Summary
Members of the Epidermal Growth Factor-Cripto-1/FRL-1/Cryptic (EGF-CFC) family, such as human Cripto-1, are important mediators of crucial events that take place during embryonic pattern formation. New evidences from gene expression and transgenic mouse studies have also shown that perturbation of Cripto-1 signaling may lead to cell transformation and tumor formation in vivo. In addition, Cripto-1 is expressed at high levels in a wide variety of human carcinomas including early and late breast cancers. Despite the clear correlation between Cripto-1 overexpression and human and mouse tumors, the exact molecular mechanism of Cripto-1 contribution to the cell transformation process is not clear. Cripto-1 has been shown to activate multiple signaling pathways to promote either differentiation during embryogenesis or cancer growth. In this review we will discuss the multifunction properties of the EGF-CFC family of proteins and the complex network of signaling molecules activated by Cripto-1 focusing in particular on the mammary gland. A better understanding of the intracellular signaling pathways that mediate Cripto-1 activity in human tumors might identify novel points of intervention to target Cripto-1 in human malignancies.
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Salomon DS, Bianco C, Ebert AD, et alet al. The EGF-CFC family: novel epidermal growth factor-related proteins in development and cancer. Endocr Relat Cancer 2000;7(4):199–226.
Bianco C, Strizzi L, Normanno N, Khan N, Salomon DS. Cripto-1: an oncofetal gene with many faces. Curr Top Dev Biol 2005;67:85–133.
Dorey K, Hill CS. A novel Cripto-related protein reveals an essential role for EGF-CFCs in Nodal signalling in Xenopus embryos. Dev Biol 2006;292(2):303–16.
Zhang J, Talbot WS, Schier AF. Positional cloning identifies zebrafish one-eyed pinhead as a permissive EGF-related ligand required during gastrulation. Cell 1998;92(2):241–51.
Colas JF, Schoenwolf GC. Subtractive hybridization identifies chick-cripto, a novel EGF-CFC ortholog expressed during gastrulation, neurulation and early cardiogenesis. Gene 2000;255(2):205–17.
Schlange T, Schnipkoweit I, Andree B, et al. Chick CFC controls Lefty1 expression in the embryonic midline and nodal expression in the lateral plate. Dev Biol 2001;234(2):376–89.
Ding J, Yang L, Yan YT, et alet al. Cripto is required for correct orientation of the anterior-posterior axis in the mouse embryo. Nature 1998;395(6703):702–7.
Shen MM, Wang H, Leder P. A differential display strategy identifies Cryptic, a novel EGF-related gene expressed in the axial and lateral mesoderm during mouse gastrulation. Development 1997;124(2):429–42.
Ciccodicola A, Dono R, Obici S, Simeone A, Zollo M, Persico MG. Molecular characterization of a gene of the ‘EGF family’ expressed in undifferentiated human NTERA2 teratocarcinoma cells. EMBO J 1989;8(7):1987–91.
Bamford RN, Roessler E, Burdine RD, et alet al. Loss-of-function mutations in the EGF-CFC gene CFC1 are associated with human left-right laterality defects. Nat Genet 2000;26(3):365–9.
Shen MM. Nodal signaling: developmental roles and regulation. Development 2007;134(6):1023–34.
Duboc V, Rottinger E, Besnardeau L, Lepage T. Nodal and BMP2/4 signaling organizes the oral-aboral axis of the sea urchin embryo. Dev Cell 2004;6(3):397–410.
Minchiotti G, Manco G, Parisi S, Lago CT, Rosa F, Persico MG. Structure–function analysis of the EGF-CFC family member Cripto identifies residues essential for nodal signalling. Development 2001;128(22):4501–10.
Hentschke M, Kurth I, Borgmeyer U, Hubner CA. Germ cell nuclear factor is a repressor of CRIPTO-1 and CRIPTO-3. J Biol Chem 2006;281(44):33497–504.
Lohmeyer M, Harrison PM, Kannan S, et alet al. Chemical synthesis, structural modeling, and biological activity of the epidermal growth factor-like domain of human cripto. Biochemistry 1997;36(13):3837–45.
Seno M, DeSantis M, Kannan S, et alet al. Purification and characterization of a recombinant human cripto-1 protein. Growth Factors 1998;15(3):215–29.
