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The epithelial–mesenchymal transition (EMT) is a process by which epithelial cells lose their cell polarity and cell-cell adhesion, and gain migratory and invasive properties to become mesenchymal stem cells; these are multipotent stromal cells that can differentiate into a variety of cell types. EMT is essential for numerous developmental processes including mesoderm formation and neural tube formation. EMT has also been shown to occur in wound healing, in organ fibrosis and in the initiation of metastasis in cancer progression.

Introduction

Human embryo—length, 2 mm. Dorsal view, with the amnion laid open. X 30.

Epithelial–mesenchymal transition was first recognized as a feature of embryogenesis by Betty Hay in the 1980s.^[1]^[2] EMT, and its reverse process, MET (mesenchymal-epithelial transition) are critical for development of many tissues and organs in the developing embryo, and numerous embryonic events such as gastrulation, neural crest formation, heart valve formation, palatogenesis and myogenesis.^[3] Epithelial and mesenchymal cells differ in phenotype as well as function, though both share inherent plasticity.^[2] Epithelial cells are closely connected to each other by tight junctions, gap junctions and adherens junctions, have an apico-basal polarity, polarization of the actin cytoskeleton and are bound by a basal lamina at their basal surface. Mesenchymal cells, on the other hand, lack this polarization, have a spindle-shaped morphology and interact with each other only through focal points.^[4] Epithelial cells express high levels of E-cadherin, whereas mesenchymal cells express those of N-cadherin, fibronectin and vimentin. Thus, EMT entails profound morphological and phenotypic changes to a cell.

Based on the biological context, EMT has been categorized into 3 types : developmental (Type I), fibrosis^[5] and wound healing (Type II), and cancer (Type III).^[6]^[7]^[8]

Inducers

Loss of E-cadherin is considered to be a fundamental event in EMT. Many transcription factors (TFs) that can repress E-cadherin directly or indirectly can be considered as EMT-TF (EMT inducing TFs). SNAI1/Snail 1, SNAI2/Snail 2 (also known as Slug), ZEB1, ZEB2, TCF3 and KLF8 (Kruppel-like factor 8) can bind to E-cadherin promoter and repress its transcription, whereas factors such as Twist, Goosecoid, TCF4 (also known as E2.2), homeobox protein SIX1 and FOXC2 (fork-head box protein C2) repress E-cadherin indirectly.^[9]^[10] SNAIL and ZEB factors bind to E-box consensus sequences on the promoter region, while KLF8 binds to promoter through GT boxes. These EMT-TFs not only directly repress E-cadherin, but also repress transcriptionally other junctional proteins, including claudins and desmosomes, thus facilitating EMT. On the other hand, transcription factors such as grainyhead-like protein 2 homologue (GRHL2), and ETS-related transcription factors ELF3 and ELF5 are downregulated during EMT – rather they actively drive MET when overexpressed in mesenchymal cells.^[11]^[12] Since EMT in cancer progression recaptures EMT in developmental programs, many of the EMT-TFs are involved in promoting metastatic events.^[13]^[14]

Several signaling pathways (TGF-beta, FGF, EGF, HGF, Wnt/beta-catenin and Notch) and hypoxia may induce EMT.^[15]^[16] In particular, Ras-MAPK has been shown to activate Snail and Slug.^[17]^[18]^[19] Slug triggers the steps of desmosomal disruption, cell spreading, and partial separation at cell–cell borders, which comprise the first and necessary phase of the EMT process. On the other hand, Slug cannot trigger the second phase,^[20] which includes the induction of cell motility, repression of the cytokeratin expression, and activation of vimentin expression.^[21] Snail and Slug are known to regulate the expression of p63 isoforms, another transcription factor that is required for proper development of epithelial structures.^[22] The altered expression of p63 isoforms reduced cell–cell adhesion and increased the migratory properties of cancer cells. The p63 factor is involved in inhibiting EMT and reduction of certain p63 isoforms may be important in the development of epithelial cancers.^[23] Some of them are known to regulate the expression of cytokeratins^[24]. The phosphatidylinositol 3' kinase (PI3K)/AKT axis, Hedgehog, nuclear factor-kappaB and Activating Transcription Factor 2 have also been implicated to be involved in EMT.^[25]^[26]^[27]^[28]

Wnt signaling pathway regulates EMT in gastrulation, cardiac valve formation and cancer.^[29] Activation of Wnt pathway in breast cancer cells induces the EMT regulator SNAIL and upregulates the mesenchymal marker, vimentin. Also, active Wnt/beta-catenin pathway correlates with poor prognosis in breast cancer patients in the clinic. Similarly, TGF-beta activates the expression of SNAIL and ZEB to regulate EMT in heart development, palatogenesis, and cancer. The breast cancer bone metastasis has activated TGF-beta signaling, which contributes to the formation of these lesions.^[30] However, on the other hand, p53, a well-known tumor suppressor, represses EMT by activating the expression of various microRNAs – miR-200 and miR-34 that inhibit the production of protein ZEB and SNAIL, and thus maintain the epithelial phenotype.^[31]

In development and wound healing

After the initial stage of embryogenesis, the implantation of the embryo and the initiation of placenta formation are associated with EMT. The trophoectoderm cells undergo EMT to facilitate the invasion of endometrium and appropriate placenta placement, thus enabling nutrient and gas exchange to the embryo. Later in embryogenesis, during gastrulation, EMT allows the cells to ingress in a specific area of the embryo – the primitive streak in amniotes, and the ventral furrow in Drosophila. The cells in this tissue express E-cadherin and apical-basal polarity.^[32] Since gastrulation is a very rapid process, E-cadherin is repressed transcriptionally by Twist and SNAI1 (commonly called Snail), and at the protein level by P38 interacting protein. The primitive streak, through invagination, further generates mesoendoderm, which separates to form a mesoderm and an endoderm, again through EMT. Mesenchymal cells from the primitive streak participate also in the formation of many epithelial mesodermal organs, such as notochord as well as somites, through the reverse of EMT, i.e. mesenchymal–epithelial transition. Amphioxus forms an epithelial neural tube and dorsal notochord but does not have the EMT potential of the primitive streak. In higher chordates, the mesenchyme originates out of the primitive streak migrates anteriorly to form the somites and participate with neural crest mesenchyme in formation of the heart mesoderm.

In vertebrates, epithelium and mesenchyme are the basic tissue phenotypes. During embryonic development, migratory neural crest cells are generated by EMT involving the epithelial cells of the neuroectoderm. As a result, these cells dissociate from neural folds, gain motility, and disseminate to various parts of the embryo, where they differentiate to many other cell types. Also, craniofacial crest mesenchyme that forms the connective tissue forming the head and face, is formed by neural tube epithelium by EMT.^[33] EMT takes place during the construction of the vertebral column out of the extracellular matrix, which is to be synthesized by fibroblasts and osteoblasts that encircle the neural tube. The major source of these cells are sclerotome and somite mesenchyme as well as primitive streak. Mesenchymal morphology allows the cells to travel to specific targets in the embryo, where they differentiate and/or induce differentiation of other cells.^[33]^[34]

During wound healing, keratinocytes at the border of the wound undergo EMT and undergo re-epithelialization or MET when the wound is closed. Snail2 expression at the migratory front influences this state, as its overexpression accelerates wound healing. Similarly, in each menstrual cycle, the ovarian surface epithelium undergoes EMT during post-ovulatory wound healing.^[35]

