Cancer: From Genomics to Pharmaceutics

42 EXOSOMES IN CANCER DEVELOPMENT AND METASTASIS2. Lung Cancer and ExosomesLung cancer continues to be the top cause of cancer-related death globally despiteimprovements in our knowledge of risk, development, immunological control, and therapeuticchoices (98, 99). When cancer cells have moved to new organs, typically through thebloodstream or lymphatic systems, metastatic disease is a primary cause of death in lung cancerpatients (40). The metastatic process involves a number of stages, with a few released tumorcells completing the whole mechanism, from the original preliminary tumor growth throughthe development of new blood vessels and intravasation through survival, extravasation, andmetastatic spread in the bloodstream (40). Discovering the pathways by which tumor cellsconnect to the environment may aid in the finding of important molecules such as biologicalindicators or possible therapeutic targets because exosomes and their cargo are involved ineach of these phases in order to guarantee effective invasion and movement of the tumor (100,101).Intermediaries act a crucial part in the development and restructuring of the lung cancerenvironment by promoting immunity cell escape, EMT, and angiogenesis with the goal ofenhancing lung cancer cells’ capacity for metastasis (40).Since lung cancer has a high mortality rate, few effective treatments are available, andthe disease has a poor 5-year survival probability, the illness is typically detected when ithas advanced (40). Consequently, a medical necessity in lung cancer is the identification ofefficient therapy targets and techniques as well as trustworthy predictive biological markersfor detection and prognosis (102, 103). Intriguingly, the researchers discovered that exosomesfrom tumors have distinct miRNA and mRNA expression patterns that differ from those ofnormal individualistic individuals, suggesting a possible predictive biological marker for lungcancer (104, 105). Given that tumor metastasis has a weak prognosis and is still the largestreason for death from cancer, more important investigation that contributes to this process iscritical for identifying preventive and diagnostic strategies (40).2.1. Exosomal Functions Aiding Lung Cancer MetastasisExosomes are known to participate in cellular communication, regulate signals betweencells, and promote the formation of PMNs, all of which contribute to the activity of the cellsreceiving them and promote tumor growth and dissemination (106, 107). These modificationshave several important effects, including improved immune evasion, increased angiogenesis,and activated EMT, all of which ultimately aid in the spread of lung cancer cells (40).2.1.1. Immune EvadingImmunosuppressive chemicals are transferred to immune cells by tumor-derived exosomesthrough paracrine signaling or direct contact, which promotes the growth of tumors andsuppresses immunological activities (108). The tumor produces exosomes to modulateanti-tumor immune responses by preventing T cell activation and proliferation, inducingCancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

Merve C¸ igdem ˘ OZGEL, S¸eref Bu ¨ gra TUNC¸ ER ˘ 43regulatory T cells (Tregs) and myeloid-derived suppressor cells (MDSCs), and inhibiting thefunction of natural killer (NK) and CD8+ T cells, and this allows the tumor to spread andgrow more effectively (109, 110). The immunosuppressive PD-L1, which binds to PD-1 viathe extracellular domain to inactivate T lymphocytes, is furthermore carried by exosomesfrom lung cancer cells, melanoma cells, and breast cancer cells (40). IFN-γ controls theexpression of exosomal PD-L1, which suppresses CD8+ T cell activity and promotes tumordevelopment (111). Exosomal PD-L1 enhances tumor cell survival, according to otherresearch; therefore, genetic blockade or antibody-based exosomal PD-L1 suppression canpromote T-cell activity in the drained lymph node, enhancing systemic anti-tumor immunityand memory (112). By decreasing cytokine production and causing death in CD8+ T cells,these exosomes also compromise immune system functioning (113). The cytotoxicity of NKcells can be inhibited both in vitro and in vivo by TGF-β1 and miR-23a, which are producedby hypoxia-preconditioned tumor-derived microvesicles (114). Exosomes purified from lungcancer biopsies included EGFR in about 80% of cases, while exosomes from samples ofchronic lung inflammation only carried EGFR in 2% of cases, according to another study(40). Tolerogenic dendritic cells (DCs) were stimulated by purified exosomes (40). Additionalresearch revealed that co-culture of tolerogenic DCs and Th0 cells led to the production oftumor antigen-specific Treg that could impede CD8+ T cell activities specific to the antigen(115).These results imply that intermediaries from malignancy might protect malignant cellsfrom immune cell monitoring, presenting a target for therapy that may help in the developmentof immunotherapy methods for battling tumors (40).2.1.2. The Epithelial-Mesenchymal TransitionBecause cell-cell adhesion qualities are lost during EMT and a mesenchymal phenotypeis subsequently acquired, this highly conserved mechanism encourages tumor cell motilityand invasion (40). Exosomes are crucial players in the EMT process, where they mediatethe communication of mesenchymal-related information between cancer cells and theirsurroundings and regulate signaling in recipient cells, and this is supported by data froma number of recent investigations (116, 117). Mesenchymal cells treated with TGF-β1produced exosomes that showed increased expression of β-catenin but decreased expressionof E-cadherin and vimentin (40). Furthermore, miR-23a levels in the released exosomes wereconsiderably higher (40). In A549 adenocarcinomic human alveolar basal epithelial cells thatwere undergoing EMT, further investigation revealed that exosomes stimulate TCF4/β-catenintranscriptional activity and start canonical Wnt signaling (118).During EMT, the exosomal profile of short RNAs changes, and these particular miRNAsmay be responsible for driving signal transduction networks that promote EMT and cancergrowth (119). Compared to non-metastatic lung cancer cells (PC14), exosomes uptaken fromCancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

44 EXOSOMES IN CANCER DEVELOPMENT AND METASTASIShighly metastatic lung cancer cells (PC14HM) express more vimentin (40). Human bronchialepithelial cells (HBEC) treated with exosomes produced from PC14HM showed significantlyhigher vimentin levels, which induced EMT in recipient HBECs (120). These findings implythat exosomes produced by tumors play a significant role in promoting EMT by altering thephenotypic profile of tumor cells to one that is more aggressive (Figure 3) (40).Figure 3: The role exosomes play in lung cancer’s immune evasion and EMT promotion. Exosomesthat block the growth of immune cells like MDSCs and Tregs and promote the recruitment, activation,and proliferation of tumor-cytotoxic cells like NK and T cells are expressed more frequently in themicroenvironment of lung cancer tumors. Exosomal payloads such as EFGR, PD-L1, TGF- β, miR-23a,and Wnt and their accompanying signals promote immune evasion and EMT, resulting in tumor spread(40) (Adapted from reference 40).2.1.3. AngiogenesisExosomes trigger the development of new blood vessels from pre-existing ones, a processknown as tumor-associated angiogenesis, and this process involves the transfer or expressionof protein molecules such as VEGF, FGF, IL-8, IL-6, and angiopoietin (Figure 4) (16, 45, 121).Angiogenesis is a critical prerequisite for tumor cell survival and is regarded as a malignanthallmark of small cell lung cancer (SCLC), which is directly associated with SCLC patients’poor prognoses (40). Human umbilical vein endothelial cells’ (HUVECs’) increased cellgrowth and creation of tubes, as well as their decreased programmed-cell death, are indicationsthat exosomes released via stimulating the development of new blood vessels stimulate lungcancer cells (40). Instead, GAS5 upregulates PTEN mRNA and protein expression whileCancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

