Review

Role of Macrophage Inhibitory Cytokine-1 in Tumorigenesis

and Diagnosis of Cancer
Asne R. Bauskin, David A. Brown, Tamara Kuffner, Heiko Johnen, X. Wei Luo,
Mark Hunter, and Samuel N. Breit
Centre for Immunology, St. Vincents Hospital and University of New South Wales, Sydney, Australia

Abstract
Macrophage inhibitory cytokine-1 (MIC-1), a transforming
growth factor-B superfamily cytokine, is involved in tumor
pathogenesis, and its measurement can be used as a clinical
tool for the diagnosis and management of a wide range of
cancers. Although generally considered to be part of the cells
antitumorigenic repertoire, MIC-1 secretion, processing, and
latent storage suggest a complex, dynamic variability in MIC-1
bioavailability in the tumor microenvironment, potentially
modulating tumor progression and invasiveness. (Cancer Res
2006; 66(10): 4983-6)

Introduction
In 1997, we first reported a novel divergent member of the
human transforming growth factor-h (TGF-h) superfamily, cloned
based on increased expression in macrophage activation, which we
named macrophage inhibitory cytokine-1 (MIC-1; refs. 1, 2).
Between 1997 and 2004, it was reported by other groups and given
a variety of names, including PTGF-h, PLAB, GDF15, PDF, NAG-1,
and PL74. The placenta is the only tissue that expresses large
amounts of MIC-1 under normal physiologic conditions (2).
However, a wide variety of epithelial cells, including the neuroepithelium express low levels of MIC-1 mRNA. Although detectible
by immunohistochemistry in central nervous system epithelium,
such as the choroid plexus and ependyma and the placenta, MIC-1
protein has been difficult to detect at other sites (3).1 In disease
states, such as acute injury, inflammation, and cancer, MIC-1
expression is dramatically increased (2, 4, 5) and has been
implicated as a key secretory cytokine in response to multiple
cellular stressors.

MIC-1 Expression in the Antitumorigenic Response

MIC-1 overexpression by multiple tumor types coincided with
the finding that p53 powerfully induced MIC-1 expression both
in vitro and in vivo (68). Mouse xenograft studies show that
measurement of circulating tumor-derived MIC-1 is a good in
vivo index of p53 pathway activation, a strategy that could be
used to assess therapies affecting p53 pathway activation (7).
MIC-1, being one of the major secreted proteins induced by p53,
is not surprisingly thought to be important in translating p53mediated activity. Indeed, several studies show MIC-1 induction

being associated with cell cycle arrest and apoptosis. In colon

carcinoma cell lines, MIC-1 overexpression correlates with
apoptosis, whereas the addition of WR1065, which leads to
p53 dependent cell cycle arrest, also strongly up-regulates
MIC-1 expression. p53 is not the only transcription factor
regulating MIC-1 expression. Other transcription factors, such as
Egr-1 and nuclear factor-nB, have also been implicated in this
process (9). Indeed, these and other factors are likely to
predominate in MIC-1 induction in p53 mutant tumors overexpressing MIC-1.
Acting largely through p53- and/or Egr-1-related pathways, the
groups of Ehling and Baek (9, 10) have shown that MIC-1
expression can be stimulated in cancer cell lines by a variety of
antitumorigenic agents, such as the nonsteroidal anti-inflammatory drugs (NSAID), peroxisome proliferator-activated receptor g
ligands, and genistein. Additionally, dietary compounds associated
with neoplastic cell growth suppression, including retinoids,
resveratrol, green tea catechins, cruciferous vegetable indole-3carbinol, and diallyl disulfide, a constituent of garlic, all induced
MIC-1 (Fig. 1). Further suggestive of a role for MIC-1 in
antitumorigenic mechanisms are a variety of studies linking
induction of MIC-1 expression with decreased cell proliferation
and altered cell survival (10, 11). Strong induction of MIC-1 occurs
following modulation of cell signaling pathways, leading to
inhibition of cell proliferation. These include inhibition of the
phosphatidylinositol 3-kinase/AKT/glycogen synthase kinase-3h
pathway in HCT 116 colorectal carcinoma cells and overexpression
of a constitutively active TGFhRI receptor in microvascular
endothelial cells, both of which inhibit cell proliferation. In a
synovial sarcoma line, knockdown of the SYT-SSX fusion gene,
critical in sarcoma development and progression, strongly
increased MIC-1 expression, whereas up-regulation of MIC-1 in
an Hsp70-2 knockout breast cancer line was thought to be the
mediator of the resultant G1 cell cycle arrest. Interestingly,
Affymetrix Genechip analysis following neoadjuvant chemotherapy
of breast cancer patients shows major up-regulation of MIC-1 (12).
However, MIC-1 expression may also play a role in the antiestrogen-resistant growth of estrogen receptor (ER)positive breast
tumors (13). Here, overexpression of AKT, which activates the ER in
the absence of estrogen, strongly induced expression of MIC-1,
together with other estrogen-regulated genes pS2 and Bcl-2. This
conferred resistance to tamoxifen-induced apoptosis, suggesting
that the context in which MIC-1 is up-regulated will dictate its final
role. Indeed, this is true for many members of the TGF-h
superfamily, where the effects of expression in tumors are often
context specific.