In cancer progression and metastasis

Initiation of metastasis requires invasion, which is enabled by EMT.^[36]^[37] Carcinoma cells in a primary tumor lose cell-cell adhesion mediated by E-cadherin repression and break through the basement membrane with increased invasive properties, and enter the bloodstream through intravasation. Later, when these circulating tumor cells (CTCs) exit the bloodstream to form micro-metastases, they undergo MET for clonal outgrowth at these metastatic sites. Thus, EMT and MET form the initiation and completion of the invasion-metastasis cascade.^[38] At this new metastatic site, the tumor may undergo other processes to optimize growth. For example, EMT has been associated with PD-L1 expression, particularly in lung cancer. Increased levels of PD-L1 suppresses the immune system which allows the cancer to spread more easily. ^[39]

EMT confers resistance to oncogene-induced premature senescence. Twist1 and Twist2, as well as ZEB1 protects human cells and mouse embryonic fibroblasts from senescence. Similarly, TGFβ can promote tumor invasion and evasion of immune surveillance at advanced stages. When TGFβ acts on activated Ras-expressing mammary epithelial cells, EMT is favored and apoptosis is inhibited.^[40] This effect can be reversed by inducers of epithelial differentiation, such as GATA-3.^[41]

EMT has been shown to be induced by androgen deprivation therapy in metastatic prostate cancer.^[13] Activation of EMT programs via inhibition of the androgen axis provides a mechanism by which tumor cells can adapt to promote disease recurrence and progression. Brachyury, Axl, MEK, and Aurora kinase A are molecular drivers of these programs, and inhibitors are currently in clinical trials to determine therapeutic applications.^[13]

EMT has been indicated to be involved in acquiring drug resistance. Gain of EMT markers was found to be associated with the resistance of ovarian carcinoma epithelial cell lines to paclitaxel. Similarly, SNAIL also confers resistance to paclitaxel, adriamycin and radiotherapy by inhibiting p53-mediated apoptosis.^[42] Furthermore, inflammation, that has been associated with the progression of cancer and fibrosis, was recently shown to be related to cancer through inflammation-induced EMT.^{[citation needed]} Consequently, EMT enables cells to gain a migratory phenotype, as well as induce multiple immunosuppression, drug resistance, evasion of apoptosis mechanisms.

Some evidence suggests that cells that undergo EMT gain stem cell-like properties, thus giving rise to Cancer Stem Cells (CSCs). Upon transfection by activated Ras, a subpopulation of cells exhibiting the putative stem cell markers CD44high/CD24low increases with the concomitant induction of EMT.^[43] Also, ZEB1 is capable of conferring stem cell-like properties, thus strengthening the relationship between EMT and stemness. Thus, EMT may present increased danger to cancer patients, as EMT not only enables the carcinoma cells to enter the bloodstream, but also endows them with properties of stemness which increases tumorigenic and proliferative potential.^[44]

However, recent studies have further shifted the primary effects of EMT away from invasion and metastasis, toward resistance to chemotherapeutic agents. Research on breast cancer and pancreatic cancer both demonstrated no difference in cells' metastatic potential upon acquisition of EMT.^[45]^[46] These are in agreement with another study showing that the EMT transcription factor TWIST actually requires intact adherens junctions in order to mediate local invasion in breast cancer.^[47] The effects of EMT and its relationship to invasion and metastasis may therefore be highly context specific.

Platelets in cancer EMT

Platelets in the blood have the ability to initiate the induction of EMT in cancer cells. When platelets are recruited to a site in the blood vessel they can release a variety of growth factors (PDGF^[48], VEGF^[49], Angiopoietin-1^[50]) and cytokines including the EMT inducer TGFβ.^[51] The release of TGFβ by platelets in blood vessels near primary tumors enhances invasiveness and promotes metastasis of cancer cells in the tumor. ^[52] Studies looking at defective platelets and reduced platelet counts in mouse models have shown that impaired platelet function is associated with decreased metastatic formation. ^[53]^[54] In humans, platelet counts and thrombocytosis within the upper end of the normal range have been associated with advanced, often metastatic, stage cancer in cervical cancer^[55], ovarian cancer^[56], gastric cancer^[57], and esophageal cancer.^[58]

To improve the chances for the development of a cancer metastasis, a cancer cell must avoid detection and targeting by the immune system once it enters the bloodstream. Activated platelets have the ability to bind glycoproteins and glycolipids (P-selectin ligands) on the surface of cancer cells to form a physical barrier that protects the cancer cell from natural killer cell-mediated lysis in the bloodstream.^[59] Furthermore, activated platelets promote the adhesion of cancer cells to activated endothelial cells lining blood vessels using adhesion molecules present on platelets.^[60]^[61]

Generation of endocrine progenitor cells from pancreatic islets

Similar to generation of Cancer Stem Cells, EMT was demonstrated to generate endocrine progenitor cells from human pancreatic islets.^[62] Initially, the human islet-derived progenitor cells (hIPCs) were proposed to be better precursors since β-cell progeny in these hIPCs inherit epigenetic marks that define an active insulin promoter region.^[63] However, later, another set of experiments suggested that labelled β-cells de-differentiate to a mesenchymal-like phenotype in vitro, but fail to proliferate; thus initiating a debate in 2007.^[64]^[65]^[66]

Since these studies in human islets lacked lineage-tracing analysis, these findings from irreversibly tagged beta cells in mice were extrapolated to human islets. Thus, using a dual lentiviral and genetic lineage tracing system to label β-cells, it was convincingly demonstrated that adult human islet β-cells undergo EMT and proliferate in vitro.^[67]^[68] Also, these findings were confirmed in human fetal pancreatic insulin-producing cells, and the mesenchymal cells derived from pancreatic islets can undergo the reverse of EMT – MET – to generate islet-like cell aggregates.^[69] Thus, the concept of generating progenitors from insulin-producing cells by EMT or generation of Cancer Stem Cells during EMT in cancer may have potential for replacement therapy in diabetes, and call for drugs targeting inhibiting EMT in cancer.^[69]

Partial EMT or a hybrid E/M phenotype

Not all cells undergo a complete EMT, i.e. losing their cell-cell adhesion and gaining solitary migration characteristics. Instead, most cells undergo partial EMT, a state in which they retain some epithelial traits such as cell-cell adhesion or apico-basal polarity, and gain migratory traits, thus cells in this hybrid epithelial/mesenchymal (E/M) phenotype are endowed with special properties such as collective cell migration.^[47]^[70]^[71]^[72]^[73]^[74]^[75]^[76] Two mathematical models have been proposed, attempting to explain the emergence of this hybrid E/M phenotype,^[73]^[77] and its highly likely that different cell lines adopt different hybrid state(s), as shown by experiments in MCF10A, HMLE and H1975 cell lines.^[74]^[78] Although a hybrid E/M state has been referred to as 'metastable' or transient, recent experiments in H1975 cells suggest that this state can be stably maintained by cells.^[79]