Marasco D, Saporito A, Ponticelli S, et alet al. Chemical synthesis of mouse cripto CFC variants. Proteins 2006;64(3):779–88.
Foley SF, van Vlijmen HW, Boynton RE, et alet al. The CRIPTO/FRL-1/CRYPTIC (CFC) domain of human Cripto Functional and structural insights through disulfide structure analysis. Eur J Biochem 2003;270(17):3610–18.
Calvanese L, Saporito A, Marasco D, et alet al. Solution structure of mouse Cripto CFC domain and its inactive variant Trp107Ala. J Med Chem 2006;49(24):7054–62.
Schiffer SG, Foley S, Kaffashan A, et alet al. Fucosylation of Cripto is required for its ability to facilitate nodal signaling. J Biol Chem 2001;276(41):37769–78.
Shi S, Ge C, Luo Y, Hou X, Haltiwanger RS, Stanley P. The threonine that carries fucose, but not fucose, is required for Cripto to facilitate Nodal signaling. J Biol Chem 2007;282(28):20133–41.
Yan YT, Liu JJ, Luo Y, et alet al. Dual roles of Cripto as a ligand and coreceptor in the nodal signaling pathway. Mol Cell Biol 2002;22(13):4439–49.
Minchiotti G, Parisi S, Liguori G, et alet al. Membrane-anchorage of Cripto protein by glycosylphosphatidylinositol and its distribution during early mouse development. Mech Dev 2000;90(2):133–42.
Watanabe K, Bianco C, Strizzi L, et alet al. Growth factor induction of cripto-1 shedding by GPI-phospholipase D and enhancement of endothelial cell migration. J Biol Chem 2007;282(43):31643–55.
Watanabe K, Hamada S, Bianco C, et alet al. Requirement of glycosylphosphatidylinositol anchor of cripto-1 for ‘trans’ activity as a nodal co-receptor. J Biol Chem 2007;282(49):35772–86.
Rampal R, Luther KB, Haltiwanger RS. Notch signaling in normal and disease States: possible therapies related to glycosylation. Curr Mol Med 2007;7(4):427–45.
Rabbani SA, Mazar AP, Bernier SM, et alet al. Structural requirements for the growth factor activity of the amino-terminal domain of urokinase. J Biol Chem 1992;267(20):14151–6.
Joutel A, Corpechot C, Ducros A, et alet al. Notch3 mutations in CADASIL, a hereditary adult-onset condition causing stroke and dementia. Nature 1996;383(6602):707–10.
Bianco C, Strizzi L, Mancino M, et alet al. Regulation of Cripto-1 signaling and biological activity by Caveolin-1 in mammary epithelial cells. Am J Pathol 2008;172:345–357.
Parisi S, D’Andrea D, Lago CT, Adamson ED, Persico MG, Minchiotti G. Nodal-dependent Cripto signaling promotes cardiomyogenesis and redirects the neural fate of embryonic stem cells. J Cell Biol 2003;163(2):303–14.
Bianco C, Strizzi L, Rehman A, et al. A Nodal- and ALK4-independent signaling pathway activated by Cripto-1 through Glypican-1 and c-Src. Cancer Res 2003;63(6):1192–7.
Bianco C, Kannan S, De Santis M, et al. Cripto-1 indirectly stimulates the tyrosine phosphorylation of erb B-4 through a novel receptor. J Biol Chem 1999;274(13):8624–9.
Schier AF. Nodal signaling in vertebrate development. Annu Rev Cell Dev Biol 2003;19:589–621.
Cheng SK, Olale F, Bennett JT, Brivanlou AH, Schier AF. EGF-CFC proteins are essential coreceptors for the TGF-beta signals Vg1 and GDF1. Genes Dev 2003;17(1):31–6.
Chen C, Ware SM, Sato A, et alet al. The Vg1-related protein Gdf3 acts in a Nodal signaling pathway in the pre-gastrulation mouse embryo. Development 2006;133(2):319–29.
Andersson O, Bertolino P, Ibanez CF. Distinct and cooperative roles of mammalian Vg1 homologs GDF1 and GDF3 during early embryonic development. Dev Biol 2007;311(2):500–11.