Requests for reprints: Samuel N. Breit and Asne R. Bauskin, Centre for
Immunology, St. Vincents Hospital, Sydney, New South Wales, Australia. Phone: 6128382-3700; Fax: 612-8382-2830; E-mail: a.bauskin@cfi.unsw.edu.au; s.breit@cfi.unsw.
edu.au.
I2006 American Association for Cancer Research.
doi:10.1158/0008-5472.CAN-05-4067

www.aacrjournals.org

4983

Unpublished observation.

Cancer Res 2006; 66: (10). May 15, 2006

Downloaded from cancerres.aacrjournals.org on March 26, 2015. 2006 American Association for Cancer
Research.

Cancer Research

Figure 1. MIC-1 in tumorigenesis. Under normal resting conditions, in epithelial cells, there is little or no detectable expression of MIC-1. However, with neoplastic
transformation, the level of MIC-1 expression rises dramatically, and this is further increased by the tumor response to a variety of antitumorigenic stimuli, such as
gamma irradiation, cytotoxic drugs, NSAIDs, etc. In early-stage cancer, this may lead to tumor cell apoptosis, inhibition of blood vessel formation, and tumor cell
cycle arrest. In late-stage cancer, MIC-1 may aid in tumor dissemination, and high serum levels of MIC-1 may lead to other systemic effects. MIC-1 bioavailability in
the tumor microenvironment is further regulated by the creation of latent stromal stores of unprocessed proMIC-1, which is commonly secreted in varying degrees
from different tumors. Only unprocessed proMIC-1 binds extracellular matrix, whereas processed mature MIC-1 is freely soluble in the tumor stroma and can move into
the blood vessel. Thus, the level of both intracellular and extracellular processing will dictate the level of bioavailable MIC-1.

MIC-1 Expression in Cancer

As well as being induced by antitumorigenic compounds, MIC-1
is overexpressed in many tumors. Many carcinoma lines secrete
large amounts of MIC-1 (14) and multiple, independent differential
expression studies (microarray and SAGE; refs. 4, 15) show MIC-1
expression is markedly increased in prostate and colon cancer
biopsies. We have also confirmed that patients with metastatic
prostate, breast, and colon cancer markedly overexpressed MIC-1
protein within tumors, and that this resulted in a large increase in
serum MIC-1 levels (4). More recent studies indicate similar results
for melanoma, pancreatic, and thyroid cancer (15, 16). Of these,
prostate cancer has been the most extensively studied with MIC-1
overexpression documented in all (17, 18) but one study. Overall,
these changes in expression suggested the use of measuring MIC-1
expression in the diagnosis and management of the disease.