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External links

Commentary: Epithelial-to-mesenchymal transition in pancreatic islet β cells

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@@ Line 14: / Line 14: @@
 ==Inducers==
 [[File:Epithelial_to_Mesenchymal_Transition_Comparison_Chart.png|left|thumb|Key inducers of the epithelial to mesenchymal transition process.]]
-Loss of [[E-cadherin]] is considered to be a fundamental event in EMT. Many [[transcription factor]]s (TFs) that can repress E-cadherin directly or indirectly can be considered as EMT-TF (EMT inducing TFs). [[SNAI1]]/Snail 1, [[SNAI2]]/Snail 2 (also known as Slug), [[ZEB1]], [[ZEB2]], E47 and [[KLF8]] (Kruppel-like factor 8) can bind to E-cadherin promoter and repress its transcription, whereas factors such as [[twist transcription factor|Twist]], Goosecoid, E2.2 (also known as TCF4), homeobox protein [[SIX1]] and [[FOXC2]] (fork-head box protein C2) repress E-cadherin indirectly.<ref>{{cite journal |vauthors=Peinado H, Olmeda D, Cano A | title = Snail, Zeb and bHLH factors in tumour progression: an alliance against the epithelial phenotype? | journal = Nature Reviews Cancer | volume = 7 | issue = 6| pages = 415–428 | year = 2007 | url =  | doi=10.1038/nrc2131 | pmid=17508028}}</ref><ref>{{cite journal |vauthors=Yang J, Weinberg RA | title = Epithelial-mesenchymal transition: at the crossroads of development and tumor metastasis | journal = Dev Cell | volume = 14 | pages = 818–829 | year = 2008 | url =| doi=10.1016/j.devcel.2008.05.009 | pmid=18539112 | issue=6}}</ref> SNAIL and ZEB factors bind to E-box consensus sequences on the promoter region, while KLF8 binds to promoter through GT boxes. These EMT-TFs not only directly repress E-cadherin, but also repress transcriptionally other junctional proteins, including claudins and desmosomes, thus facilitating EMT. On the other hand, transcription factors such as grainyhead-like protein 2 homologue (GRHL2), and ETS-related transcription factors ELF3 and [[ELF5]] are downregulated during EMT – rather they actively drive MET when overexpressed in mesenchymal cells.<ref>{{cite journal |vauthors=De Craene B, Berx G | title = Regulatory networks defining EMT during cancer initiation and progression | journal = Nature Reviews Cancer | volume = 13 | pages = 97–110 | year = 2013 | doi= 10.1038/nrc3447}}</ref><ref>{{cite journal |vauthors=Chakrabarti R, Hwang J, Andres Blanco M, Wei Y, Lukačišin M, Romano RA, Smalley K, Liu S, Yang Q, Ibrahim T, Mercatali L, Amadori D, Haffty BG, Sinha S, Kang Y | title = Elf5 inhibits the epithelial-mesenchymal transition in mammary gland development and breast cancer metastasis by transcriptionally repressing Snail2 | journal = Nat Cell Biol | volume = 14 | issue=11 | pages = 1212–1222 | year = 2012 | doi= 10.1038/ncb2607 }}</ref> Since EMT in cancer progression recaptures EMT in developmental programs, many of the EMT-TFs are involved in promoting metastasis.<ref name="ncbi.nlm.nih.gov">{{cite journal |vauthors=Nouri M, Ratther E, Stylianou N, Nelson CC, Hollier BG, Williams ED | year = 2014| title = Androgen-targeted therapy-induced epithelial mesenchymal plasticity and neuroendocrine transdifferentiation in prostate cancer: an opportunity for intervention | url = | journal = Front Oncol| volume =  4| issue = | pages =  370| pmid = 25566507 | doi=10.3389/fonc.2014.00370 | pmc=4274903}}</ref>
+Loss of [[E-cadherin]] is considered to be a fundamental event in EMT. Many [[transcription factor]]s (TFs) that can repress E-cadherin directly or indirectly can be considered as EMT-TF (EMT inducing TFs). [[SNAI1]]/Snail 1, [[SNAI2]]/Snail 2 (also known as Slug), [[ZEB1]], [[ZEB2]], [[TCF3]] and [[KLF8]] (Kruppel-like factor 8) can bind to E-cadherin promoter and repress its transcription, whereas factors such as [[twist transcription factor|Twist]], Goosecoid, [[TCF4]] (also known as E2.2), homeobox protein [[SIX1]] and [[FOXC2]] (fork-head box protein C2) repress E-cadherin indirectly.<ref>{{cite journal |vauthors=Peinado H, Olmeda D, Cano A | title = Snail, Zeb and bHLH factors in tumour progression: an alliance against the epithelial phenotype? | journal = Nature Reviews Cancer | volume = 7 | issue = 6| pages = 415–428 | year = 2007 | url =  | doi=10.1038/nrc2131 | pmid=17508028}}</ref><ref>{{cite journal |vauthors=Yang J, Weinberg RA | title = Epithelial-mesenchymal transition: at the crossroads of development and tumor metastasis | journal = Dev Cell | volume = 14 | pages = 818–829 | year = 2008 | url =| doi=10.1016/j.devcel.2008.05.009 | pmid=18539112 | issue=6}}</ref> SNAIL and ZEB factors bind to E-box consensus sequences on the promoter region, while KLF8 binds to promoter through GT boxes. These EMT-TFs not only directly repress E-cadherin, but also repress transcriptionally other junctional proteins, including [[Claudin|claudins]] and [[Desmosome|desmosomes]], thus facilitating EMT. On the other hand, transcription factors such as grainyhead-like protein 2 homologue (GRHL2), and ETS-related transcription factors ELF3 and [[ELF5]] are downregulated during EMT – rather they actively drive MET when overexpressed in mesenchymal cells.<ref>{{cite journal |vauthors=De Craene B, Berx G | title = Regulatory networks defining EMT during cancer initiation and progression | journal = Nature Reviews Cancer | volume = 13 | pages = 97–110 | year = 2013 | doi= 10.1038/nrc3447}}</ref><ref>{{cite journal |vauthors=Chakrabarti R, Hwang J, Andres Blanco M, Wei Y, Lukačišin M, Romano RA, Smalley K, Liu S, Yang Q, Ibrahim T, Mercatali L, Amadori D, Haffty BG, Sinha S, Kang Y | title = Elf5 inhibits the epithelial-mesenchymal transition in mammary gland development and breast cancer metastasis by transcriptionally repressing Snail2 | journal = Nat Cell Biol | volume = 14 | issue=11 | pages = 1212–1222 | year = 2012 | doi= 10.1038/ncb2607 }}</ref> Since EMT in cancer progression recaptures EMT in developmental programs, many of the EMT-TFs are involved in promoting metastatic events.<ref name="ncbi.nlm.nih.gov">{{cite journal |vauthors=Nouri M, Ratther E, Stylianou N, Nelson CC, Hollier BG, Williams ED | year = 2014| title = Androgen-targeted therapy-induced epithelial mesenchymal plasticity and neuroendocrine transdifferentiation in prostate cancer: an opportunity for intervention | url = | journal = Front Oncol| volume =  4| issue = | pages =  370| pmid = 25566507 | doi=10.3389/fonc.2014.00370 | pmc=4274903}}</ref><ref>{{Cite journal|last=Puisieux|first=Alain|last2=Brabletz|first2=Thomas|last3=Caramel|first3=Julie|date=2014/06|title=Oncogenic roles of EMT-inducing transcription factors|url=https://www.nature.com/articles/ncb2976.pdf?origin=ppub|journal=Nature Cell Biology|language=En|volume=16|issue=6|pages=488–494|doi=10.1038/ncb2976|issn=1476-4679}}</ref>
