to treat
rheumatoid arthritis and other inflammatory diseases,
including ankylosing spondylitis and Crohns disease.
Etanercept is a recombinant human soluble fusion
protein in which the extracellular, TNF-binding
domains of TNFR2 are coupled to the Fc portion of
IgG. Infliximab is a humanmurine chimeric IgG1
monoclonal anti-TNF antibody. Adalibumab is a
human anti-human TNF antibody produced by phage
display. Golimumab is a humanized monoclonal
antibody derived from TNF-immunized transgenic
mice engineered to express human IgGs. Certolizumab
pegol is an antigen-binding fragment (Fab
) of a
humanized anti-TNF antibody that has been attached
to a large molecular weight polyethylene glycol
molecule, with the aim of prolonging the half-life of
the antibody in the circulation.
Copyright 2013 Pathological Society of Great Britain and Ireland.
Published by John Wiley & Sons, Ltd. www.pathsoc.org.uk
JP Waters et al
Different anti-TNF therapies may have different
binding and pharmacokinetic profiles [56]. Infliximab
binds transmembrane TNF with higher avidity, forming
more stable complexes and more effectively inhibit-
ing the actions of transmembrane TNF than etaner-
cept [57]. Transmembrane TNF is superior to soluble
TNF in activating TNFR2 in various systems, including
T cell activation, thymocyte proliferation and granu-
locyte/macrophage colony-stimulating factor produc-
tion [58]. Thus, under certain conditions, infliximab
may be more effective at blocking signalling through
TNFR2 than etanercept (despite the fact that etanercept
was derived from TNFR2). Furthermore, cell surface-
expressed transmembrane TNF appears to be able to act
as a receptor that is itself involved in signal transduc-
tion [59], and infliximab but not etanercept can induce
apoptosis and cell cycle arrest in transmembrane TNF-
expressing Jurkat T cells [60].
A meta-analysis with intention to treat and per pro-
tocol analyses of cancer risk in patients with adult
rheumatoid arthritis who received anti-TNF treatment
in double-blind randomized controlled trials did not
find any excess cancer risk in patients followed up
for 12104 weeks [61]. An analysis of 23 458 patients
through nearly 12 years of exposure to adalimumab in
71 global clinical trials in rheumatoid arthritis, juve-
nile idiopathic arthritis, ankylosing spondylitis, pso-
riatic arthritis, psoriasis and Crohns disease found
that overall malignancy rates for adalimumab-treated
patients were as expected for the general population
[62]. Long-term follow-up of patients in disease reg-
istries have identified an increased risk of cancer in
patients with rheumatoid arthritis [37], but no evidence
of an overall increased risk of malignancy in patients
receiving anti-TNF treatment [63]. However, the inci-
dence of lymphoma may be increased in patients with
rheumatoid arthritis receiving anti-TNF therapy [64],
and this risk may be higher with monoclonal antibody
than with soluble-receptor anti-TNF therapy [65,66].
Anti-TNF therapies are licensed for the treatment
of children with inflammatory diseases, and post-
marketing surveillance has identified an increased
risk of cancer in this group of patients. The US
Food and Drug Administration (FDA) has highlighted
the increased risk of cancer in children and adoles-
cents who receive anti-TNF therapies to treat juvenile
rheumatoid arthritis, inflammatory bowel disease and
other inflammatory diseases. The FDA received 48
reports of paediatric malignancy in children and ado-
lescents receiving anti-TNF treatment over an 8 year
period from 2001 to 2008. It was estimated that
14 837 children aged 018 years received infliximab
up to February 2008, 9200 children aged 017 years
received etanercept up to December 2007 and 2636
children aged 016 years received adalimumab for
the 2 year period 20062007. Ten paediatric cases of
anti-TNF-associated hepatosplenic T cell lymphoma
were reported in patients with inflammatory bowel
disease who were treated with infliximab with 6-
mercaptopurine or azathioprine.