Merve C¸ igdem ˘ OZGEL, S¸eref Bu ¨ gra TUNC¸ ER ˘ 45downregulating Akt and phosphatidylinositol-4,5-biphosphate 3-kinase catalytic subunit alpha(PI3K) phosphorylation in HUVECs to prevent lung tumor-associated angiogenesis, and GAS5also competes with PTEN for binding to miRNA-29-3p (122). A substantial correlation existsbetween advanced TNM stages and circulating miR-141, which is up-regulated in samplesfrom SCLC patients (40). In order to promote HUVEC proliferation, migration, invasion,and tube formation and boost microvessel sprouting from mouse aortic rings, SCLC-derivedexosomes transmit miR-141 via exosomes to HUVECs (40). Additionally, exosomal miR-141activates neo-angiogenesis in vivo via activating the miR-141/KLF12 pathway, which resultsin increased microvessel density and development (123). CAFs effectively promote tumorangiogenesis (40). In lung cancer, the MORC2 gene promotes the development of new bloodvessels and tumor-associated macrophage recruitment through the Wnt/β-catenin pathway(124).Figure 4: Lung tumor angiogenesis triggered by exosomes. Through the JAK2/STAT3 signalingpathway, exosomes produced from lung tumors induce fibroblasts to secrete exosomes that expressmolecules like MMP9, VEGF-A, FGF2, and miR-210. These exosomes promote the activationof tumor-supporting cells like macrophages and neutrophils in conjunction with the vesicles thetumor produces. Other exosomal payloads directly stimulate angiogenesis by boosting blood vesselproliferation, sprouting, and density, which leads to an increase in metastasis (40) (Adapted fromreference 40).2.2. Lung Cancer Metastasis and ExosomesMetastasis is a significant issue in cancer research as it is the primary cause of lungcancer fatalities (40). Because oncogenes are unstable, inflammatory, hypoxic, and acidoticconditions can lead to tumor cells secreting more intermediear, which helps to create a TMEthat promotes rapid tumor cell growth and enhances their capacity for invasion and the spreadof tumor cells (125, 126). Higher expression of TGF-β and IL-10 in intermediearies fromtumors is related to exosomes from cancer cell motility (127). Exosomes from various origins,Cancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

46 EXOSOMES IN CANCER DEVELOPMENT AND METASTASISlikely the human umbilical cord, bone marrow, and adipocytes, have also been well studiedin order to compare their effects to those of exosomes originating from tumors (40).2.2.1. Involvement in the Pre-Metastatic Niche (PMN) PhasePMN is a key tumor-derived factor that drives the spread of cancer, together with hoststromal cells and exosomes (40). In addition to encouraging cancer cell immigration,spreading over, and localization at the metastatic location through the expression ofniche-specific genes likely BV8, MMP9, S100A8, and S100A9 has also been linked to PMNdevelopment (128). Lung epithelial cells have been shown to be crucial in activating neutrophilreinforcement and the creation of lung spreading niches by recognizing tumor exosomal RNAsvia TLR3 (40). While tumor-derived exosomal short nuclear RNAs stimulated TLR3 in lungepithelial cells to increase chemokine production (CXCL1, CXCL2, CXCL5, and CXCL12)and neutrophil reinforcement, TLR3-deficient mice demonstrated reduced lung metastases(129).Exosomes produced by tumors have the ability to mobilize bone marrow-derived cells intoPMN and, by expressing membrane-bound integrins, to identify organotropic metastases (70).Certain exosomal integrins, such as exosomal integrins α6β1 and α6β4, are associated withcancer cells in specific organs and predict organ-specific metastasis (40). Exosomes fromtumors are taken up by organ-specific cells, preparing PMN (40). Additionally, exosomalintegrin absorption by ingrained cells stimulates Src phosphorylation and the expression ofthe pro-inflammatory gene S100 (70).Exosomes cause tissue matrices to remodel and microanatomical niches to be preparedin both mice and human individuals, which makes it easier for cancer cells to spreadlymphatically (130). Intermediaries also cause vascular infiltration at pre-metastatic locations,reprogramming bone marrow progenitor cells to have enhanced lung endothelial cellpermeability and a pro-vasculogenic phenotype (131). Cells primarily produce the RNAsRAB1A, RAB5B, RAB7, and RAB27A, which regulate exosome synthesis and membranetrafficking, and Rab27A RNA level interference inhibits exosome production, tumor growth,and metastasis (131). The same as this, delivery of B16-F10 exosomes to lung tissueled to an increase in the expression of genes implicated in inflammation and remodelingof the extracellular matrix, including TNFα, a mediator of vascular permeability, andPMN-forming molecules S100A9 and S100A8 (132). By modulating the expression ofVEGFR2, occludin, ZO-1, and Claudin-5 in endothelial cells and targeting KLF2 and KLF4,exosomal miR-25-3p contributes to PMN development by increasing vascular permeability,angiogenesis, and metastasis (133). Intermediaries from tumors also encourage angiogenesis,vascular infiltration (134), and activation of coagulation, which increases the adhesion oftumor cells in circulation (135).Cancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