-Several signaling pathways ([[TGF-beta]], [[fibroblast growth factor|FGF]], [[epidermal growth factor|EGF]], [[hepatocyte growth factor|HGF]], [[Wnt signaling pathway|Wnt]]/[[beta-catenin]] and [[notch signaling pathway|Notch]]) and [[hypoxia (medical)|hypoxia]] may induce EMT. In particular, Ras-[[MAPK]] has been shown to activate Snail and Slug. Slug triggers the steps of [[Desmosome|desmosomal]] disruption, cell spreading, and partial separation at cell–cell borders, which comprise the first and necessary phase of the EMT process. On the other hand, Slug cannot trigger the second phase,<ref>{{cite journal |vauthors=Savagner P, Yamada KM, Thiery JP | title = The zinc-finger protein slug causes desmosome dissociation, an initial and necessary step for growth factor-induced epithelial–mesenchymal transition | journal=J Cell Biol | volume = 137 | issue = 6 | pages = 1403–19 | year = 1997 | pmid = 9182671 | doi = 10.1083/jcb.137.6.1403| pmc=2132541}}</ref> which includes the induction of cell motility, repression of the [[cytokeratin]] expression, and activation of [[vimentin]] expression.<ref>{{cite journal |vauthors=Boyer B, Tucker GC, Vallés AM, Franke WW, Thiery JP | title = Rearrangements of desmosomal and cytoskeletal proteins during the transition from epithelial to fibroblastoid organization in cultured rat bladder carcinoma cells | journal=J Cell Biol | volume = 109 | pages = 1495–509 | year = 1989 | pmid = 2677020 | url = https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2115780/pdf/jc10941495.pdf  | pmc=2115780 | issue=4 Pt 1 | doi=10.1083/jcb.109.4.1495}}</ref> Snail and Slug are known to regulate the expression of isoforms of another transcription factor [[TP63|p63]] that is required for proper development of epithelial structures.<ref>{{cite journal |vauthors=Herfs M, Hubert P, Suarez-Carmona M, Reschner A, Saussez S, Berx G, Savagner P, Boniver J, Delvenne P | title = Regulation of p63 isoforms by snail and slug transcription factors in human squamous cell carcinoma | journal=Am J Pathol | volume = 176 | issue = 4 | pages = 1941–49 | year = 2010 | pmid = 20150431 | doi = 10.2353/ajpath.2010.090804| pmc=2843482}}</ref> The altered expression of [[TP63|p63]] isoforms reduced cell–cell adhesion and increased the migratory properties of cancer cells. The [[TP63|p63]] factor is involved in inhibiting EMT and reduction of certain p63 isoforms may be important in the development of epithelial cancers.<ref>{{cite journal |vauthors=Lindsay J, McDade SS, Pickard A, McCloskey KD, McCance DJ | title = Role of DeltaNp63gamma in epithelial to mesenchymal transition | journal=J Biol Chem | volume = 286 | issue = 5 | pages = 3915–24 | year = 2011 | pmid = 21127042 | doi = 10.1074/jbc.M110.162511 | pmc=3030392}}</ref> Some of them are known to regulate the expression of cytokeratins.<ref>{{cite journal |vauthors=Boldrup L, Coates PJ, Gu X, Nylander K | title = DeltaNp63 isoforms regulate CD44 and keratins 4, 6, 14 and 19 in squamous cell carcinoma of head and neck | journal=J Pathol | volume = 213 | issue = 4 | pages = 384–91 | year = 2007 | pmid = 17935121 | doi = 10.1002/path.2237 }}</ref> Recently, activation of the [[Phosphoinositide 3-kinase|phosphatidylinositol 3' kinase]] (PI3K)/AKT axis is emerging as a central feature of EMT. Similarly,  [[Hedgehog]], [[NF-κB|nuclear factor-kappaB]] and Activating Transcription Factor 2 have been implicated to be involved in EMT.<ref>{{cite journal |vauthors=Vlahopoulos SA, Logotheti S, Mikas D, Giarika A, Gorgoulis V, Zoumpourlis V |date=Apr 2008 | title = The role of ATF-2 in oncogenesis | url = | journal = BioEssays | volume = 30 | issue = 4| pages = 314–27 | doi=10.1002/bies.20734 | pmid=18348191}}</ref><ref>{{cite journal |vauthors=Huber MA, Beug H, Wirth T |date=Dec 2004 | title = Epithelial-mesenchymal transition: NF-kappaB takes center stage | url = | journal = Cell Cycle | volume = 3 | issue = 12| pages = 1477–80 | doi=10.4161/cc.3.12.1280 | pmid=15539952}}</ref><ref>{{cite journal |vauthors=Katoh Y, Katoh M |date=Sep 2008 | title = Hedgehog signaling, epithelial-to-mesenchymal transition and miRNA | url = | journal = Int J Mol Med. | volume = 22 | issue = 3| pages = 271–5 }}</ref>
+Several signaling pathways ([[TGF-beta]], [[fibroblast growth factor|FGF]], [[epidermal growth factor|EGF]], [[hepatocyte growth factor|HGF]], [[Wnt signaling pathway|Wnt]]/[[beta-catenin]] and [[notch signaling pathway|Notch]]) and [[hypoxia (medical)|hypoxia]] may induce EMT.<ref>{{Cite journal|last=Kalluri|first=Raghu|last2=Weinberg|first2=Robert A.|date=2009-06-01|title=The basics of epithelial-mesenchymal transition|url=http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2689101/|journal=The Journal of Clinical Investigation|volume=119|issue=6|pages=1420–1428|doi=10.1172/JCI39104|issn=0021-9738|pmc=PMC2689101|pmid=19487818}}</ref><ref>{{Cite journal|last=Zhang|first=Lin|last2=Huang|first2=Gang|last3=Li|first3=Xiaowu|last4=Zhang|first4=Yujun|last5=Jiang|first5=Yan|last6=Shen|first6=Junjie|last7=Liu|first7=Jia|last8=Wang|first8=Qingliang|last9=Zhu|first9=Jin|date=2013-03-09|title=Hypoxia induces epithelial-mesenchymal transition via activation of SNAI1 by hypoxia-inducible factor -1α in hepatocellular carcinoma|url=https://www.ncbi.nlm.nih.gov/pubmed/23496980|journal=BMC cancer|volume=13|pages=108|doi=10.1186/1471-2407-13-108|issn=1471-2407|pmc=PMC3614870|pmid=23496980}}</ref> In particular, Ras-[[MAPK]] has been shown to activate Snail and Slug.<ref>{{Cite journal|last=Horiguchi|first=Kana|last2=Shirakihara|first2=Takuya|last3=Nakano|first3=Ayako|last4=Imamura|first4=Takeshi|last5=Miyazono|first5=Kohei|last6=Saitoh|first6=Masao|date=2009-01-02|title=Role of Ras Signaling in the Induction of Snail by Transforming Growth Factor-β|url=http://www.jbc.org/content/284/1/245|journal=Journal of Biological Chemistry|language=en|volume=284|issue=1|pages=245–253|doi=10.1074/jbc.m804777200|issn=0021-9258|pmid=19010789}}</ref><ref>{{Cite journal|last=Ciruna|first=B.|last2=Rossant|first2=J.|date=July 2001|title=FGF signaling regulates mesoderm cell fate specification and morphogenetic movement at the primitive streak|url=https://www.ncbi.nlm.nih.gov/pubmed/11703922|journal=Developmental Cell|volume=1|issue=1|pages=37–49|issn=1534-5807|pmid=11703922}}</ref><ref>{{Cite journal|last=Lu|first=Zhimin|last2=Ghosh|first2=Sourav|last3=Wang|first3=Zhiyong|last4=Hunter|first4=Tony|date=December 2003|title=Downregulation of caveolin-1 function by EGF leads to the loss of E-cadherin, increased transcriptional activity of beta-catenin, and enhanced tumor cell invasion|url=https://www.ncbi.nlm.nih.gov/pubmed/14706341|journal=Cancer Cell|volume=4|issue=6|pages=499–515|issn=1535-6108|pmid=14706341}}</ref> Slug triggers the steps of [[Desmosome|desmosomal]] disruption, cell spreading, and partial separation at cell–cell borders, which comprise the first and necessary phase of the EMT process. On the other hand, Slug cannot trigger the second phase,<ref>{{cite journal |vauthors=Savagner P, Yamada KM, Thiery JP | title = The zinc-finger protein slug causes desmosome dissociation, an initial and necessary step for growth factor-induced epithelial–mesenchymal transition | journal=J Cell Biol | volume = 137 | issue = 6 | pages = 1403–19 | year = 1997 | pmid = 9182671 | doi = 10.1083/jcb.137.6.1403| pmc=2132541}}</ref> which includes the induction of cell motility, repression of the [[cytokeratin]] expression, and activation of [[vimentin]] expression.