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TNF and cancer 245

AUTOPHAGY

TNF
TNF
TNFR1 DD

TNFR1 DD
TRAF2 RIPK1
TRADD
SIGNALLING
COMPLEX I p
Ser967
TRAF2 RIPK1 ASK1 p Phagocyte
TRADD AIP1 Thr845
ASK1 JNK/p38MAPK

Caspase-8/-10
TRAF2 RIPK1 Caspase-9 APOPTOSIS
FADD
TRADD
DISC Caspase-3
(COMPLEX II)

TRAF2 RIPK1
TRADD RIPK3

NECROPTOSIS
Understanding Disease

Figure 1. TNF-mediated cell death. TNF, signalling through TNFR1, can mediate cancer cell death by triggering apoptotis, necroptosis and
autophagy

with TNFR1 36G/A [74], and the TNFR1 promoter

Angiogenesis 329G/T polymorphism resulting in allele-specific
repression of TNFR1 expression may be important in
the development of hepatocellular carcinoma [75]. A
single nucleotide polymorphism changing T to G in
TAM exon 6 at nucleotide 676 of TNFR2 mRNA results in
Cancer cell
invasion and an amino acid change in the fourth extracellular cys-
Cancer cell
proliferation
migration
teine rich domain from methionine (TNFR2196Met ) to
arginine (TNFR2196Arg ) and has been associated with
an increased risk for chronic inflammatory disorders,
including systemic lupus erythematosus [76]. Geneti-
Inflammatory
cell infiltration
cally modified cells expressing the TNFR2196Arg vari-
ant show normal TNF binding, but diminished recruit-
Understanding Disease ment of TRAF2 to TNFR2196Arg , impaired TNFR2-
mediated NF-B activation and enhanced TNFR1-
Figure 2. Pro-cancer effects of TNF. TNF can support progression induced apoptosis [77]. This SNP has been shown to
of tumours by promoting cancer cell survival, proliferation,
predict survival of non-small cell lung cancer patients
migration and metastasis, tumour angiogenesis and inflammatory
cell recruitment and infiltration treated with chemotherapy [78] and predicts late onset,
relapse and death of patients with breast cancer.

TNF and TNF receptor polymorphisms and cancer
A number of polymorphisms in the TNF promoter
have been described, including single nucleotide poly-
morphisms at 238, 308, 857 and 1301. Their
functional significance in terms of transcriptional con-
trol is unclear [6770], but the 308 polymorphism
appears to influence the risk of breast cancer [71,72],
gastric cancer [73] and hepatocellular cancer [35] in
certain ethnic populations. Functional polymorphisms
in TNF receptor genes may also influence cancer
risk. The risk of breast cancer has been associated
Copyright 2013 Pathological Society of Great Britain and Ireland.
Published by John Wiley & Sons, Ltd. www.pathsoc.org.uk
Selective TNF receptor modulation
The generation of human TNF mutants that bind selec-
tively to one or the other of the two TNF receptors has
raised the possibility that the toxic effects of TNF could
be limited, whilst maintaining its anti-tumour activity
[79]. Increased understanding of the regulation, signal
transduction pathways and biological effects of TNFR1
and TNFR2 has raised the possibility that selective
modulation of TNF receptors may provide a useful
therapeutic approach for cancer and other diseases.
TNF receptors are highly regulated on different cell
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246
types within normal and diseased tissues [23,8082].
In renal cell carcinoma, expression of TNFR2 increases
in malignant tubular epithelial cells, and this increased
TNFR2 expression correlates with increasing malig-
nant grade, consistent with the observation that soluble
(shed) TNFR2 plasma levels are significantly higher
in patients with metastatic renal cell carcinoma and
increase with tumour stage [83]. In contrast, TNFR1
is expressed at low levels in malignant tubular epithe-
lial cells regardless of grade. Furthermore, ligation of
TNFR2 increases expression of TNFR2, activates NF-
B, Etk and VEGFR2 and increases entry into the cell
cycle in malignant epithelial cells, whereas ligation of
TNFR increases TNFR1, activates apoptotic signalling
kinase and NF-B and promotes apoptosis.