Merve C¸ igdem ˘ OZGEL, S¸eref Bu ¨ gra TUNC¸ ER ˘ 47Another crucial step in the establishment of PMN is the reduction of immunologicalsurveillance (40). Exosomes from tumors have been found to interfere with adaptive immuneresponses by preventing antigen-presenting cells (APCs) and cytotoxic T cells from activating,proliferating, and improving T cell responses; mobilizing myeloid-derived suppressor cells(136); activating macrophages (137), and neutrophils (138), that are favorable to tumor growth;and depleting natural killer (NK) cells by exposing NKGD ligands (139-141). Internalizingtumor-derived exosomes in the microenvironment of lung tumors causes M0 macrophages todifferentiate into the pro-inflammatory and pro-tumorigenic M2 phenotype (142).2.2.2. Involvement in the Metastatic PhaseExosomes produced by tumors have an impact on the development and spread of lungtumors by altering the physiological functions of the cells in the surrounding tissue and themicroenvironment (40). For instance, MSCs can acquire tumor-promoting qualities by beingconverted to a pro-inflammatory phenotype by tumor-associated exosomes via the NF-?B/TLRsignaling pathway (40). Signal transduction molecules like EGFR, GRB2, and SRC (143), aswell as functional exosomal RNAs like circSATB2 and miR-660-5p (144, 145), which activelymodulate recipient cell proliferation and promote tumor growth and metastasis, as well as theabnormal proliferation of normal human bronchial epithelial cells, are more abundant inexosomes derived from lung cancer. According to a study that looked into the relationshipbetween circ-CPA4, let-7 miRNA, and programmed cell death ligand 1 (PD-L1) in lungcancer, circ-CPA4 regulates NSCLC cell growth, stemness, mobility, and drug resistance,as well as inactivating CD8+ T cells in the tumor microenvironment (40). PD-L1, whichserves as an RNA sponge for let-7 miRNA and inhibits cell growth, motility, and EMT, isdownregulated by the reduction of circ-CPA4, which causes an increase in cell mortality inNSCLC cells (146).TGF-β has been shown to modulate exosomal miRNAs that affect lung cancer cells’invasion and migration (40). Through TGF-β-mediated exosomal transfer of cellularinteractions, TGF-β-pretreatment of lung cancer cells improves mobility, permeation ofblood vessels, and aggressive ability of lung tumor cells (40). Exosomal lnc-MMP2-2 RNAcontrols lung tumor cells’ mobility and aggressive throughout this process by boosting MMP2expression (147). Additionally, by acting as an SLUG enhancer in lung cancer cells (148)and modifying the miR-367/141-ZEB2 axis in NSCLC, lnc-RNAs AC026904.1 and XISTare essential for enhancing TGF-β-induced migration and EMT (149). According to onestudy, miR-378 significantly differs in expression in NSCLC cells from those of patientswith brain metastases and encourages tumor angiogenesis, cell invasion, and migration (150).Exosomal miR-619-5p has also been discovered to be a powerful inducer of RCAN1.4-targetedangiogenesis in lung cancer (40). Angiogenesis, cellular growth, and spread are all inducedin NSCLC cells by targeted suppression of RCAN1.4 (151).Bone metastases are the most frequent consequence of NSCLC, affecting 20–40% ofCancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

48 EXOSOMES IN CANCER DEVELOPMENT AND METASTASISlung cancer patients and causing osteolytic lesions as a result of an unbalance amongst thefunctions of osteoblasts that create bones and osteoclasts that bone-resorb (40). Amphiregulinebinds to the EGFR pathway, which is constitutively active during this process (40).Amphiregulin is a protein that is highly expressed in exosomes from lung cancer, and ithelps cause bone metastases (40). The EGFR pathway is activated in pre-osteoclasts byNSCLC-derived exosomes, which causes increased expression of the receptor activator ofnuclear factor-kappa-B ligand (RANKL), which is linked to the poor cycle in osteolytic bonemetastases (152). Lung cancer patients’ exosomal miRNAs from plasma were sequenced,and three consensus clusters with notable differential expression were discovered (40).Further investigation revealed that the cluster most likely contributes to getting the metastaticniche ready, inducing EMT, and bone metastasis (40). In patients with bone metastases,exosomal miR-574-5p, an inhibitor of the Wnt/β-catenin pathway, as well as miR-423-3p andmiR328-3p, activators of the Wnt/β-catenin pathway, were down-regulated and up-regulated,respectively (153).The primary cause of SCLC death is early brain metastasis, which it prefers to develop (40).S100A16, a protein-coding gene linked to SCLC brain metastasis, is expressed more frequentlywhen SCLC cells and human brain microvascular endothelial cells (HBMECs) are co-cultured(40). S100A16 was transferred and expressed in recipient SCLC cells via exosomes, whichalso prevented the decrease in the potential of mitochondrial membranes and increased thecell’s ability to resist cell death through prohibitin (PHB)-1 during difficult circumstances(154). Lung cancer patients with and without brain metastases can be distinguished from oneanother by exosomal cargos, according to reports (40). The serum of NSCLC patients withcerebral metastases contains more miR-330-3p than does the serum of patients without cerebralmetastases, and increased miR-330-3p expression encourages NSCLC growth, immigration,aggression, and EMT both in vivo and in vitro (155).Intermediears from the tumor help to create invadopodia, which are actin-rich protrusionsof the cell membrane dependent on disturbances of the ECM in tumor spread (40). It hasalso been demonstrated that a number of exosomal components encourage spread and impartmetastatic capacity to target cells (126, 156). Prior to tumor metastasis, a critical processknown as EMT occurs, which is complicated and involves down-regulation of the expressionof the adheren junction protein E-cadherin as well as cytoskeletal alterations (40). Humanadvanced carcinoma of the lung serum and exosomes generated by extremely aggressive lungcancer cells promote EMT and cause benign cells that are targeted to grow, move around,and become invasive (120). Through inducing EMT in lung cancer, TGF-β promotes tumorinvasion and metastasis, in part by interacting with circRNAs (40). In NSCLC cells subjectedto TGF-β-induced EMT, CircPTK2 and TIF1γ are dramatically decreased (40). On the otherhand, circPTK2 overexpression boosts TIF1γ expression, blocks TGF-β-induced EMT, andCancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

Merve C¸ igdem ˘ OZGEL, S¸eref Bu ¨ gra TUNC¸ ER ˘ 49prevents NSCLC cell invasion (157). SNAI1 is required for the promotion of EMT in lungcancer cells by exosomes produced by CAFs (158). Exosomal regulatory factors that promotelung tumor spread are shown in Figure 5.Figure 5: Microenvironmental variables in lung cancer are linked to exosomal metastatic consequences.Exosomes either directly or indirectly regulate a number of components that are categorized asgrowth/cytokine factors, exosomal payloads, genes, pathways/axes, and receptors that contribute tothe development of lung tumor metastasis. Brain, bone, liver, kidney, and other contralateral healthylungs are distant organs that are frequently susceptible to lung tumor spread (40) (Adapted from reference40).3. Endometrial Cancer and ExosomesThe fourth most prevalent cancer of the female genital system is endometrial cancer(159). Endometrial cancer incidence has been rising recently, particularly in Europe (160).Most endometrial cancer patients receive an early diagnosis as a result of symptomaticpost-menopausal metrorrhagia, but about 20% of cases progress to high-grade tumors (159).The survival rate for these individuals falls to 15%, which is very crucial (159). Adjuvantradiation and chemotherapy are also options for patients, even though surgery is advised asthe primary form of treatment (161, 162).Exosomes are currently the subject of intense research into their potential part in thedevelopment of endometrial tumor (163). It is intriguingly proposed that intermediearsharboring various regulatory RNAs facilitate cell-to-cell communication among endometrialfibroblast cells and endometrial tumor cells (164). Accordingly, one study has demonstratedCancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