<ref>{{cite journal |vauthors=Boyer B, Tucker GC, Vallés AM, Franke WW, Thiery JP | title = Rearrangements of desmosomal and cytoskeletal proteins during the transition from epithelial to fibroblastoid organization in cultured rat bladder carcinoma cells | journal=J Cell Biol | volume = 109 | pages = 1495–509 | year = 1989 | pmid = 2677020 | url = https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2115780/pdf/jc10941495.pdf  | pmc=2115780 | issue=4 Pt 1 | doi=10.1083/jcb.109.4.1495}}</ref> Snail and Slug are known to regulate the expression of [[TP63|p63]] isoforms, another transcription factor that is required for proper development of epithelial structures.<ref>{{cite journal |vauthors=Herfs M, Hubert P, Suarez-Carmona M, Reschner A, Saussez S, Berx G, Savagner P, Boniver J, Delvenne P | title = Regulation of p63 isoforms by snail and slug transcription factors in human squamous cell carcinoma | journal=Am J Pathol | volume = 176 | issue = 4 | pages = 1941–49 | year = 2010 | pmid = 20150431 | doi = 10.2353/ajpath.2010.090804| pmc=2843482}}</ref> The altered expression of [[TP63|p63]] isoforms reduced cell–cell adhesion and increased the migratory properties of cancer cells. The [[TP63|p63]] factor is involved in inhibiting EMT and reduction of certain p63 isoforms may be important in the development of epithelial cancers.<ref>{{cite journal |vauthors=Lindsay J, McDade SS, Pickard A, McCloskey KD, McCance DJ | title = Role of DeltaNp63gamma in epithelial to mesenchymal transition | journal=J Biol Chem | volume = 286 | issue = 5 | pages = 3915–24 | year = 2011 | pmid = 21127042 | doi = 10.1074/jbc.M110.162511 | pmc=3030392}}</ref> Some of them are known to regulate the expression of [[Cytokeratin|cytokeratins]]<ref>{{cite journal |vauthors=Boldrup L, Coates PJ, Gu X, Nylander K | title = DeltaNp63 isoforms regulate CD44 and keratins 4, 6, 14 and 19 in squamous cell carcinoma of head and neck | journal=J Pathol | volume = 213 | issue = 4 | pages = 384–91 | year = 2007 | pmid = 17935121 | doi = 10.1002/path.2237 }}</ref>. The [[Phosphoinositide 3-kinase|phosphatidylinositol 3' kinase]] (PI3K)/AKT axis, [[Hedgehog]], [[NF-κB|nuclear factor-kappaB]] and Activating Transcription Factor 2 have also been implicated to be involved in EMT.<ref>{{Cite journal|last=Larue|first=Lionel|last2=Bellacosa|first2=Alfonso|date=2005-11-14|title=Epithelial–mesenchymal transition in development and cancer: role of phosphatidylinositol 3′ kinase/AKT pathways|url=https://www.nature.com/articles/1209091|journal=Oncogene|language=En|volume=24|issue=50|pages=7443–7454|doi=10.1038/sj.onc.1209091|issn=1476-5594}}</ref><ref>{{cite journal |vauthors=Vlahopoulos SA, Logotheti S, Mikas D, Giarika A, Gorgoulis V, Zoumpourlis V |date=Apr 2008 | title = The role of ATF-2 in oncogenesis | url = | journal = BioEssays | volume = 30 | issue = 4| pages = 314–27 | doi=10.1002/bies.20734 | pmid=18348191}}</ref><ref>{{cite journal |vauthors=Huber MA, Beug H, Wirth T |date=Dec 2004 | title = Epithelial-mesenchymal transition: NF-kappaB takes center stage | url = | journal = Cell Cycle | volume = 3 | issue = 12| pages = 1477–80 | doi=10.4161/cc.3.12.1280 | pmid=15539952}}</ref><ref>{{cite journal |vauthors=Katoh Y, Katoh M |date=Sep 2008 | title = Hedgehog signaling, epithelial-to-mesenchymal transition and miRNA | url = | journal = Int J Mol Med. | volume = 22 | issue = 3| pages = 271–5 }}</ref>
-Wnt signaling pathway regulates EMT in gastrulation, cardiac valve formation and cancer.<ref>{{cite journal |author1=Micalizzi Ds |author2=Farabaugh SM |author3=Ford HL | title = Epithelial-Mesenchymal Transition in Cancer: Parallels between Normal Development and Tumor Progression | journal=J Mammary Gland Biol Neoplasia | volume = 15 | pages = 117–134 | year = 2010 | doi = 10.1007s/10911-010-9178-9 }}</ref> Activation of Wnt pathway in breast cancer cells induces the EMT regulator SNAIL and upregulates the mesenchymal marker, [[vimentin]]. Also, active Wnt/beta-catenin pathway correlates with poor prognosis in breast cancer patients in the clinic. Similarly, TGF-beta activates the expression of SNAIL and ZEB to regulate EMT in heart development, palatogenesis and cancer. The breast cancer bone metastasis has activated TGF-beta signaling, which contributes to the formation of these lesions.<ref>{{cite journal |vauthors=Kang Y, He W, Tulley S, Gupta GP, Serganova I, Chen CR, Manova-Todorova K, Blasberg R, Gerald WL, Massagué J | title = Breast cancer bone metastasis mediated by the Smad tumor suppressor pathway | journal= PNAS | volume = 102 | issue= 39| pages = 13909–14 | year = 2005| doi=10.1073/pnas.0506517102 | pmid=16172383 | pmc=1236573}}</ref> However, on the other hand, [[p53]], a well-known tumor suppressor, represses EMT by activating the expression of various [[microRNA]]s – miR-200 and miR-34 that inhibit the production of protein ZEB and SNAIL, and thus maintain the epithelial phenotype.<ref>{{cite journal |vauthors=Chang C, Chao C, Xia W, Yang J, Xiong Y, Li C, Yu W, Rehman SK, Hsu JL, Lee H, Liu M, Chen C, Yu D, Hung M | title = p53 regulates epithelial-mesenchymal transition (EMT) and stem cell properties through modulating miRNAs | journal= Nat Cell Biol | volume = 13 | issue= 3| pages = 317–323 | year = 2011 | doi=10.1038/ncb2173}}</ref>