Yeo C, Whitman M. Nodal signals to Smads through Cripto-dependent and Cripto-independent mechanisms. Mol Cell 2001;7(5):949–57.
Attisano L, Silvestri C, Izzi L, Labbe E. The transcriptional role of Smads and FAST (FoxH1) in TGFbeta and activin signalling. Mol Cell Endocrinol 2001;180(1–2):3–11.
Yamamoto M, Mine N, Mochida K, et alet al. Nodal signaling induces the midline barrier by activating Nodal expression in the lateral plate. Development 2003;130(9):1795–804.
Shen MM, Schier AF. The EGF-CFC gene family in vertebrate development. Trends Genet 2000;16(7):303–9.
Reissmann E, Jornvall H, Blokzijl A, et alet al. The orphan receptor ALK7 and the Activin receptor ALK4 mediate signaling by Nodal proteins during vertebrate development. Genes Dev 2001;15(15):2010–22.
Gray PC, Shani G, Aung K, Kelber J, Vale W. Cripto binds transforming growth factor beta (TGF-beta) and inhibits TGF-beta signaling. Mol Cell Biol 2006;26(24):9268–78.
Harms PW, Chang C. Tomoregulin-1 (TMEFF1) inhibits nodal signaling through direct binding to the nodal coreceptor Cripto. Genes Dev 2003;17(21):2624–9.
Tanegashima K, Haramoto Y, Yokota C, Takahashi S, Asashima M. Xantivin suppresses the activity of EGF-CFC genes to regulate nodal signaling. Int J Dev Biol 2004;48(4):275–83.
Uchida T, Wada K, Akamatsu T, et alet al. A novel epidermal growth factor-like molecule containing two follistatin modules stimulates tyrosine phosphorylation of erbB-4 in MKN28 gastric cancer cells. Biochem Biophys Res Commun 1999;266(2):593–602.
Cheng SK, Olale F, Brivanlou AH, Schier AF. Lefty blocks a subset of TGFbeta signals by antagonizing EGF-CFC coreceptors. PLoS Biol 2004;2(2):E30.
Chen C, Shen MM. Two modes by which Lefty proteins inhibit nodal signaling. Curr Biol 2004;14(7):618–24.
Adkins HB, Bianco C, Schiffer SG, et alet al. Antibody blockade of the Cripto CFC domain suppresses tumor cell growth in vivo. J Clin Invest 2003;112(4):575–87.
Gray PC, Harrison CA, Vale W. Cripto forms a complex with activin and type II activin receptors and can block activin signaling. Proc Natl Acad Sci USA 2003;100(9):5193–8.
Mancino M, Strizzi L, Wechselberger C, et alet al. Regulation of human cripto-1 gene expression by TGF-beta1 and BMP-4 in embryonal and colon cancer cells. J Cell Physiol 2008;215:192–203.
Shani G, Fischer WH, Justice NJ, Kelber JA, Vale W, Gray PC. GRP78 and Cripto form a complex at the cell surface and collaborate to inhibit TGF-β signaling and enhance cell growth. Mol Cell Biol 2008;28:666–677.
Li J, Lee AS. Stress induction of GRP78/BiP and its role in cancer. Curr Mol Med 2006;6(1):45–54.
Lee AS. GRP78 induction in cancer: therapeutic and prognostic implications. Cancer Res 2007;67(8):3496–9.
Lee E, Nichols P, Spicer D, Groshen S, Yu MC, Lee AS. GRP78 as a novel predictor of responsiveness to chemotherapy in breast cancer. Cancer Res 2006;66(16):7849–53.
De Santis ML, Kannan S, Smith GH, et alet al. Cripto-1 inhibits beta-casein expression in mammary epithelial cells through a p21ras-and phosphatidylinositol 3′-kinase-dependent pathway. Cell Growth Differ 1997;8(12):1257–66.
Ebert AD, Wechselberger C, Frank S, et al. Cripto-1 induces phosphatidylinositol 3′-kinase-dependent phosphorylation of AKT and glycogen synthase kinase 3beta in human cervical carcinoma cells. Cancer Res 1999;59(18):4502–5.