Conclusions
Defining the molecular mechanisms through which
TNF signals its diverse effects has demonstrated that
TNF can, under different circumstances, promote either
death or survival of tumour cells, and identified TNF
as a key regulator of the immune and inflammatory
response to cancer. Understanding the complex roles
of TNF in cancer biology has highlighted TNF as both
a therapy and a target in cancer therapy. Selective
modulation of TNF signal transduction may provide
a key therapeutic approach in cancer treatment.
Acknowledgements
JPW is supported by Kidney Research UK and the
British Heart Foundation; JSP is supported by NIH;
JRB is supported by the NIHR Cambridge Biomedical
Research Centre, Kidney Research UK and the British
Heart Foundation.
Author contributions
All authors contributed to this review, and reviewed
the final manuscript.
References
1. Carswell EA, Old LJ, Kassel RL, et al . An endotoxin-induced
serum factor that causes necrosis of tumors. Proc Natl Acad Sci
USA 1975; 72: 36663670.
2. Green S, Dobrjansky A, Carswell EA, et al . Partial purification of
a serum factor that causes necrosis of tumors. Proc Natl Acad Sci
USA 1976; 73: 381385.
3. Pennica D, Nedwin GE, Hayflick JS, et al . Human tumour
necrosis factor: precursor structure, expression and homology to
lymphotoxin. Nature 1984; 312: 724729.
4. Tracey KJ, Beutler B, Lowry SF, et al . Shock and tissue injury
induced by recombinant human cachectin. Science 1986; 234:
470474.
Copyright 2013 Pathological Society of Great Britain and Ireland.
Published by John Wiley & Sons, Ltd. www.pathsoc.org.uk
JP Waters et al
5. Cerami A, Ikeda Y, Le Trang N, et al . Weight loss associated with
an endotoxin-induced mediator from peritoneal macrophages: the
role of cachectin (tumor necrosis factor). Immunol Lett 1985; 11:
173177.
6. Tracey KJ, Wei H, Manogue KR, et al . Cachectin/tumor necrosis
factor induces cachexia, anemia, and inflammation. J Exp Med
1988; 167: 12111227.
7. Creaven PJ, Brenner DE, Cowens JW, et al . A phase I clinical trial
of recombinant human tumor necrosis factor given daily for 5 days.
Cancer Chemother Pharmacol 1989; 23: 186191.
8. Abbruzzese JL, Levin B, Ajani JA, et al . Phase I trial of
recombinant human gamma-interferon and recombinant human
tumor necrosis factor in patients with advanced gastrointestinal
cancer. Cancer Res 1989; 49: 40574061.
9. Schiller JH, Storer BE, Witt PL, et al . Biological and clinical effects
of intravenous tumor necrosis factor- administered three times
weekly. Cancer Res 1991; 51: 16511658.
10. Waters JP, Pober JS, Bradley JR. Tumor necrosis factor in infectious
disease. J Pathol 2013; 230: 132147.
11. Yang J, Lin Y, Guo Z, et al . The essential role of MEKK3 in
TNF-induced NF-B activation. Nat Immunol 2001; 2: 620624.
12. Blonska M, Shambharkar PB, Kobayashi M, et al . TAK1 is
recruited to the tumor necrosis factor- (TNF) receptor 1 com-
plex in a receptor-interacting protein (RIP)-dependent manner and
cooperates with MEKK3, leading to NF-B activation. J Biol Chem
2005; 280: 4305643063.
13. Devin A, Lin Y, Yamaoka S, et al . The - and -subunits of IB
kinase (IKK) mediate TRAF2-dependent IKK recruitment to tumor
necrosis factor (TNF) receptor 1 in response to TNF. Mol Cell Biol
2001; 21: 39863994.
14. Xu XS, Vanderziel C, Bennett CF, et al . A role for c-Raf kinase and
Ha-Ras in cytokine-mediated induction of cell adhesion molecules.
J Biol Chem 1998; 273: 3323033238.
15. Micheau O, Tschopp J. Induction of TNF receptor I-mediated
apoptosis via two sequential signaling complexes. Cell 2003; 114:
181190.