+Wnt signaling pathway regulates EMT in gastrulation, cardiac valve formation and cancer.<ref>{{cite journal |author1=Micalizzi Ds |author2=Farabaugh SM |author3=Ford HL | title = Epithelial-Mesenchymal Transition in Cancer: Parallels between Normal Development and Tumor Progression | journal=J Mammary Gland Biol Neoplasia | volume = 15 | pages = 117–134 | year = 2010 | doi = 10.1007s/10911-010-9178-9 }}</ref> Activation of Wnt pathway in breast cancer cells induces the EMT regulator [[SNAI1|SNAIL]] and upregulates the mesenchymal marker, [[vimentin]]. Also, active Wnt/beta-catenin pathway correlates with poor prognosis in breast cancer patients in the clinic. Similarly, TGF-beta activates the expression of SNAIL and ZEB to regulate EMT in heart development, palatogenesis, and cancer. The breast cancer bone metastasis has activated TGF-beta signaling, which contributes to the formation of these lesions.<ref>{{cite journal |vauthors=Kang Y, He W, Tulley S, Gupta GP, Serganova I, Chen CR, Manova-Todorova K, Blasberg R, Gerald WL, Massagué J | title = Breast cancer bone metastasis mediated by the Smad tumor suppressor pathway | journal= PNAS | volume = 102 | issue= 39| pages = 13909–14 | year = 2005| doi=10.1073/pnas.0506517102 | pmid=16172383 | pmc=1236573}}</ref> However, on the other hand, [[p53]], a well-known tumor suppressor, represses EMT by activating the expression of various [[microRNA]]s – miR-200 and miR-34 that inhibit the production of protein ZEB and SNAIL, and thus maintain the epithelial phenotype.<ref>{{cite journal |vauthors=Chang C, Chao C, Xia W, Yang J, Xiong Y, Li C, Yu W, Rehman SK, Hsu JL, Lee H, Liu M, Chen C, Yu D, Hung M | title = p53 regulates epithelial-mesenchymal transition (EMT) and stem cell properties through modulating miRNAs | journal= Nat Cell Biol | volume = 13 | issue= 3| pages = 317–323 | year = 2011 | doi=10.1038/ncb2173}}</ref>
 ==In development and wound healing==
@@ Line 30: / Line 30: @@
 ==In cancer progression and metastasis==
-Initiation of [[metastasis]] requires invasion, which is enabled by EMT.<ref>{{Cite journal|last=Hanahan|first=D.|last2=Weinberg|first2=R. A.|date=2000-01-07|title=The hallmarks of cancer|url=|journal=Cell|volume=100|issue=1|pages=57–70|pmid=10647931}}</ref><ref>{{Cite journal|last=Hanahan|first=Douglas|last2=Weinberg|first2=Robert A.|date=2011-03-04|title=Hallmarks of cancer: the next generation|url=|journal=Cell|volume=144|issue=5|pages=646–674|doi=10.1016/j.cell.2011.02.013|pmid=21376230}}</ref> Carcinoma cells in primary tumor lose cell-cell adhesion mediated by E-cadherin repression and break through the basement membrane with increased invasive properties, and enter the bloodstream through [[intravasation]]. Later, when these [[circulating tumor cell]]s (CTCs) exit the bloodstream to form micro-metastases, they undergo MET for clonal outgrowth at these metastatic sites. Thus, EMT and MET form the initiation and completion of the invasion-metastasis cascade.<ref>{{cite journal|year=2011|title=A perspective on cancer cell metastasis|url=|journal=Science|volume=331|issue=6024|pages=1559–1564|doi=10.1126/science.1203543|pmid=21436443|vauthors=Chaffer CL, Weinberg RA}}</ref> At this new metastatic site, the tumor may undergo other processes to optimize growth. For example, EMT has been associated with [[PD-L1]] expression, particularly in lung cancer. Increased levels of PD-L1 suppresses the immune system which allows the cancer to spread more easily.&nbsp;<ref>{{Cite journal|last=Ye|first=Xin|last2=Weinberg|first2=Robert A.|date=November 2015|title=Epithelial-Mesenchymal Plasticity: A central regulator of cancer progression|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4628843/|journal=Trends in Cell Biology|volume=25|issue=11|pages=675–686|doi=10.1016/j.tcb.2015.07.012|pmc=4628843|pmid=26437589}}</ref>
+Initiation of [[metastasis]] requires invasion, which is enabled by EMT.<ref>{{Cite journal|last=Hanahan|first=D.|last2=Weinberg|first2=R. A.|date=2000-01-07|title=The hallmarks of cancer|url=|journal=Cell|volume=100|issue=1|pages=57–70|pmid=10647931}}</ref><ref>{{Cite journal|last=Hanahan|first=Douglas|last2=Weinberg|first2=Robert A.|date=2011-03-04|title=Hallmarks of cancer: the next generation|url=|journal=Cell|volume=144|issue=5|pages=646–674|doi=10.1016/j.cell.2011.02.013|pmid=21376230}}</ref> Carcinoma cells in a primary tumor lose cell-cell adhesion mediated by E-cadherin repression and break through the basement membrane with increased invasive properties, and enter the bloodstream through [[intravasation]]. Later, when these [[circulating tumor cell]]s (CTCs) exit the bloodstream to form micro-metastases, they undergo MET for clonal outgrowth at these metastatic sites. Thus, EMT and MET form the initiation and completion of the invasion-metastasis cascade.<ref>{{cite journal|year=2011|title=A perspective on cancer cell metastasis|url=|journal=Science|volume=331|issue=6024|pages=1559–1564|doi=10.1126/science.1203543|pmid=21436443|vauthors=Chaffer CL, Weinberg RA}}</ref> At this new metastatic site, the tumor may undergo other processes to optimize growth. For example, EMT has been associated with [[PD-L1]] expression, particularly in lung cancer. Increased levels of PD-L1 suppresses the immune system which allows the cancer to spread more easily.&nbsp;<ref>{{Cite journal|last=Ye|first=Xin|last2=Weinberg|first2=Robert A.|date=November 2015|title=Epithelial-Mesenchymal Plasticity: A central regulator of cancer progression|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4628843/|journal=Trends in Cell Biology|volume=25|issue=11|pages=675–686|doi=10.1016/j.tcb.2015.07.012|pmc=4628843|pmid=26437589}}</ref>
 EMT confers resistance to [[oncogene]]-induced premature [[senescence]]. Twist1 and Twist2, as well as [[ZEB1]] protects human cells and mouse embryonic fibroblasts from senescence. Similarly, TGFβ can promote tumor invasion and evasion of immune surveillance at advanced stages. When TGFβ acts on activated Ras-expressing mammary epithelial cells, EMT is favored and apoptosis is inhibited.<ref>{{ cite journal| author= Massague J | title= TGFβ in cancer| journal = Cell | volume= 134 | issue= | pages= 215–229 | year= 2008 | doi= 10.1016/j.cell.2008.07.001 | pmid=18662538 | pmc=3512574}}</ref>  This effect can be reversed by inducers of epithelial differentiation, such as GATA-3.<ref>{{cite journal|vauthors=Chu IM, Lai WC, Aprelikova O, El Touny LH, Kouros-Mehr H, Green JE |title=Expression of GATA3 in MDA-MB-231 triple-negative breast cancer cells induces a growth inhibitory response to TGFß.|journal=PLoS ONE|year=2013|volume=8|issue=4|pages=e61125|pmid=23577196|doi=10.1371/journal.pone.0061125|pmc=3620110}}</ref>
@@ Line 36: / Line 36: @@
 EMT has been shown to be induced by [[androgen deprivation therapy]] in metastatic [[prostate cancer]].<ref name="ncbi.nlm.nih.gov"/> Activation of EMT programs via inhibition of the androgen axis provides a mechanism by which tumor cells can adapt to promote disease recurrence and progression. [[Brachyury]], [[AXL receptor tyrosine kinase|Axl]], [[Mitogen-activated protein kinase kinase|MEK]], and [[Aurora kinase A]] are molecular drivers of these programs, and inhibitors are currently in clinical trials to determine therapeutic applications.<ref name="ncbi.nlm.nih.gov"/>