Bianco C, Normanno N, De Luca A, et al. Detection and localization of Cripto-1 binding in mouse mammary epithelial cells and in the mouse mammary gland using an immunoglobulin-cripto-1 fusion protein. J Cell Physiol 2002;190(1):74–82.
Bianco C, Adkins HB, Wechselberger C, et al. Cripto-1 activates nodal- and ALK4-dependent and -independent signaling pathways in mammary epithelial Cells. Mol Cell Biol 2002;22(8):2586–97.
Morkel M, Huelsken J, Wakamiya M, et al. Beta-catenin regulates Cripto- and Wnt3-dependent gene expression programs in mouse axis and mesoderm formation. Development 2003;130(25):6283–94.
Hamada S, Watanabe K, Hirota M, et al. beta-Catenin/TCF/LEF regulate expression of the short form human Cripto-1. Biochem Biophys Res Commun 2007;355(1):240–4.
Segditsas S, Tomlinson I. Colorectal cancer and genetic alterations in the Wnt pathway. Oncogene 2006;25(57):7531–7.
Tao Q, Yokota C, Puck H, et al. Maternal wnt11 activates the canonical wnt signaling pathway required for axis formation in Xenopus embryos. Cell 2005;120(6):857–71.
Zamparini AL, Watts T, Gardner CE, Tomlinson SR, Johnston GI, Brickman JM. Hex acts with beta-catenin to regulate anteroposterior patterning via a Groucho-related co-repressor and Nodal. Development 2006;133(18):3709–22.
Krebs LT, Iwai N, Nonaka S, et al. Notch signaling regulates left-right asymmetry determination by inducing Nodal expression. Genes Dev 2003;17(10):1207–12.
Dono R, Scalera L, Pacifico F, Acampora D, Persico MG, Simeone A. The murine cripto gene: expression during mesoderm induction and early heart morphogenesis. Development 1993;118(4):1157–68.
Johnson SE, Rothstein JL, Knowles BB. Expression of epidermal growth factor family gene members in early mouse development. Dev Dyn 1994;201(3):216–26.
Xu C, Liguori G, Persico MG, Adamson ED. Abrogation of the Cripto gene in mouse leads to failure of postgastrulation morphogenesis and lack of differentiation of cardiomyocytes. Development 1999;126(3):483–94.
Gritsman K, Zhang J, Cheng S, Heckscher E, Talbot WS, Schier AF. The EGF-CFC protein one-eyed pinhead is essential for nodal signaling. Cell 1999;97(1):121–32.
Schier AF, Shen MM. Nodal signalling in vertebrate development. Nature 2000;403(6768):385–9.
Warga RM, Kane DA. One-eyed pinhead regulates cell motility independent of Squint/Cyclops signaling. Dev Biol 2003;261(2):391–411.
Yan YT, Gritsman K, Ding J, et al. Conserved requirement for EGF-CFC genes in vertebrate left-right axis formation. Genes Dev 1999;13(19):2527–37.
Saijoh Y, Adachi H, Sakuma R, et al. Left-right asymmetric expression of lefty2 and nodal is induced by a signaling pathway that includes the transcription factor FAST2. Mol Cell 2000;5(1):35–47.
Gaio U, Schweickert A, Fischer A, et al. A role of the cryptic gene in the correct establishment of the left-right axis. Curr Biol 1999;9(22):1339–42.
Schier AF, Talbot WS. Nodal signaling and the zebrafish organizer. Int J Dev Biol 2001;45(1):289–97.
de la Cruz JM, Bamford RN, Burdine RD, et al. A loss-of-function mutation in the CFC domain of TDGF1 is associated with human forebrain defects. Hum Genet 2002;110(5):422–8.
Kenney NJ, Huang RP, Johnson GR, et al. Detection and location of amphiregulin and Cripto-1 expression in the developing postnatal mouse mammary gland. Mol Reprod Dev 1995;41(3):277–86.
Kenney NJ, Adkins HB, Sanicola M. Nodal and cripto-1: embryonic pattern formation genes involved in mammary gland development and tumorigenesis. J Mammary Gland Biol Neoplasia 2004;9(2):133–44.