50 EXOSOMES IN CANCER DEVELOPMENT AND METASTASISthat exosomes produced by CAFs promote the growth of endometrial cancer in part bytargeting DNA DNMT1 to inhibit endometrial cancer spread and in part by causing the lossof miR-148b, a crucial tumor suppressor (159). DNMT1 promotes metastasis via boostingEMT (165). Another study found that the expression of exosomal miR-320a, which isderived from CAFs, was lower in tissues and cells containing endometrial cancer (159).They discovered that miR-320a targets HIF1α, which causes VEGFA production to decreaseand hence limits cell growth (166). On the other hand, exosomes from endometrial cancerpatients’ plasma stimulated cell proliferation and HUVEC angiogenesis through activatingthe PI3K/AKT/VEGFA signaling pathway (159). In this manner, the plasma exosomal lectingalactoside-binding soluble 3 binding protein (LGALS3BP) level was increased and wasrelated to the expression of VEGFA (167).The latest research found that endometrium malignant cells transport the exosomalmiRNA-21 in hypoxic settings to cause the transformation of monocyte THP-1 cellsinto M2-like polarization macrophages (168). Exosomes isolated from polycystic ovariansyndrome patients’ serums have also been shown to promote the invasion and migrationof endometrial tumor cell lines (159). Intriguingly, these exosomes displayed the highestincreased level of miR-27a-5p targeting SMAD4 (169).The most significant biological miRNA in endometrial cancer patients’ urine isexosomal hsa-miR-200c-3p, which has been presented as a non-invasive biomarker (170).An endometrial cancer bioinformatics study showed that Forkhead Box L2 (FOXL2)down-regulation in endometrial tumor tissues or cells is related to cell proliferation(159). It was discovered that miR-133a, which targets FOXL2, could be transferred tohealthy endometrium cells by intermediears when this research obtained intermediears fromsupernatants of endometrial tumor cell lines (171).A different investigation of blood samples from the uterus and the periphery fromendometrial cancer patients found greater levels of total (TF+), endothelial (CD144+), andmonocytic (CD14+) microparticles as potential biological markers (159). The histologicalgrade and clinical stage of the malignancy are also correlated with these findings (172). Inlight of the function of exosomes, this research offers fresh insights into the pathophysiology ofendometrial cancer (159). More investigation is required to identify the types of fluid samplesthat would offer the most useful data for diagnosing and delivering targeted treatments forendometrial cancer (159).4. Bone Sarcomas and ExosomesSarcomas come in more than 50 different varieties, manifesting in various tissues, withvarious genetic origins, and at various ages (173). In addition to this variety, they occurconsiderably less often than carcinomas (40). Despite the fact that the development ofchemotherapy has increased survival rates, the range of available treatments has not changedCancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

Merve C¸ igdem ˘ OZGEL, S¸eref Bu ¨ gra TUNC¸ ER ˘ 51significantly in the last ten years, and metastasis continues to pose a serious threat to patientsurvival (173). According to estimates, metastatic disease will cause one-third of patientsto pass away (32). A subtype of bone tissue known as bone sarcomas appears amongsarcomas (32). These are incredibly rare, making up less than 0.2% of the tumors recorded inEUROCARE, with a ratio of just 1-2 new diagnoses per 100,000 people each year (174, 175).Chondrosarcoma (CS), osteosarcoma (OS), and Ewing’s sarcoma (ES) are the three mostprevalent bone sarcomas (32). Rare tumors like bone sarcomas still have poor survival ratesbecause they frequently have metastatic disease (32). While some hereditary and acquiredhereditary variables may be linked to the development of these malignancies, most of themremain without a known etiology, making it difficult to correctly diagnose and treat them(176). Because of this, it is crucial to understand what triggers the development of this bonesarcoma and how to prevent and treat metastatic illness more effectively (32).Metastasis from bone sarcomas is the clinical feature that has the worst prognosticimplications and is linked to low survival rates (173). One reason for this is that the molecularprocesses behind tumor metastasis and tumor growth are not fully understood (173, 177, 178).Lung first, then osseous and bone buttonhole second, is the most typical metastatic locationin both OS and ES (32). Contrary to popular belief, extrapulmonary metastasis has a worseprognosis than lung metastasis (173, 179). Metastatic OS was discovered to have increasedexpression of CD155 (180), loss of TP53, RB1, and PTEN (181), as well as up-regulationof Notch genes (182), among other genes associated with OS. Several metastasis-associatedgenes have been identified in ES, including ROR1 (183); MSH2, MSH6, RPA2, and RFC2genes (184) from the mismatch repair pathway; PPP1R1A (185) and TWIST1 proteins (186);Cad11 adhesion molecule (187); and ERBB4 (188) via activation of the PI3K-Akt-FAKcascade. In OS and ES, hypoxia has been linked to metastasis induction similar to othermalignancies by upregulation of HIF1α via HIF1α (189) or increased expression of CXCR4(190) in ES. CS compares to OS and ES in that it typically has locally aggressive tumors thatare not metastatic (191). The lung-specific spreading organotropism of CS, however, may bemediated by integrins, according to some studies (192, 193).4.1. Exosomes in OsteosarcomaWith a frequency of 0.3 per 100,000 persons annually, OS is the most prevalent primarybone malignancy (194). The majority of cases are between the ages of 0 and 24 and 60 to85, and the disease has a bimodal distribution (195). It is an intraosseous tumor that developsin areas of the bone where active cellular development occurs and an unbalanced ratio ofosteoclasts to osteoblasts exists (196). High genetic instability is one of its defining traits(32). As a result, complex karyotypes are produced, including copy number variations (197)and chromothripsis frequency (198). Regardless of recent breakthroughs in diagnosis andtreatment, the majority of patients’ survival rates remain dismal (178). When diagnosed,Cancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