16. Hitomi J, Christofferson DE, Ng A, et al . Identification of a
molecular signaling network that regulates a cellular necrotic cell
death pathway. Cell 2008; 135: 13111323.
17. Pan S, An P, Zhang R, et al . Etk/Bmx as a tumor necrosis factor
receptor type 2-specific kinase: role in endothelial cell migration
and angiogenesis. Mol Cell Biol 2002; 22: 75127523.
18. Zhang R, Xu Y, Ekman N, et al . Etk/Bmx transactivates vascular
endothelial growth factor 2 and recruits phosphatidylinositol 3-
kinase to mediate the tumor necrosis factor-induced angiogenic
pathway. J Biol Chem 2003; 278: 5126751276.
19. Norman KE, Williams TJ, Feldmann M, et al . Effect of soluble
P55 tumour-necrosis factor binding fusion protein on the local
Shwartzman and Arthus reactions. Br J Pharmacol 1996; 117:
471478.
20. Zhang Y, Deng Y, Luther T, et al . Tissue factor controls the balance
of angiogenic and antiangiogenic properties of tumor cells in mice.
J Clin Invest 1994; 94: 13201327.
21. Kalthoff H, Roeder C, Brockhaus M, et al . Tumor necrosis
factor (TNF) up-regulates the expression of p75 but not p55 TNF
receptors, and both receptors mediate, independently of each other,
up-regulation of transforming growth factor- and epidermal growth
factor receptor mRNA. J Biol Chem 1993; 268: 27622766.
22. Schmiegel W, Roeder C, Schmielau J, et al . Tumor necrosis factor
alpha induces the expression of transforming growth factor- and
the epidermal growth factor receptor in human pancreatic cancer
cells. Proc Natl Acad Sci USA 1993; 90: 863867.
23. Al-Lamki RS, Sadler TJ, Wang J, et al . Tumor necrosis factor
receptor expression and signaling in renal cell carcinoma. Am J
Pathol 2010; 177: 943954.
J Pathol 2013; 230: 241248
www.thejournalofpathology.com
TNF and cancer
24. Fadok VA, Voelker DR, Campbell PA, et al . Exposure of phos-
phatidylserine on the surface of apoptotic lymphocytes triggers
specific recognition and removal by macrophages. J Immunol 1992;
148: 22072216.
25. Gardai SJ, McPhillips KA, Frasch SC, et al . Cell-surface calreti-
culin initiates clearance of viable or apoptotic cells through trans-
activation of LRP on the phagocyte. Cell 2005; 123: 321334.
26. Bonnet MC, Preukschat D, Welz PS, et al . The adaptor protein
FADD protects epidermal keratinocytes from necroptosis in vivo
and prevents skin inflammation. Immunity 2011; 35: 572582.
27. Welz PS, Wullaert A, Vlantis K, et al . FADD prevents RIP3-
mediated epithelial cell necrosis and chronic intestinal inflamma-
tion. Nature 2011; 477: 330334.
28. Prins JB, Ledgerwood EC, Ameloot P, et al . Tumor necrosis
factor-induced cytotoxicity is not related to rates of mitochondrial
morphological abnormalities or autophagy-changes that can be
mediated by TNFR-I or TNFR-II. Biosci Rep 1998; 18: 329340.
29. Majno G, Joris I. Apoptosis, oncosis, and necrosis. An overview of
cell death. Am J Pathol 1995; 146: 315.
30. Gunther C, Martini E, Wittkopf N, et al . Caspase-8 regulates TNF-
induced epithelial necroptosis and terminal ileitis. Nature 2011;
477: 335339.
31. Steinman RM, Turley S, Mellman I, et al . The induction of
tolerance by dendritic cells that have captured apoptotic cells. J
Exp Med 2000; 191: 411416.
32. Obeid M, Tesniere A, Ghiringhelli F, et al . Calreticulin exposure
dictates the immunogenicity of cancer cell death. Nat Med 2007;
13: 5461.
33. Panaretakis T, Kepp O, Brockmeier U, et al . Mechanisms of pre-
apoptotic calreticulin exposure in immunogenic cell death. EMBO
J 2009; 28: 578590.