Bianco C, Wechselberger C, Ebert A, Khan NI, Sun Y, Salomon DS. Identification of Cripto-1 in human milk. Breast Cancer Res Treat 2001;66(1):1–7.
Brandt R, Normanno N, Gullick WJ, et al. Identification and biological characterization of an epidermal growth factor-related protein: cripto-1. J Biol Chem 1994;269(25):17320–8.
Ciardiello F, Dono R, Kim N, Persico MG, Salomon DS. Expression of cripto, a novel gene of the epidermal growth factor gene family, leads to in vitro transformation of a normal mouse mammary epithelial cell line. Cancer Res 1991;51(3):1051–4.
Kenney N, Smith G, Johnson M, Rosemberg K, Salomon DS, Dickson R. Cripto-1 activity in the intact and ovariectomized virgin mouse mammary gland. Pathogenesis 1997;1:57–71.
Normanno N, De Luca A, Bianco C, et al. Cripto-1 overexpression leads to enhanced invasiveness and resistance to anoikis in human MCF-7 breast cancer cells. J Cell Physiol 2004;198(1):31–9.
Thiery JP, Chopin D. Epithelial cell plasticity in development and tumor progression. Cancer Metastasis Rev 1999;18(1):31–42.
Wechselberger C, Strizzi L, Kenney N, et al. Human Cripto-1 overexpression in the mouse mammary gland results in the development of hyperplasia and adenocarcinoma. Oncogene 2005;24(25):4094–105.
Strizzi L, Bianco C, Normanno N, et al. Epithelial mesenchymal transition is a characteristic of hyperplasias and tumors in mammary gland from MMTV-Cripto-1 transgenic mice. J Cell Physiol 2004;201(2):266–76.
Thiery JP. Epithelial-mesenchymal transitions in tumour progression. Nat Rev Cancer 2002;2(6):442–54.
Henderson BR, Fagotto F. The ins and outs of APC and beta-catenin nuclear transport. EMBO Rep 2002;3(9):834–9.
Sun Y, Strizzi L, Raafat A, et al. Overexpression of human Cripto-1 in transgenic mice delays mammary gland development and differentiation and induces mammary tumorigenesis. Am J Pathol 2005;167(2):585–97.
Miyoshi K, Rosner A, Nozawa M, et al. Activation of different Wnt/beta-catenin signaling components in mammary epithelium induces transdifferentiation and the formation of pilar tumors. Oncogene 2002;21(36):5548–56.
Miyoshi K, Shillingford JM, Le Provost F, et al. Activation of beta-catenin signaling in differentiated mammary secretory cells induces transdifferentiation into epidermis and squamous metaplasias. Proc Natl Acad Sci USA 2002;99(1):219–24.
Polakis P. Wnt signaling and cancer. Genes Dev 2000;14(15):1837–51.
Normanno N, Kim N, Wen D, et al. Expression of messenger RNA for amphiregulin, heregulin, and cripto-1, three new members of the epidermal growth factor family, in human breast carcinomas. Breast Cancer Res Treat 1995;35(3):293–7.
Dublin EA, Bobrow LG, Barnes DM, Gullick WJ. Amphiregulin and cripto-1 overexpression in breast cancer: relationship with prognosis and clinical and molecular variables. Int J Oncol 1995;7:617–22.
Panico L, D’Antonio A, Salvatore G, et al. Differential immunohistochemical detection of transforming growth factor alpha, amphiregulin and CRIPTO in human normal and malignant breast tissues. Int J Cancer 1996;65(1):51–6.
Qi CF, Liscia DS, Normanno N, et al. Expression of transforming growth factor alpha, amphiregulin and cripto-1 in human breast carcinomas. Br J Cancer 1994;69(5):903–10.
Gong YP, Yarrow PM, Carmalt HL, et al. Overexpression of Cripto and its prognostic significance in breast cancer: a study with long-term survival. Eur J Surg Oncol 2007;33(4):438–43.
Carmalt HL, Gong YP, Yarrow PM, Lin BP, Xing PX, Gillett DJ. Bs10 the prognostic significance of the overexpression of the growth factor cripto in patients with breast cancer. ANZ J Surg 2007;77 Suppl 1:A3.