Serum MIC-1 as a Clinical Tool

Increased tissue expression of MIC-1 is often associated with
serum levels outside the reference range of about 200 to 1,200 pg/
mL. Studies of serum MIC-1 levels in several cohorts of patients

Cancer Res 2006; 66: (10). May 15, 2006

have revealed potential clinical use in the diagnosis and/or

monitoring of prostate, thyroid, pancreatic, and colonic cancers.
In colon cancer, there are significant increases in serum MIC-1
levels with disease progression from normal to adenoma,
carcinoma, and metastatic disease (19). In colon cancer, MIC-1
serum levels reflect tumor stage and extent, and measurement at
presentation is an independent predictor of metastasis and overall
survival (19).
Pancreatic cancer is usually an occult disease, often leading to
late diagnosis and poor survival. Historically, tumor markers have
been unhelpful. However, measurement in serum of a combination of MIC-1 with CA19-9 significantly improved the diagnosis of
pancreatic cancer leading to a sensitivity of 70% and specificity of
85%. Interestingly, whereas patients with pancreatic ductal
adenocarcinoma had significantly higher levels of MIC-1 than
those with chronic pancreatitis or healthy controls, patients with
early disease had the highest serum MIC-1 levels. This may offer
hope for monitoring patients at higher risk of pancreatic cancer
development (16).
In prostate cancer, serum MIC-1 levels combined with total and
free prostate-specific antigen measurement significantly improves

4984

www.aacrjournals.org

Downloaded from cancerres.aacrjournals.org on March 26, 2015. 2006 American Association for Cancer
Research.

MIC-1 in Cancer

diagnostic specificity and is potentially useful for the monitoring

of disease progression (20). It is also possible that serial serum
MIC-1 levels will be useful for the detection of higher grade
prostate malignancy, missed due to biopsy sampling error and to
indicate when patients treated with watchful waiting are at risk
of disease progression. As serum levels of MIC-1 tend to be stable
over time in otherwise healthy individuals,2 and MIC-1 is
overexpressed in a wide variety of tumors, it is quite likely that,
at least in at risk populations, serial measurement of MIC-1 may
provide an early warning of the development of a premalignant or
malignant lesion.

MIC-1 Polymorphism and Cancer

Further linking MIC-1 to cancer biology was the finding of a
single nucleotide polymorphism in the MIC-1 coding region that
significantly affected both on predisposition to cancer and patient
survival. This polymorphism results in the change of a histadine
(H) to an aspartic acid (D) residue at position 6 of the mature
MIC-1 protein (19, 21). The MIC-1 D allele of the H6D
polymorphism is associated with significantly better patient
survival in a cohort of about 200 patients with colon cancer
(19). In contrast, the presence of the H allele leads to an
increased risk of prostate cancer, contributing to 7.2% of sporadic
and 19.2% of familial prostate cancer cases in a Swedish study of
1383 patients and 700 controls (21). The presence of this
polymorphism in the coding region of mature MIC-1, resulting
in amino acids with divergent properties, suggests a functional
alteration in protein rather than linkage disequilibrium with other
genes.

Role of MIC-1 in Tumor Development

Although there is strong linkage of MIC-1 expression to
epithelial tumors, less is known about its role and the manner
in which it exerts its effect. Most studies point to an
antitumorigenic role for MIC-1. In particular, a number of reports
suggest a role in induction of apoptosis via both p53-dependent
and p53-independent mechanisms. MIC-1 overexpression in HCT116 colon and MDA-MB-468 breast carcinoma lines resulted in
reduction in cell viability, and nude mice xenograft models of the
HCT-116 transfectants showed a significant reduction in tumor
size (6, 22). These findings suggest that MIC-1 may negatively
affect tumor growth. Interestingly, a similar study using a
glioblastoma cell line, which unlike the HCT-116 line, was
unresponsive to MIC-1 in vitro, completely failed to grow as a
tumor xenograft in nude mice when transfected with MIC-1 (8).
This suggests MIC-1 has significant paracrine effects, which
modulate the tumor environment. Further supporting a role for
MIC-1 in the development and evolution of tumors is data
showing that MIC-1 has antiangiogenic activity both in vitro and
in vivo (23).
Recent studies shed light on the possible mechanisms of tumor
growth modulation. MIC-1 inhibits the expression of the cyclin D1
oncogene that promotes breast and other solid tumors (24).
Additionally, inhibition of MIC-1 expression with small interfering
RNA prevented NSAID-induced cell cycle arrest of ovarian cancer
cells, in part by down-regulation of p21WAF1 (25). Our studies,