-EMT has been indicated to be involved in acquiring drug resistance. Gain of EMT markers was found to be associated with the resistance of ovarian carcinoma epithelial cell lines to paclitaxel. Similarly, SNAIL also confers resistance to paclitaxel, adriamycin and radiotherapy by inhibiting p53-mediated apoptosis.<ref>{{ cite journal|vauthors=Kajiyama H, Shibata K, Terauchi M, Yamashita M, Ino K, Nawa A, Kikkawa F | title = Chemoresistance to paclitaxel induces epithelial-mesenchymal transition and enhances metastatic potential for epithelial ovarian carcinoma cells | journal = Int J Oncol | volume= 31 | issue= | pages= 277–283 | year= 2007 | doi= 10.3892/ijo.31.2.277 }}</ref> Furthermore, inflammation, that has been associated with the progression of cancer and fibrosis, was recently shown to be related to cancer through inflammation-induced EMT.{{Citation needed|date=November 2017}} Thus, EMT not only enables cells the migratory phenotype, but also acts on multiple immunosuppression, drug resistance, evasion of apoptosis, thus showing an altered response of the host to the tumor.
+EMT has been indicated to be involved in acquiring drug resistance. Gain of EMT markers was found to be associated with the resistance of ovarian carcinoma epithelial cell lines to paclitaxel. Similarly, SNAIL also confers resistance to paclitaxel, adriamycin and radiotherapy by inhibiting p53-mediated apoptosis.<ref>{{ cite journal|vauthors=Kajiyama H, Shibata K, Terauchi M, Yamashita M, Ino K, Nawa A, Kikkawa F | title = Chemoresistance to paclitaxel induces epithelial-mesenchymal transition and enhances metastatic potential for epithelial ovarian carcinoma cells | journal = Int J Oncol | volume= 31 | issue= | pages= 277–283 | year= 2007 | doi= 10.3892/ijo.31.2.277 }}</ref> Furthermore, inflammation, that has been associated with the progression of cancer and fibrosis, was recently shown to be related to cancer through inflammation-induced EMT.{{Citation needed|date=November 2017}} Consequently, EMT enables cells to gain a migratory phenotype, as well as induce multiple immunosuppression, drug resistance, evasion of apoptosis mechanisms.
 Some evidence suggests that cells that undergo EMT gain stem cell-like properties, thus giving rise to [[Cancer Stem Cells]] (CSCs). Upon transfection by activated Ras, a subpopulation of cells exhibiting the putative stem cell markers CD44high/CD24low increases with the concomitant induction of EMT.<ref>{{cite journal |vauthors=Mani SA, Guo W, Liao MJ, Eaton EN, Ayyanan A, Zhou AY, Brooks M, Reinhard F, Zhang CC, Shipitsin M, Campbell LL, Polyak K, Brisken C, Yang J, Weinberg RA |title=The epithelial-mesenchymal transition generates cells with properties of stem cells |journal=Cell |volume=133 |issue=4 |pages=704–15 |year=2008 |pmid=18485877 |pmc=2728032 |doi=10.1016/j.cell.2008.03.027}}</ref> Also, ZEB1 is capable of conferring stem cell-like properties, thus strengthening the relationship between EMT and stemness. Thus, EMT may present increased danger to cancer patients, as EMT not only enables the carcinoma cells to enter the bloodstream, but also endows them with properties of stemness which increases tumorigenic and proliferative potential.<ref>{{cite journal |vauthors=Singh A, Settleman J | title = EMT, cancer stem cells and drug resistance: an emerging axis of evil in the war on cancer | journal= Oncogene | volume = 29 | pages = 4741–4751 | year = 2010 | doi = 10.1038/onc.2010.215 | pmid=20531305 | pmc=3176718}}</ref>
 However, recent studies have further shifted the primary effects of EMT away from invasion and metastasis, toward resistance to chemotherapeutic agents. Research on breast cancer and pancreatic cancer both demonstrated no difference in cells' metastatic potential upon acquisition of EMT.<ref>{{Cite journal|title = Epithelial-to-mesenchymal transition is not required for lung metastasis but contributes to chemoresistance|url = http://www.nature.com/nature/journal/v527/n7579/full/nature15748.html|journal = Nature|date = 2015-11-26|pmc = 4662610|pmid = 26560033|pages = 472–476|volume = 527|issue = 7579|doi = 10.1038/nature15748|first = Kari R.|last = Fischer|first2 = Anna|last2 = Durrans|first3 = Sharrell|last3 = Lee|first4 = Jianting|last4 = Sheng|first5 = Fuhai|last5 = Li|first6 = Stephen T. C.|last6 = Wong|first7 = Hyejin|last7 = Choi|first8 = Tina|last8 = El Rayes|first9 = Seongho|last9 = Ryu}}</ref><ref>{{Cite journal|title = Epithelial-to-mesenchymal transition is dispensable for metastasis but induces chemoresistance in pancreatic cancer|url = http://www.nature.com/nature/journal/v527/n7579/full/nature16064.html|journal = Nature|date = 2015-11-26|pages = 525–530|volume = 527|issue = 7579|doi = 10.1038/nature16064|first = Xiaofeng|last = Zheng|first2 = Julienne L.|last2 = Carstens|first3 = Jiha|last3 = Kim|first4 = Matthew|last4 = Scheible|first5 = Judith|last5 = Kaye|first6 = Hikaru|last6 = Sugimoto|first7 = Chia-Chin|last7 = Wu|first8 = Valerie S.|last8 = LeBleu|first9 = Raghu|last9 = Kalluri|pmid=26560028|pmc=4849281}}</ref> These are in agreement with another study showing that the EMT transcription factor TWIST actually requires intact [[adherens junction]]s in order to mediate local invasion in breast cancer.<ref name=":0">{{Cite journal|title = Twist1-induced dissemination preserves epithelial identity and requires E-cadherin|url = http://jcb.rupress.org/content/204/5/839|journal = The Journal of Cell Biology|date = 2014-03-03|pmc = 3941052|pmid = 24590176|pages = 839–856|volume = 204|issue = 5|doi = 10.1083/jcb.201306088|first = Eliah R.|last = Shamir|first2 = Elisa|last2 = Pappalardo|first3 = Danielle M.|last3 = Jorgens|first4 = Kester|last4 = Coutinho|first5 = Wen-Ting|last5 = Tsai|first6 = Khaled|last6 = Aziz|first7 = Manfred|last7 = Auer|first8 = Phuoc T.|last8 = Tran|first9 = Joel S.|last9 = Bader}}</ref> The effects of EMT and its relationship to invasion and metastasis may therefore be highly context specific.
+== Platelets in cancer EMT ==
+[[Platelet|Platelets]] in the blood have the ability to initiate the induction of EMT in cancer cells. When platelets are recruited to a site in the blood vessel they can release a variety of growth factors ([[Platelet-derived growth factor|PDGF]]<ref>{{Cite journal|last=Kepner|first=N.|last2=Lipton|first2=A.|date=February 1981|title=A mitogenic factor for transformed fibroblasts from human platelets|url=https://www.ncbi.nlm.nih.gov/pubmed/6256066|journal=Cancer Research|volume=41|issue=2|pages=430–432|issn=0008-5472|pmid=6256066}}</ref>, [[Vascular endothelial growth factor|VEGF]]<ref>{{Cite journal|last=Möhle|first=Robert|last2=Green|first2=David|last3=Moore|first3=Malcolm A. S.|last4=Nachman|first4=Ralph L.|last5=Rafii|first5=Shahin|date=1997-01-21|title=Constitutive production and thrombin-induced release of vascular endothelial growth factor by human megakaryocytes and platelets|url=http://www.ncbi.nlm.nih.gov/pmc/articles/PMC19570/|journal=Proceedings of the National Academy of Sciences of the United States of America|volume=94|issue=2|pages=663–668|issn=0027-8424|pmc=PMC19570|pmid=9012841}}</ref>, [[Angiopoietin 1|Angiopoietin-1]]<ref>{{Cite journal|last=Li|first=J. J.