34. Parsonnet J, Hansen S, Rodriguez L, et al . Helicobacter pylori
infection and gastric lymphoma. N Engl J Med 1994; 330:
12671271.
35. Yang Y, Luo C, Feng R, et al . The TNF, IL-1B and IL-10
polymorphisms and risk for hepatocellular carcinoma: a meta-
analysis. J Cancer Res Clin Oncol 2011; 137: 947952.
36. Ekbom A, Helmick C, Zack M, et al . Ulcerative colitis and
colorectal cancer. A population-based study. N Engl J Med 1990;
323: 12281233.
37. Mercer LK, Green AC, Galloway JB, et al . The influence of
anti-TNF therapy upon incidence of keratinocyte skin cancer in
patients with rheumatoid arthritis: longitudinal results from the
British Society for Rheumatology Biologics Register. Ann Rheum
Dis 2012; 71: 869874.
38. Baecklund E, Iliadou A, Askling J, et al . Association of chronic
inflammation, not its treatment, with increased lymphoma risk in
rheumatoid arthritis. Arthritis Rheum 2006; 54: 692701.
39. Mantovani A, Allavena P, Sica A, et al . Cancer-related inflamma-
tion. Nature 2008; 454: 436444.
40. Charles KA, Kulbe H, Soper R, et al . The tumor-promoting actions
of TNF involve TNFR1 and IL-17 in ovarian cancer in mice and
humans. J Clin Invest 2009; 119: 30113023.
41. Li B, Vincent A, Cates J, et al . Low levels of tumor necrosis factor-
increase tumor growth by inducing an endothelial phenotype
of monocytes recruited to the tumor site. Cancer Res 2009; 69:
338348.
42. Li B, Pozzi A, Young PP. TNF accelerates monocyte to endothelial
transdifferentiation in tumors by the induction of integrin 5
expression and adhesion to fibronectin. Mol Cancer Res 2011; 9:
702711.
43. Lo SZ, Steer JH, Joyce DA. TNF renders macrophages resistant to
a range of cancer chemotherapeutic agents through NF-B-mediated
antagonism of apoptosis signalling. Cancer Lett 2011; 307: 8092.
Copyright 2013 Pathological Society of Great Britain and Ireland.
Published by John Wiley & Sons, Ltd. www.pathsoc.org.uk
247
44. Meng Y, Beckett MA, Liang H, et al . Blockade of tumor necrosis
factor- signaling in tumor-associated macrophages as a radiosen-
sitizing strategy. Cancer Res 2010; 70: 15341543.
45. Schioppa T, Moore R, Thompson RG, et al . B regulatory cells and
the tumor-promoting actions of TNF during squamous carcino-
genesis. Proc Natl Acad Sci USA 2011; 108: 1066210667.
46. Bagheri-Yarmand R, Mandal M, Taludker AH, et al . Etk/Bmx
tyrosine kinase activates Pak1 and regulates tumorigenicity of breast
cancer cells. J Biol Chem 2001; 276: 2940329409.
47. Cohen I, Maoz M, Turm H, et al . Etk/Bmx regulates proteinase-
activated-receptor 1 (PAR1) in breast cancer invasion: signaling
partners, hierarchy and physiological significance. PLoS One 2010;
5: e11135.
48. Fujisawa Y, Li W, Wu D, et al . Ligand-independent activation of
the arylhydrocarbon receptor by ETK (Bmx) tyrosine kinase helps
MCF10AT1 breast cancer cells to survive in an apoptosis-inducing
environment. Biol Chem 2011; 392: 897908.
49. Grunhagen DJ, de Wilt JH, ten Hagen TL, et al . Technology insight:
Utility of TNF-based isolated limb perfusion to avoid amputation
of irresectable tumors of the extremities. Nat Clin Pract Oncol
2006; 3: 94103.
50. Grunhagen DJ, de Wilt JH, van Geel AN, et al . Isolated limb
perfusion with TNF and melphalan in locally advanced soft tissue
sarcomas of the extremities. Recent Results Cancer Res 2009; 179:
257270.