52 EXOSOMES IN CANCER DEVELOPMENT AND METASTASIS10% to 20% of patients already had metastases, and their overall 5-year survival rate is under20% (32). Although data indicates that 80% of patients had micrometastases at diagnosisthat would be resistant to chemotherapy, survival rates are higher for immediately localizeddisease (5-year OS: 60–80%) (32). For 30–40% of patients with nonmetastatic OS, this causesmetastasis and recurrences (199, 200).In exosomes produced from OS, both metastatic and not, a variation in miRNA content wasobserved (32). Among the predicted targets for differentially expressed miRNAs, there was again in genome related to tumor development and spread (32). A more thorough examination ofmiRNAs enriched with intermediears from the most metastatic OS cell line (SAOS2) indicatedthat 4 miRNAs target 31 target genes from a single signal chain linked to cell attachment andprogrammed cell death (201). As a result, the findings of this research imply that OS-derivedexosomes may be able to maintain a trait that favors spreading by dispersing certain miRNA andproteins to different OS cells, causing modifications to migration, adhesion, and angiogenesis(32).Exosomes generated from metastatic OS had significant levels of miR-675 (32). miR-675absorption via exosomes results in the down-regulation of migration-associated CALN1expression, according to confirmation studies employing exosome transfer and mimictreatments for metastatic and non-metastatic cancers (202). Further evidence that OS couldlimit the ability of malignant cells to spread by regulating the TME came from endothelialcells’ uptake of exosomes released from OS, which led to an increase in pro-angiogenicmolecules and the creation of capillary structures in vitro (203). miR-148a and miR-21-5pwere found to be responsible for the modification of endothelial and osteoclast characteristicsfollowing intermediary uptake through profiling of the miRNA content of these exosomes,and this is because increased expression of these miRNAs in target cells led to the inductionof osteoclast indicators, elevated vascular development, and enhanced destruction of bones invitro (203).When MSCs were injected into an OS mouse model together with exosomes frommetastatic OS, the tumors grew larger in vivo and metastatic spread to the lungs occurred(204). According to exosome profiling, TGFβ is present on the exosome’s surface when itinteracts with MSCs, triggering a signaling cascade that increases the MSCs’ production ofthe cytokines IL-6 and IL-8 (204). Due to OS cells’ inability to produce IL-6, this releasefrom MSCs may strengthen the pro-inflammatory milieu that promotes spread (32).Few studies have looked into exosomes formed from OS, despite the fact that they do nothave metastatic potential (32). In order to lower the tumorigenic potential of OS cells, Shimboet al. assessed their capacity to transport synthetic miRNAs to OS cells via exosomes (205).This miRNA, which increased the expression of miR-143 in MSCs, was transferred to OScells and reduced their ability to migrate without changing their rate of in vitro proliferationCancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

Merve C¸ igdem ˘ OZGEL, S¸eref Bu ¨ gra TUNC¸ ER ˘ 53(32). Despite having a lower delivery efficiency than lipofection, the decrease in migrationwas identical and was accompanied by less cytotoxicity (205).4.2. Exosomes in Ewing SarcomaWith a high incidence between 15 and 24 years old, ES ranks as the next-highest prevalentkind of osseous tumor among kids and adolescents (175). In 85% of cases, the EWSR1 geneon chromosome 22 translocates to the FLI1 gene on chromosome 11, which is a transcriptionfactor belonging to the ETS family (206). ERG, ETV1, E1AF, and FEV are examples ofuncommon ETS members that have also been discovered (207). As a result, an abnormaltranscription factor that is necessary for ES tumorigenic transformation is produced (177). In95–100% of instances, the cell surface glycoprotein CD99 is also highly expressed (208) andis connected to the development of ES tumors. (209, 210). Survival is still low for patientswith ES, despite improvements in diagnosis and treatment (179). The majority of ES patients(75%) have localized disease, and the 5-year survival rate is 75% (211). But when it comes tosurvival rates (5-year OS < 30%), 25% of patients have already been diagnosed with advancedcancer (179). A portion of patients with refractory disease will either relapse immediately orover time, both of which are linked to low survival rates (5-year OS < 25%) (212).Exosomes may have a role in the advancement of ES, but this has not been proven; however,their cargo has been found to include several mRNAs linked to ES carcinogenesis, includingthe EWSR1-FLI1 fusion and EZH2 (213). Soon after this study’s publication, another teamdiscovered that exosomes made from ES included EWSR1-FLI1 mRNA (214). Both ES cellsand non-ES cells (in this case, osteoblasts and osteoclasts) can receive EZH2 as part of thecargo carried by ES-derived exosomes (215). This is the first proof that exosomes formedfrom ES can transfer genetic material into cells that are not cancerous, setting the frameworkfor further investigation into the interactions and effects of this information transmission (32).In 2015, the initial investigation on the effects of exosomal transfer in ES was completed(216). The study is predicated on the observation that the effect of EWSR1-FLI1 on EScells is counteracted by CD99 silencing via miR-34a-Notch-NF?B, which induces neuraldevelopment in ES cells (216). Other research from the same team has demonstrated thatES cells that have been exposed to exosomes silenced for CD99 exhibit increased neuraldifferentiation and decreased cellular growth, proliferation, and migration (217). On the otherhand, when CD99-expressing ES-derived exosomes were uptaken by CD99-silenced ES cells,migratory capacity was recovered and neural indicators were decreased (32). It has beendemonstrated that ES exosomes can mimic other cells and alter their biological function (32).4.3. Exosomes in ChondrosarcomaWith a peak incidence between the ages of 50 and 70, CS ranks as the second-to-last mostprevalent kind of osseous sarcoma (191). This bone sarcoma is heterogeneous in nature andvery resistant to radiotherapy and chemotherapy due to the delayed expansion of cells, theCancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

54 EXOSOMES IN CANCER DEVELOPMENT AND METASTASISdevelopment of hyaline cartilage cell-surrounded tissue, and a low vascular structure (191).Furthermore, Grade 3 advanced disease with a significant likelihood of metastasis is found in5–10% of CS patients (218).There is presently no information on the potential role that intermediaries may play in thiscancer, compared to OS and ES (32). In CS, angiogenesis is linked to a worse outcome (219).According to research, CCL5 causes greater amounts of VEGFA in cells, down-regulatesmiR-199a and miR-200b, and fails to control VEGFA (220, 221). Similar to this, miR-181ais more abundant in hypoxic CS cells, which raises VEGF levels by activating the RGD16and CXCR4 signaling pathways (222). Because SOX4 was reduced by high amounts ofmiR-129-5p, proliferation, migration, and apoptosis were all inhibited (223). Also, it hasbeen demonstrated that miR-141 and miR-101 control c-Src to reduce the ability of CS tospread through the body (224, 225).5. Breast Cancer and ExosomesBreast cancer (BC) is the most common type of prevalent tumor in women and one ofthe main reasons for cancer-caused deaths globally (226). Due to its significant geneticand clinical heterogeneity, BC can be divided into a number of subtypes, including luminalA, luminal B, HER2-enriched, basal-like, and normal-like subtypes (227). The risk ofaggressiveness, spread, repetition, and ability to resist pharmaceuticals in BC remains highdespite improvements in early diagnosis and somewhat successful therapies such as surgery,radiation, and chemotherapy (228). Challenges to responding to treatments and a weakprognosis brought on by distant metastases are the main management difficulties for patientswith advanced BC (229).Exosomes generated from BC can augment the oncogenic phenotype by enhancing BC cellmotility, proliferation, and metastasis (230). Additionally, according to Piao et al., exosomesproduced by BC cells promote macrophage polarization, which in turn fosters the developmentof lymph node metastatic processes in triple-negative breast cancer (TNBC) (231).miR-130a-3p generated from exosomes is expressed at a decrease in nodes of lymphmetastases and an advanced TNM stage, as Kong et al. found that miR-130a-3p is abnormallydown-regulated in people’s breast tumor tissues and intermediears taken from circulation(232). By specifically influencing RAB5B/epidermal growth factor receptor signalingpathways, exosomal miR-130a-3p inhibited the growth, mobility, and aggressiveness of humanbreast cancer stem cells (BCSCs) in vitro (229). According to Li et al., miR-770 contained intumor exosomes can be transferred to macrophages associated with the tumor, enhancingthe expression of miR-770 in those cells (233). Additionally, miR-770 overexpressionprevented TNBC from migrating and invading by targeting STMN1 (229). Let-7a, whichis produced from MDA-MB-231 cell exosomes, works by suppressing c-Myc expression toprevent growth, mobility, and aggressiveness both in vitro and in vivo (234). Additionally,Cancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