Srinivasan R, Gillett CE, Barnes DM, Gullick WJ. Nuclear expression of the c-erbB-4/HER-4 growth factor receptor in invasive breast cancers. Cancer Res 2000;60(6):1483–7.
Bianco C, Strizzi L, Mancino M, et al. Identification of cripto-1 as a novel serologic marker for breast and colon cancer. Clin Cancer Res 2006;12(17):5158–64.
Zeisberg M, Kalluri R. The role of epithelial-to-mesenchymal transition in renal fibrosis. J Mol Med 2004;82(3):175–81.
Willis BC, Liebler JM, Luby-Phelps K, et al. Induction of epithelial-mesenchymal transition in alveolar epithelial cells by transforming growth factor-beta1: potential role in idiopathic pulmonary fibrosis. Am J Pathol 2005;166(5):1321–32.
Liu Y. Epithelial to mesenchymal transition in renal fibrogenesis: pathologic significance, molecular mechanism, and therapeutic intervention. J Am Soc Nephrol 2004;15(1):1–12.
Strizzi L, Bianco C, Raafat A, et al. Netrin-1 regulates invasion and migration of mouse mammary epithelial cells overexpressing Cripto-1 in vitro and in vivo. J Cell Sci 2005;118 (Part 20):4633–43.
Normanno N, Bianco C, Damiano V, et al. Growth inhibition of human colon carcinoma cells by combinations of anti-epidermal growth factor-related growth factor antisense oligonucleotides. Clin Cancer Res 1996;2(3):601–9.
Hu XF, Xing PX. Cripto as a target for cancer immunotherapy. Expert Opin Ther Targets 2005;9(2):383–94.
De Luca A, Casamassimi A, Selvam MP, et al. EGF-related peptides are involved in the proliferation and survival of MDA-MB-468 human breast carcinoma cells. Int J Cancer 1999;80(4):589–94.
Casamassimi A, De Luca A, Agrawal S, Stromberg K, Salomon DS, Normanno N. EGF-related antisense oligonucleotides inhibit the proliferation of human ovarian carcinoma cells. Ann Oncol 2000;11(3):319–25.
De Luca A, Arra C, D’Antonio A, et al. Simultaneous blockage of different EGF-like growth factors results in efficient growth inhibition of human colon carcinoma xenografts. Oncogene 2000;19(51):5863–71.
Normanno N, De Luca A, Maiello MR, Bianco C, Mancino M, Strizzi L, Arra C, Ciardiello F, Agrawal S, Salomon DS. Cripto-1: a novel target for therapeutic intervention in human carcinoma. Int J Oncol 2004;25(4):1013–20.
Bianco C, Strizzi L, Ebert A, Chang C, Rehman A, Normanno N, Guedez L, Salloum R, Ginsburg E, Sun Y, Khan N, Hirota M, Wallace-Jones B, Wechselberger C, Vonderhaar BK, Tosato G, Stetler-Stevenson WG, Sanicola M, Salomon DS. Role of human cripto-1 in tumor angiogenesis. J Natl Cancer Inst 2005;97(2):132–41.
Xing PX, Hu XF, Pietersz GA, Hosick HL, McKenzie IF. Cripto: a novel target for antibody-based cancer immunotherapy. Cancer Res 2004;64(11):4018–23.
Hu XF, Li J, Yang E, Vandervalk S, Xing PX. Anti-Cripto Mab inhibit tumour growth and overcome MDR in a human leukaemia MDR cell line by inhibition of Akt and activation of JNK/SAPK and bad death pathways. Br J Cancer 2007;96(6):918–27.
Topczewska JM, Postovit LM, Margaryan NV, Sam A, Hess AR, Wheaton WW, Nickoloff BJ, Topczewski J, Hendrix MJ. Embryonic and tumorigenic pathways converge via Nodal signaling: role in melanoma aggressiveness. Nat Med 2006;12(8):925–32.
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Strizzi, L., Watanabe, K., Mancino, M., Salomon, D.S., Bianco, C. (2009). Role of the EGF-CFC Family in Mammary Gland Development and Neoplasia. In: Giordano, A., Normanno, N. (eds) Breast Cancer in the Post-Genomic Era. Current Clinical Oncology. Humana Press. https://doi.org/10.1007/978-1-60327-945-1_6
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