51. Deroose JP, Grunhagen DJ, van Geel AN, et al . Long-term
outcome of isolated limb perfusion with tumour necrosis factor-
for patients with melanoma in-transit metastases. Br J Surg 2011;
98: 15731580.
52. Alexander HR, Bartlett DL, Libutti SK, et al . Analysis of factors
associated with outcome in patients undergoing isolated hepatic
perfusion for unresectable liver metastases from colorectal center.
Ann Surg Oncol 2009; 16: 18521859.
53. Ruegg C, Yilmaz A, Bieler G, et al . Evidence for the involvement
of endothelial cell integrin V3 in the disruption of the tumor
vasculature induced by TNF and IFN. Nat Med 1998; 4: 408414.
54. Brooks PC, Montgomery AM, Rosenfeld M, et al . Integrin v3
antagonists promote tumor regression by inducing apoptosis of
angiogenic blood vessels. Cell 1994; 79: 11571164.
55. Zhang Y, Deng Y, Wendt T, et al . Intravenous somatic gene
transfer with antisense tissue factor restores blood flow by reducing
tumor necrosis factor-induced tissue factor expression and fibrin
deposition in mouse meth-A sarcoma. J Clin Invest 1996; 97:
22132224.
56. Horiuchi T, Mitoma H, Harashima S, et al . Transmembrane
TNF: structure, function and interaction with anti-TNF agents.
Rheumatology (Oxford) 2010; 49: 12151228.
57. Scallon B, Cai A, Solowski N, et al . Binding and functional
comparisons of two types of tumor necrosis factor antagonists. J
Pharmacol Exp Ther 2002; 301: 418426.
58. Grell M, Douni E, Wajant H, et al . The transmembrane form of
tumor necrosis factor is the prime activating ligand of the 80 kDa
tumor necrosis factor receptor. Cell 1995; 83: 793802.
59. Kirchner S, Boldt S, Kolch W, et al . LPS resistance in monocytic
cells caused by reverse signaling through transmembrane TNF
(mTNF) is mediated by the MAPK/ERK pathway. J Leukoc Biol
2004; 75: 324331.
60. Mitoma H, Horiuchi T, Hatta N, et al . Infliximab induces potent
anti-inflammatory responses by outside-to-inside signals through
transmembrane TNF. Gastroenterology 2005; 128: 376392.
61. Moulis G, Sommet A, Bene J, et al . Cancer risk of anti-TNF at
recommended doses in adult rheumatoid arthritis: a meta-analysis
with intention to treat and per protocol analyses. PLoS One 2012;
7: e48991.
J Pathol 2013; 230: 241248
www.thejournalofpathology.com
248
62. Burmester GR, Panaccione R, Gordon KB, et al . Adalimumab:
long-term safety in 23 458 patients from global clinical trials
in rheumatoid arthritis, juvenile idiopathic arthritis, ankylosing
spondylitis, psoriatic arthritis, psoriasis and Crohns disease. Ann
Rheum Dis 2013; 72: 517524.
63. Raaschou P, Simard JF, Neovius M, et al . Does cancer that occurs
during or after anti-tumor necrosis factor therapy have a worse
prognosis? A national assessment of overall and site-specific cancer
survival in rheumatoid arthritis patients treated with biologic agents.
Arthritis Rheum 2011; 63: 18121822.
64. Pallavicini FB, Caporali R, Sarzi-Puttini P, et al . Tumour necrosis
factor antagonist therapy and cancer development: analysis of the
LORHEN registry. Autoimmun Rev 2010; 9: 175180.
65. Mariette X, Tubach F, Bagheri H, et al . Lymphoma in patients
treated with anti-TNF: results of the 3-year prospective French
RATIO registry. Ann Rheum Dis 2010; 69: 400408.
66. Mariette X, Gottenberg JE, Ravaud P, et al . Registries in rheuma-
toid arthritis and autoimmune diseases: data from the French reg-
istries. Rheumatology (Oxford) 2011; 50: 222229.