|last2=Huang|first2=Y. Q.|last3=Basch|first3=R.|last4=Karpatkin|first4=S.|date=February 2001|title=Thrombin induces the release of angiopoietin-1 from platelets|url=https://www.ncbi.nlm.nih.gov/pubmed/11246533|journal=Thrombosis and Haemostasis|volume=85|issue=2|pages=204–206|issn=0340-6245|pmid=11246533}}</ref>) and cytokines including the EMT inducer TGFβ.<ref>{{Cite journal|last=Assoian|first=R. K.|last2=Komoriya|first2=A.|last3=Meyers|first3=C. A.|last4=Miller|first4=D. M.|last5=Sporn|first5=M. B.|date=1983-06-10|title=Transforming growth factor-beta in human platelets. Identification of a major storage site, purification, and characterization|url=https://www.ncbi.nlm.nih.gov/pubmed/6602130|journal=The Journal of Biological Chemistry|volume=258|issue=11|pages=7155–7160|issn=0021-9258|pmid=6602130}}</ref> The release of TGFβ by platelets in blood vessels near primary tumors enhances invasiveness and promotes metastasis of cancer cells in the tumor. <ref>{{Cite journal|last=Oft|first=M.|last2=Heider|first2=K. H.|last3=Beug|first3=H.|date=1998-11-19|title=TGFbeta signaling is necessary for carcinoma cell invasiveness and metastasis|url=https://www.ncbi.nlm.nih.gov/pubmed/9822576|journal=Current biology: CB|volume=8|issue=23|pages=1243–1252|issn=0960-9822|pmid=9822576}}</ref> Studies looking at defective platelets and reduced platelet counts in mouse models have shown that impaired platelet function is associated with decreased metastatic formation. <ref>{{Cite journal|last=Bakewell|first=Suzanne J.|last2=Nestor|first2=Patrick|last3=Prasad|first3=Srinivasa|last4=Tomasson|first4=Michael H.|last5=Dowland|first5=Nikki|last6=Mehrotra|first6=Mukund|last7=Scarborough|first7=Robert|last8=Kanter|first8=James|last9=Abe|first9=Keith|date=2003-11-25|title=Platelet and osteoclast β3 integrins are critical for bone metastasis|url=http://www.ncbi.nlm.nih.gov/pmc/articles/PMC283570/|journal=Proceedings of the National Academy of Sciences of the United States of America|volume=100|issue=24|pages=14205–14210|doi=10.1073/pnas.2234372100|issn=0027-8424|pmc=PMC283570|pmid=14612570}}</ref><ref>{{Cite journal|last=Camerer|first=Eric|last2=Qazi|first2=Aisha A.|last3=Duong|first3=Daniel N.|last4=Cornelissen|first4=Ivo|last5=Advincula|first5=Rommel|last6=Coughlin|first6=Shaun R.|date=2004-07-15|title=Platelets, protease-activated receptors, and fibrinogen in hematogenous metastasis|url=https://www.ncbi.nlm.nih.gov/pubmed/15031212|journal=Blood|volume=104|issue=2|pages=397–401|doi=10.1182/blood-2004-02-0434|issn=0006-4971|pmid=15031212}}</ref> In humans, platelet counts and [[thrombocytosis]] within the upper end of the normal range have been associated with advanced, often metastatic, stage cancer in cervical cancer<ref>{{Cite journal|last=Hernandez|first=E.|last2=Lavine|first2=M.|last3=Dunton|first3=C. J.|last4=Gracely|first4=E.|last5=Parker|first5=J.|date=1992-06-15|title=Poor prognosis associated with thrombocytosis in patients with cervical cancer|url=https://www.ncbi.nlm.nih.gov/pubmed/1591690|journal=Cancer|volume=69|issue=12|pages=2975–2977|issn=0008-543X|pmid=1591690}}</ref>, ovarian cancer<ref>{{Cite journal|last=Zeimet|first=A. G.|last2=Marth|first2=C.|last3=Müller-Holzner|first3=E.|last4=Daxenbichler|first4=G.|last5=Dapunt|first5=O.|date=February 1994|title=Significance of thrombocytosis in patients with epithelial ovarian cancer|url=https://www.ncbi.nlm.nih.gov/pubmed/8116711|journal=American Journal of Obstetrics and Gynecology|volume=170|issue=2|pages=549–554|issn=0002-9378|pmid=8116711}}</ref>, gastric cancer<ref>{{Cite journal|last=Ikeda|first=Masataka|last2=Furukawa|first2=Hiroshi|last3=Imamura|first3=Hiroshi|last4=Shimizu|first4=Jyunzo|last5=Ishida|first5=Hideyuki|last6=Masutani|first6=Seizo|last7=Tatsuta|first7=Masayuki|last8=Satomi|first8=Takashi|date=April 2002|title=Poor prognosis associated with thrombocytosis in patients with gastric cancer|url=https://www.ncbi.nlm.nih.gov/pubmed/11923136|journal=Annals of Surgical Oncology|volume=9|issue=3|pages=287–291|issn=1068-9265|pmid=11923136}}</ref>, and esophageal cancer.<ref>{{Cite journal|last=Shimada|first=Hideaki|last2=Oohira|first2=Gaku|last3=Okazumi|first3=Shin-ichi|last4=Matsubara|first4=Hisahiro|last5=Nabeya|first5=Yoshihiro|last6=Hayashi|first6=Hideki|last7=Takeda|first7=Akihiko|last8=Gunji|first8=Yoshio|last9=Ochiai|first9=Takenori|date=May 2004|title=Thrombocytosis associated with poor prognosis in patients with esophageal carcinoma|url=https://www.ncbi.nlm.nih.gov/pubmed/15110807|journal=Journal of the American College of Surgeons|volume=198|issue=5|pages=737–741|doi=10.1016/j.jamcollsurg.2004.01.022|issn=1072-7515|pmid=15110807}}</ref>
+To improve the chances for the development of a cancer metastasis, a cancer cell must avoid detection and targeting by the immune system once it enters the bloodstream. Activated platelets have the ability to bind glycoproteins and glycolipids ([[P-selectin]] ligands) on the surface of cancer cells to form a physical barrier that protects the cancer cell from natural killer cell-mediated lysis in the bloodstream.<ref>{{Cite journal|last=Palumbo|first=Joseph S.|last2=Talmage|first2=Kathryn E.|last3=Massari|first3=Jessica V.|last4=La Jeunesse|first4=Christine M.|last5=Flick|first5=Matthew J.|last6=Kombrinck|first6=Keith W.|last7=Jirousková|first7=Markéta|last8=Degen|first8=Jay L.|date=2005-01-01|title=Platelets and fibrin(ogen) increase metastatic potential by impeding natural killer cell-mediated elimination of tumor cells|url=https://www.ncbi.nlm.nih.gov/pubmed/15367435|journal=Blood|volume=105|issue=1|pages=178–185|doi=10.1182/blood-2004-06-2272|issn=0006-4971|pmid=15367435}}</ref> Furthermore, activated platelets promote the adhesion of cancer cells to activated endothelial cells lining blood vessels using adhesion molecules present on platelets.<ref>{{Cite journal|last=Gay|first=Laurie J.|last2=Felding-Habermann|first2=Brunhilde|date=February 2011|title=Contribution of platelets to tumour metastasis|url=https://www.ncbi.nlm.nih.gov/pubmed/21258396|journal=Nature Reviews. Cancer|volume=11|issue=2|pages=123–134|doi=10.1038/nrc3004|issn=1474-1768|pmid=21258396}}</ref><ref>{{Cite journal|last=Erpenbeck|first=Luise|last2=Schön|first2=Michael P.|date=2010-04-29|title=Deadly allies: the fatal interplay between platelets and metastasizing cancer cells|url=http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2867258/|journal=Blood|volume=115|issue=17|pages=3427–3436|doi=10.1182/blood-2009-10-247296|issn=0006-4971|pmc=PMC2867258|pmid=20194899}}</ref>
 ==Generation of endocrine progenitor cells from pancreatic islets==