Merve C¸ igdem ˘ OZGEL, S¸eref Bu ¨ gra TUNC¸ ER ˘ 55it has been discovered that miR-188-5p blocks BC-cell migration and proliferation throughthe function of its downstream target, IL-6 signal transducer (IL6ST) (235). This findingshowed that miR-188-5p only segregated intermediaries from cancerous BC cells rather thanpatient blood (229). miR-155 can be transferred from BC exosomes to adipocytes and musclecells, reprogramming their metabolisms to cause lipolysis and muscle atrophy, which resultsin cancer-associated cachexia, which encourages BC spread (236).According to Feng et al.’s research, BC cells release exosomal miR-22-3p, which promotescancer budding and BC development in vivo by inhibiting transgelin (237). Exosomal miR-145was discovered by Pan et al. in MDA-MB-231 cells; it targeted IRS1 and prevented HUVECangiogenesis by controlling the IRS1/PI3K/Akt/mTOR and IRS1/Raf/ERK pathways (238).Exosomal miR-939 has been shown by Modica et al. in TNBC cells to promote cancer celltrans-endothelial migration and specifically target VE-cadherin in endothelial cells, which isa marker of vascular endothelial destiny (239). The tight junction protein zona occluden-1(ZO-1) is the target of miR-105, a powerful migratory regulator that is typically released bymBC cells (240). By thoroughly impairing the integrity of the natural barriers in endothelialmonolayers, exosomal miR-105 produced by BC promoted metastasis (229).Feng et al. demonstrated using high-throughput sequencing analysis that multiplefunctional involvements of abnormally expressed lncRNAs derived from BC cells inducelung fibroblast growth and mobility, which creates an ideal arrangement for PMN formationand promotes tumor pulmonary metastasis (241).In the intermediaries of patients with mBC, Wang et al. found a total of 1061 circRNAsthat were up-regulated and 86 circRNAs that were down-regulated (242). According to Yanget al., two circRNAs, hsa-circRNA-00005795 and hsa-circRNA-0088088, were down- andup-regulated, respectively, in intermediaries from BC tissues as compared to tissues free ofcancer (243).By activating focal adhesion kinase/Src and increasing the production of pro-inflammatorycytokines and MMP9, BC-derived exosomal fibronectin was able to promote BC spread in vivo(244). According to Didiasova et al., co-culturing MDA-MB-231 cells with exosomes releasedby cells overexpressing ENO-1 increased these cells’ ability to invade (245). The amount ofexosomal ENO-1 released outside of cells has also been linked to the aggressiveness andmetastatic capability of tumor cells, as has the amount of membrane-surface-bound ENO-1expression (229). By modifying the exosomal production of heparin-binding epidermalgrowth factor (HBEGF), Sethuraman et al. demonstrated that hypoxia-induced activation ofBHLHE40 promotes in vivo cell survival and lung metastasis of BC (246).Cancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

56 EXOSOMES IN CANCER DEVELOPMENT AND METASTASIS6. Ovarian Cancer and ExosomesThe most frequent form of invasive cancer in the female seminal system, ovarian cancer,is the main reason for gynecological cancer fatalities worldwide (247). When they are sentto clinics, more than 50% of individuals with ovarian cancer are already in advanced stages(159). Each year, ovarian cancer is reported to cause more than 230,000 new cases and150,000 fatalities worldwide (159). Conspicuously, patients’ 5-year survival rates are lessthan 50% (160, 248). Lack of early detection methods caused patients’ low survival rates andpoor quality of life (159). Exosomes released by ovarian cancer cells can be ingested by othercancerous or healthy cells to improve the intercellular communication necessary for tumorgrowth, spread, and aggressiveness (159). Additionally, intermediaries produced by ovariancancer might be used as new biological indicators and goals for therapy (248).Exosomal Hsp70 and Hsp90 are considered to contribute to the pathophysiology of theillness (249-252). Intriguingly, one study found that ovarian cancer patients’ exosomes hadenhanced levels of Hsp27 expression (253).The modulators of treatment resistance in ovarian cancer include miR-106a, miR-130a,miR-221, miR-222, miR-433, and miR-591 (254-258). Furthermore, a recent study showedthat the PI3K/AKT signaling pathway is used by exosomes produced from macrophages totransfer miR-223 to epithelial ovarian cancer cells, which increases drug resistance (259).miR-200f has been proposed as a diagnostic marker in earlier research because it is elevatedin the blood of people with epithelial ovarian cancer (260-262). Furthermore, a recentstudy found increased levels of exosomal miR-21, miR-100, and miR-320 and lower levels ofmiR-16, miR-93, and miR-126 in the plasma of patients with epithelial ovarian cancer (263).Exosomal miRNAs, such as miR-141-3p and miR-205, which are produced by epithelialovarian cancer, have been shown to play a role in promoting endothelial cell vascularizationin recent studies (264, 265). As a result, exosomal miRNAs including miR-21, miR-184,miR-193b, miR-200a, miR-200b, miR-200c, miR-203, miR-214, and miR-215 can be thoughtof as diagnostic biomarkers (252, 266-268). Let-7 miR, miR-21, miR-25, miR-29b, miR-100,miR-105, miR-150, miR-187, miR-221, and miR-335, for example, have been associated withthe formation of malignant ovarian tumors (252, 266, 269). One of them, miR-21, has beendemonstrated to have a significant role in oncogenesis and metastasis by targeting PDCD4 asa tumor suppressor in serous ovarian cancer (270).7. Pancreatic Cancer and ExosomesPancreatic cancer (PaCa) is one of the most frequent and deadly digestive systemmalignancies globally (19). No viable treatment plan against this aggressive cancer hasyet been identified, save for early surgical resection (271). PaCa is thought to have a less than5% 5-year overall survival rate, and advanced PaCa has a short survival period of just 3-6months (272).Cancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