using DU-145 prostate cancer cells treated with recombinant

MIC-1, show loss of adhesion and induction of apoptosis
mediated by a reduction in the expression of antiapoptotic gene
metallothionein 1E and genes RhoE and catenin d1. The latter two,
being involved in cell adhesion, may also point to a possible role
in tumor dissemination (14).
Adding to the potential of MIC-1 as a tumorigenic protagonist
is the finding that higher MIC-1 expression in gastric cancer cell
lines has been associated with a more invasive phenotype. This
seems to be due to MIC-1 increasing expression of the urokinase
type plasminogen activator (uPA) and the uPA receptor, an effect
mediated through extracellular signal-regulated kinase 1/2 (ERK1/
2; ref. 26). Thus, whereas most studies highlight an antitumorigenic role for MIC-1, these suggest that this may not always be
the case. Such apparently contradictory effects are typical of
TGF-h and are mediated by a variety of factors including the
nature of the tumor and its environment. Furthermore, tumor
progression is often associated with accumulated genetic alterations that can erode its sensitivity to pro-apoptotic molecules.
Thus, it is possible that overexpression of MIC-1 in early cancer
induces apoptotic or other pathways that serve to limit tumor
growth (Fig. 1).
Adding another level of complexity to its role in tumor
development is the finding that MIC-1 is commonly secreted
from tumors in its unprocessed, propeptide containing precursor
form, with the degree of processing varying widely from tumor
to tumor. The MIC-1 propeptide mediates binding to extracellular matrix, creating latent stromal stores of proMIC-1.
Intracellular processing of MIC-1, thus, ultimately determines
the proportion of MIC-1 that remains localized in the tumor
microenvironment versus that diffusing into the systemic
circulation. The biological relevance of these latent stromal
stores to tumor progression was highlighted when examination
of a prostate cancer tissue array revealed considerable patient
variability in the degree of stromal staining. Decreasing tumor
stromal staining for proMIC-1 was an important independent
predictor of disease relapse (27). As unprocessed proMIC-1 is
secreted by tumors other than prostate, it seems likely that
modulating local MIC-1 bioavailability will affect patient
outcome not only in prostate cancer but also other epithelial
tumors.
A lot remains to be uncovered on the roles of MIC-1 and its
biology, and whereas the evidence linking MIC-1 with cancer is
compelling, it is still incomplete. Its receptor is unknown, and its
signaling pathways are as yet to be delineated. Activation of Akt
and ERK pathways has been reported, and there is some
evidence for SMAD pathway activation, suggesting MIC-1 may
act through a TGF-h superfamily receptor. The effects of MIC-1
can sometimes be apparently contradictory, and in differing
circumstances, MIC-1 can exhibit tumorigenic and antitumorigenic activity. More recent studies suggest that this is very likely
a function of the tumor stage, tissue of origin, and the
interaction of the tumor with its local microenvironment.
However, what is clear, is that there is strong evidence for
MIC-1 measurement in blood and tissues to detect and monitor
cancer.

Acknowledgments
2

Unpublished observations.

www.aacrjournals.org

Received 11/21/2005; revised 2/14/2006; accepted 3/2/2006.

Our apologies to all those authors whose work has been invaluable in compiling
this review and could not be cited due to editorial guidelines.

4985

Cancer Res 2006; 66: (10). May 15, 2006

Downloaded from cancerres.aacrjournals.org on March 26, 2015. 2006 American Association for Cancer
Research.