67. Kroeger KM, Carville KS, Abraham LJ. The 308 tumor necrosis
factor- promoter polymorphism effects transcription. Mol Immunol
1997; 34: 391399.
68. Bayley JP, de Rooij H, van den Elsen PJ, et al . Functional analysis
of linker-scan mutants spanning the 376, -308, -244, and 238
polymorphic sites of the TNF promoter. Cytokine 2001; 14:
316323.
69. Kaijzel EL, Bayley JP, van Krugten MV, et al . Allele-specific
quantification of tumor necrosis factor- (TNF) transcription and
the role of promoter polymorphisms in rheumatoid arthritis patients
and healthy individuals. Genes Immun 2001; 2: 135144.
70. Mekinian A, Tamouza R, Pavy S, et al . Functional study of TNF
promoter polymorphisms: literature review and meta-analysis. Eur
Cytokine Netw 2011; 22: 88102.
71. Shen C, Sun H, Sun D, et al . Polymorphisms of tumor necrosis
factor- and breast cancer risk: a meta-analysis. Breast Cancer Res
Treat 2011; 126: 763770.
72. Pooja S, Francis A, Bid HK, et al . Role of ethnic variations in
TNF and TNF polymorphisms and risk of breast cancer in India.
Breast Cancer Res Treat 2011; 126: 739747.
Copyright 2013 Pathological Society of Great Britain and Ireland.
Published by John Wiley & Sons, Ltd. www.pathsoc.org.uk
JP Waters et al
73. Zhang J, Dou C, Song Y, et al . Polymorphisms of tumor necrosis
factor- are associated with increased susceptibility to gastric
cancer: a meta-analysis. J Hum Genet 2008; 53: 479489.
74. Madeleine MM, Johnson LG, Malkki M, et al . Genetic variation in
proinflammatory cytokines IL6, IL6R, TNF-region and TNFRSF1A
and risk of breast cancer. Breast Cancer Res Treat 2011; 129:
887899.
75. Kim S, Moon SM, Kim YS, et al . TNFR1 promoter -329G/T poly-
morphism results in allele-specific repression of TNFR1 expression.
Biochem Biophys Res Commun 2008; 368: 395401.
76. Horiuchi T, Kiyohara C, Tsukamoto H, et al . A functional M196R
polymorphism of tumour necrosis factor receptor type 2 is associ-
ated with systemic lupus erythematosus: a casecontrol study and
a meta-analysis. Ann Rheum Dis 2007; 66: 320324.
77. Till A, Rosenstiel P, Krippner-Heidenreich A, et al . The Met-
196Arg variation of human tumor necrosis factor receptor 2
(TNFR2) affects TNF-induced apoptosis by impaired NF-B
signaling and target gene expression. J Biol Chem 2005; 280:
59946004.
78. Guan X, Liao Z, Ma H, et al . TNFRSF1B +676 T > G poly-
morphism predicts survival of non-small cell lung cancer patients
treated with chemoradiotherapy. BMC Cancer 2011; 11: 447.
79. Van Ostade X, Vandenabeele P, Everaerdt B, et al . Human TNF
mutants with selective activity on the p55 receptor. Nature 1993;
361: 266269.
80. Al-Lamki RS, Wang J, Skepper JN, et al . Expression of tumor
necrosis factor receptors in normal kidney and rejecting renal
transplants. Lab Invest 2001; 81: 15031515.
81. Al-Lamki RS, Wang J, Vandenabeele P, et al . TNFR1- and TNFR2-
mediated signaling pathways in human kidney are cell type-specific
and differentially contribute to renal injury. FASEB J 2005; 19:
16371645.
82. Al-Lamki RS, Bradley JR, Pober JS. Endothelial cells in allograft
rejection. Transplantation 2008; 86: 13401348.
83. Elsasser-Beile U, Kolble N, Grussenmeyer T, et al . Correlation of
clinical and immunological parameters of metastatic renal cell car-
cinoma patients undergoing therapy with interleukin 2, interferon-
and retinoic acid. Anticancer Res 1998; 18: 18831890.
J Pathol 2013; 230: 241248
www.thejournalofpathology.com