Merve C¸ igdem ˘ OZGEL, S¸eref Bu ¨ gra TUNC¸ ER ˘ 57Exosomes made from PaCa can transfer proteins, lipids, or nucleic acids from the originto target cells; these substances then trigger pro-inflammatory activities, mediate vascularinfiltration, suppress the immune response, regulate programmed-cell death resistance, andpromote angiogenesis and cell growth, which aid in the metastasis of tumors (19).Exosomes produced by PaCa include a range of protein compounds that can stimulatestromal cells nearby, cause ECM remodeling, and trigger neovascularization, resulting in theformation of a TME that aids in metastasis (19). PaCa can use exosomes to create PMNsin distant organs such as the liver or lungs, as noted by Costa Silva and colleagues (273).According to mechanistic research, PaCa cell-derived MIF-positive exosomes can increaseTGF-β expression in Kupffer cells and activate fibronectin in hepatic stellate cells, both ofwhich can lead to liver metastasis (273). Exosomal MIF levels in serum are frequently higherin PaCa patients with liver metastases compared to normal people or people with 5-yearprogression-free PaCa (274). As a result, exosomal MIF may play a significant role in hepaticPMN development (19). According to other data, exosomes originating from PaCa that arepositive for integrin αvβ5 often travel to the liver, while exosomes carrying integrin α6β4and α6β1 are delivered to the lungs (274).It has been demonstrated that PaCa cell lines and cancer tissues from PaCa patients bothoverexpress miR-27a (275). Human microvascular endothelial cells can undergo proliferation,invasion, and angiogenesis when exosomes from PaCa are present because miR-27a inhibitsthe BTG2 gene, which supports the survival and growth of PaCa cells (276).8. Prostate Cancer and ExosomesMen around the world continue to face a serious risk of dying from prostate cancer (PCa)(93). Metastatic illness, which is defined by the spread of prostate tumor cells to a variety ofdistant tissues, including the bone, liver, and lung, is the cause of the majority of PCa-relatedfatalities (93). Prostate cancer patients who have osteoblastic and osteolytic lesions are morelikely to develop bone metastasis (93). A diagnostic biomarker for PCa patients is serumprostate-specific antigen (PSA) (93). Its lack of specificity, however, has been demonstratedto cause overdiagnosis and overtreatment of PCa (277).Exosomes produced by tumors have been linked to the spread of prostate cancer to otherparts of the body, including the bones (93). The protein Src, which stimulates focal adhesionkinase through activation of integrins and results in angiogenesis and metastasis, has beenfound to be present in exosomes from prostate cancer cells, according to research by DeRitaet al. (278). Studies have also revealed that exosomes from prostate cancer cells boost MMPsin hypoxic environments, which results in vascular infiltration and encourages the invasion ofcirculating tumor cells, increasing angiogenesis (121, 279).The Hyal1 protein, which encourages prostate stromal cell migration and has anever-increasing impact on prostate cancer progression, is found in exosomes released byCancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

CANCER: FROM GENOMICS TO PHARMACEUTICSprostate tumor cells (280). According to one study, exosomes carrying the microRNAsmiR-125b, miR-130b, and miR-155 cause stem cells derived from adipose tissues of prostatecancer patients to undergo neoplastic transformation and mesenchymal-epithelial transition(281). miR-105 works as a tumor suppressor in tumor-derived exosomes and inhibits cellproliferation in prostate cancer via targeting CDK-6 (240, 282).9. Cervical Cancer and ExosomesThe squamocolumnar junction cells of the cervix are where cervical cancer develops,which is the most important leading reason for death from cancer in young women (159). Themost prevalent sexually transmitted infection, HPV, has been related to almost all cases (283,284).Numerous studies indicate that various exosomal miRNAs contribute significantly to thedevelopment of cervical cancer (159). EMT in cancer cells can be controlled by miR-221-3p(159). It has a significant role in the regulation of tissue-specific angiogenesis (159).Several lnRNAs, including CCND1, HOTAIR, TUG1, MALAT1, MEG3, GAS5.132, EXOC7,lincRNA-p21, and HNF1AAS1, have been identified as ceRNAs for miR-34b in exosomesobtained from cervicovaginal lavage, serum, or HeLa cells (159). These exosomal lncRNAsare implicated in cancer progression and may be noninvasive biomarkers for cervical canceridentification (285-288).Higher levels of Hedgehog signaling pathway targets, such as Patched1, Smoothened,Sonic hedgehog, and Indian hedgehog, are seen in the exosomes of cervical cancer cell lines(159). As a result, the Hedgehog signaling system is crucial for cervical cancer growth,metastasis, invasion, and medication resistance (289).10. ConclusionExosomes have been implicated in the establishment of PMN and distant metastasis by theirrole in cell-to-cell interactions within the tumor microenvironment, according to a number ofstudies. Future research will examine if exosomes can be used to transport therapeutic drugsand how they can function as prognostic and predictive indicators for metastasis in variousmalignancies. There are a number of questions that need to be asked in order to use exosomesin cancer treatment: What should be the donor cell type, what should be the therapeutic cargoto be transported in the exosomes (drug, miRNA, etc.), how these cargoes will be loaded intothe exosomes and how they will be targeted are among these questions.REFERENCES1. Trams EG, Lauter CJ, Salem N, Heine U. Exfoliation of Membrane Ecto-Enzymes inthe Form of Micro-Vesicles. Biochim Biophys Acta. 1981;645(1):63-70.Cancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

Merve C¸ igdem ˘ OZGEL, S¸eref Bu ¨ gra TUNC¸ ER ˘ 592. Johnstone RM, Adam M, Hammond JR, Orr L, Turbide C. Vesicle formation duringreticulocyte maturation. Association of plasma membrane activities with releasedvesicles (exosomes). J Biol Chem. 1987;262(19):9412-20.3. Xu W, Yang Z, Lu N. From pathogenesis to clinical application: insights into exosomesas transfer vectors in cancer. J Exp Clin Cancer Res. 2016;35(1):156.4. S. B. Eksozomlar ve Kanserdeki Rolleri. Dicle Medical Journal. 2018;45(2) 209-17.5. Tkach M, Thery C. Communication by Extracellular Vesicles: Where We Are andWhere We Need to Go. Cell. 2016;164(6):1226-32.6. Yuana Y, Sturk A, Nieuwland R. Extracellular vesicles in physiological and pathologicalconditions. Blood Rev. 2013;27(1):31-9.7. Thery C, Amigorena S, Raposo G, Clayton A. Isolation and characterization of exosomesfrom cell culture supernatants and biological fluids. Curr Protoc Cell Biol. 2006;Chapter3:Unit 3 22.8. Heijnen HF, Schiel AE, Fijnheer R, Geuze HJ, Sixma JJ. Activated plateletsrelease two types of membrane vesicles: microvesicles by surface shedding andexosomes derived from exocytosis of multivesicular bodies and alpha-granules. Blood.1999;94(11):3791-9.9. Jaiswal R, Gong J, Sambasivam S, Combes V, Mathys JM, Davey R, et al.Microparticle-associated nucleic acids mediate trait dominance in cancer. FASEB J.2012;26(1):420-9.10. Stein JM, Luzio JP. Ectocytosis caused by sublytic autologous complement attack onhuman neutrophils. The sorting of endogenous plasma-membrane proteins and lipidsinto shed vesicles. Biochem J. 1991;(274):381-6.11. Colombo M, Raposo G, Thery C. Biogenesis, secretion, and intercellular interactions ofexosomes and other extracellular vesicles. Annu Rev Cell Dev Biol. 2014;(30):255-89.12. Villarroya-Beltri C, Baixauli F, Gutierrez-Vazquez C, Sanchez-Madrid F, MittelbrunnM. Sorting it out: regulation of exosome loading. Semin Cancer Biol. 2014;(28):3-13.13. van Niel G, Porto-Carreiro I, Simoes S, Raposo G. Exosomes: a common pathway fora specialized function. J Biochem. 2006;140(1):13-21.14. Fang T, Lv HW, Lv GS, Li T, Wang CZ, Han Q, et al. Tumor-derived exosomalmiR-1247-3p induces cancer-associated fibroblast activation to foster lung metastasis ofliver cancer. Nature Communications. 2018;(9):191Cancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