Cancer Research

References
1. Bootcov MR, Bauskin AR, Valenzuela SM, et al. MIC-1,
a novel macrophage inhibitory cytokine, is a divergent
member of the TGF-beta superfamily cluster. Proc Natl
Acad Sci U S A 1997;94:115149.
2. Fairlie WD, Moore AG, Bauskin AR, Russell PK, Zhang
H-P, Breit SN. MIC-1 is a novel TGF-h superfamily
cytokine associated with macrophage activation.
J Leukocyte Biol 1999;65:25.
3. Bottner M, Suter-Crazzolara C, Schober A, Unsicker K.
Expression of a novel member of the TGF-beta
superfamily, growth/differentiation factor-15/macrophage-inhibiting cytokine-1 (GDF-15/MIC-1) in adult
rat tissues. Cell Tissue Res 1999;297:10310.
4. Welsh JB, Sapinoso LM, Kern SG, et al. Large-scale
delineation of secreted protein biomarkers overexpressed in cancer tissue and serum. Proc Natl Acad
Sci U S A 2003;100:34105.
5. Schober A, Bottner M, Strelau J, et al. Expression of
growth differentiation factor-15/macrophage inhibitory
cytokine-1 (GDF-15/MIC-1) in the perinatal, adult, and
injured rat brain. J Comp Neurol 2001;439:3245.
6. Li PX, Wong J, Ayed A, et al. Placental transforming
growth factor-beta is a downstream mediator of the
growth arrest and apoptotic response of tumor cells to
DNA damage and p53 overexpression. J Biol Chem 2000;
75:2012735.
7. Yang H, Filipovic Z, Brown D, Breit SN, Vassilev LT.
Macrophage inhibitory cytokine-1: a novel biomarker for
p53 pathway activation. Mol Cancer Ther 2003;2:10239.
8. Albertoni M, Shaw PH, Nozaki M, et al. Anoxia induces
macrophage inhibitory cytokine-1 (MIC-1) in glioblastoma cells independently of p53 and HIF-1. Oncogene
2002;21:42129.
9. Baek SJ, Kim JS, Moore SM, Lee SH, Martinez J, Eling
TE. Cyclooxygenase inhibitors induce the expression of
the tumor suppressor gene EGR-1, which results in the
up-regulation of NAG-1, an antitumorigenic protein.
Mol Pharmacol 2005;67:35664.

Cancer Res 2006; 66: (10). May 15, 2006

10. Yamaguchi K, Lee SH, Eling TE, Baek SJ. Identification of nonsteroidal anti-inflammatory drug-activated gene (NAG-1) as a novel downstream target of
phosphatidylinositol 3-kinase/AKT/GSK-3beta pathway.
J Biol Chem 2004;279:4961723.
11. Lamouille S, Mallet C, Feige JJ, Bailly S. Activin
receptor-like kinase 1 is implicated in the
maturation phase of angiogenesis. Blood 2002;100:
4495501.
12. Modlich O, Prisack HB, Munnes M, Audretsch W,
Bojar H. Immediate gene expression changes after the
first course of neoadjuvant chemotherapy in patients
with primary breast cancer disease. Clin Cancer Res
2004;10:641831.
13. Campbell RA, Bhat-Nakshatri P, Patel NM, Constantinidou D, Ali S, Nakshatri H. Phosphatidylinositol 3kinase/AKT-mediated activation of estrogen receptor
alpha: a new model for anti-estrogen resistance. J Biol
Chem 2001;276:981724.
14. Liu T, Bauskin AR, Zaunders J, et al. MIC-1 reduces
cell adhesion and induces apoptosis in prostate cancer
cells. Cancer Res 2003;63:503440.
15. de Wit NJ, Rijntjes J, Diepstra JH, et al. Analysis of
differential gene expression in human melanocytic
tumour lesions by custom made oligonucleotide arrays.
Br J Cancer 2005;92:224961.
16. Koopmann J, Buckhaults P, Brown DA, et al. Serum
macrophage inhibitory cytokine 1 as a marker of pancreatic and other periampullary cancers. Clin Cancer
Res 2004;10:238692.
17. Nakamura T, Scorilas A, Stephan C, et al. Quantitative
analysis of macrophage inhibitory cytokine-1 (MIC-1)
gene expression in human prostatic tissues. Br J Cancer
2003;88:11014.
18. Cheung PK, Woolcock B, Adomat H, et al. Protein
profiling of microdissected prostate tissue links growth
differentiation factor 15 to prostate carcinogenesis.
Cancer Res 2004;64:592933.
19. Brown DA, Ward RL, Buckhaults P, et al. MIC-1
serum level and genotype: associations with progress

4986

and prognosis of colorectal carcinoma. Clinical Cancer

Res 2003;9:264250.
20. Brown DA, Stephan C, Ward RL, et al. Serum
marcrophage inhibitory cytokine-1 (MIC-1) levels for
the diagnosis of prostate cancer. Clinical Cancer Res
2006;12:8996.
21. Lindmark F, Zheng SL, Wiklund F, et al. H6D
polymorphism in macrophage-inhibitory cytokine-1
gene associated with prostate cancer. J Natl Cancer Inst
2004;96:124854.
22. Baek SJ, Kim KS, Nixon JB, Wilson LC, Eling TE.
Cyclooxygenase inhibitors regulate the expression of a
TGF-beta superfamily member that has proapoptotic
and antitumorigenic activities. Mol Pharmacol 2001;59:
9018.
23. Ferrari N, Pfeffer U, DellEva R, Ambrosini C, Noonan
DM, Albini A. The transforming growth factor-beta
family members bone morphogenetic protein-2 and
macrophage inhibitory cytokine-1 as mediators of the
antiangiogenic activity of N -(4-hydroxyphenyl)retinamide. Clin Cancer Res 2005;11:46109.
24. Graichen R, Liu D, Sun Y, Lee KO, Lobie PE.
Autocrine human growth hormone inhibits placental
transforming growth factor-beta gene transcription to
prevent apoptosis and allow cell cycle progression of
human mammary carcinoma cells. J Biol Chem 2002;
277:2666272.
25. Kim JS, Baek SJ, Sali T, Eling TE. The conventional
nonsteroidal anti-inflammatory drug sulindac sulfide
arrests ovarian cancer cell growth via the expression
of NAG-1/MIC-1/GDF-15. Mol Cancer Ther 2005;4:
48793.
26. Lee DH, Yang Y, Lee SJ, et al. Macrophage inhibitory
cytokine-1 induces the invasiveness of gastric cancer
cells by up-regulating the urokinase-type plasminogen
activator system. Cancer Res 2003;63:464855.
27. Bauskin AR, Brown DA, Junankar S, et al. The
propeptide mediates formation of stromal stores of
PROMIC-1: role in determining prostate cancer outcome. Cancer Res 2005;15:65:23306.

www.aacrjournals.org

Downloaded from cancerres.aacrjournals.org on March 26, 2015. 2006 American Association for Cancer
Research.

Role of Macrophage Inhibitory Cytokine-1 in Tumorigenesis

and Diagnosis of Cancer
Asne R. Bauskin, David A. Brown, Tamara Kuffner, et al.
Cancer Res 2006;66:4983-4986.

Updated version

Access the most recent version of this article at:

http://cancerres.aacrjournals.org/content/66/10/4983

Cited Articles

This article cites by 25 articles, 20 of which you can access for free at:
http://cancerres.aacrjournals.org/content/66/10/4983.full.html#ref-list-1

Citing articles

This article has been cited by 23 HighWire-hosted articles. Access the articles at:
http://cancerres.aacrjournals.org/content/66/10/4983.full.html#related-urls

E-mail alerts
Reprints and
Subscriptions
Permissions

Sign up to receive free email-alerts related to this article or journal.

To order reprints of this article or to subscribe to the journal, contact the AACR Publications
Department at pubs@aacr.org.
To request permission to re-use all or part of this article, contact the AACR Publications
Department at permissions@aacr.org.

Downloaded from cancerres.aacrjournals.org on March 26, 2015. 2006 American Association for Cancer
Research.