60 EXOSOMES IN CANCER DEVELOPMENT AND METASTASIS15. Li W, Li C, Zhou T, Liu X, Liu X, Li X, et al. Role of exosomal proteins in cancerdiagnosis. Mol Cancer. 2017;16(1):145.16. Alipoor SD, Mortaz E, Varahram M, Movassaghi M, Kraneveld AD, Garssen J, et al.The Potential Biomarkers and Immunological Effects of Tumor-Derived Exosomes inLung Cancer. Front Immunol. 2018;(9):819.17. Jalalian SH, Ramezani M, Jalalian SA, Abnous K, Taghdisi SM. Exosomes, newbiomarkers in early cancer detection. Anal Biochem. 2019;(571):1-13.18. Bu H, He D, He X, Wang K. Exosomes: Isolation, Analysis, and Applications in CancerDetection and Therapy. Chembiochem. 2019;20(4):451-61.19. Sun W, Ren Y, Lu Z, Zhao X. The potential roles of exosomes in pancreatic cancerinitiation and metastasis. Mol Cancer. 2020;19(1):135.20. Staubach S, Razawi H, Hanisch FG. Proteomics of MUC1-containing lipid rafts fromplasma membranes and exosomes of human breast carcinoma cells MCF-7. Proteomics.2009;9(10):2820-35.21. Yim N, Ryu SW, Choi K, Lee KR, Lee S, Choi H, et al. Exosome engineering for efficientintracellular delivery of soluble proteins using optically reversible protein-proteininteraction module. Nat Commun. 2016;(7):122-77.22. Subra C, Laulagnier K, Perret B, Record M. Exosome lipidomics unravels lipid sortingat the level of multivesicular bodies. Biochimie. 2007;89(2):205-12.23. Huotari J, Helenius A. Endosome maturation. Embo J. 2011;30(17):3481-500.24. Ostrowski M, Carmo NB, Krumeich S, Fanget I, Raposo G, Savina A, et al. Rab27a andRab27b control different steps of the exosome secretion pathway. Nature Cell Biology.2010;12(1):19-U61.25. Pfeffer SR. Unsolved mysteries in membrane traffic. Annual Review of Biochemistry.2007;(76):629-45.26. Stuffers S, Wegner CS, Stenmark H, Brech A. Multivesicular Endosome Biogenesis inthe Absence of ESCRTs. Traffic. 2009;10(7):925-37.27. Escola JM, Kleijmeer MJ, Stoorvogel W, Griffith JM, Yoshie O, Geuze HJ. Selectiveenrichment of tetraspan proteins on the internal vesicles of multivesicular endosomesand on exosomes secreted by human B-lymphocytes. Journal of Biological Chemistry.1998;273(32):20121-7.Cancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

Merve C¸ igdem ˘ OZGEL, S¸eref Bu ¨ gra TUNC¸ ER ˘ 6128. Trajkovic K. Ceramide triggers budding of exosome vesicles into multivesicularendosomes (vol 319, pg 1244, 2008). Science. 2008;320(5873):179-.29. Jadli AS, Ballasy N, Edalat P, Patel VB. Inside(sight) of tiny communicator: exosomebiogenesis, secretion, and uptake. Mol Cell Biochem. 2020;467(1-2):77-94.30. Munich S, Sobo-Vujanovic A, Buchser WJ, Beer-Stolz D, Vujanovic NL. Dendritic cellexosomes directly kill tumor cells and activate natural killer cells via TNF superfamilyligands. Oncoimmunology. 2012;1(7):1074-83.31. Thery C. Exosomes: Secreted vesicles and intercellular communications. F1000 BiolRep. 2011;(3):1-8.32. Chicon-Bosch M, Tirado OM. Exosomes in Bone Sarcomas: Key Players in Metastasis.Cells. 2020;9(1).33. Pegtel DM, Gould SJ. Exosomes. Annu Rev Biochem. 2019;(88):487-514.34. Thery C, Ostrowski M, Segura E. Membrane vesicles as conveyors of immune responses.Nat Rev Immunol. 2009;9(8):581-93.35. Lachenal G, Pernet-Gallay K, Chivet M, Hemming FJ, Belly A, Bodon G, et al. Releaseof exosomes from differentiated neurons and its regulation by synaptic glutamatergicactivity. Mol Cell Neurosci. 2011;46(2):409-18.36. Ratajczak J, Miekus K, Kucia M, Zhang J, Reca R, Dvorak P, et al. Embryonicstem cell-derived microvesicles reprogram hematopoietic progenitors: evidence forhorizontal transfer of mRNA and protein delivery. Leukemia. 2006;20(5):847-56.37. Dias MVS, Costa CS, daSilva LLP. The Ambiguous Roles of Extracellular Vesicles inHIV Replication and Pathogenesis. Front Microbiol. 2018;(9):2411.38. Miller IV, Grunewald TG. Tumour-derived exosomes: Tiny envelopes for big stories.Biol Cell. 2015;107(9):287-305.39. Tai YL, Chen KC, Hsieh JT, Shen TL. Exosomes in cancer development and clinicalapplications. Cancer Sci. 2018;109(8):2364-74.40. Yin L, Liu X, Shao X, Feng T, Xu J, Wang Q, et al. The role of exosomes in lung cancermetastasis and clinical applications: an updated review. J Transl Med. 2021;19(1):312.41. Arrighetti N, Corbo C, Evangelopoulos M, Pasto A, Zuco V, Tasciotti E. Exosome-likeNanovectors for Drug Delivery in Cancer. Curr Med Chem. 2019;26(33):6132-48.Cancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

62 EXOSOMES IN CANCER DEVELOPMENT AND METASTASIS42. Yuan D, Zhao Y, Banks WA, Bullock KM, Haney M, Batrakova E, et al. Macrophageexosomes as natural nanocarriers for protein delivery to inflamed brain. Biomaterials.2017;(142):1-12.43. Haney MJ, Klyachko NL, Zhao Y, Gupta R, Plotnikova EG, He Z, et al. Exosomes as drugdelivery vehicles for Parkinson’s disease therapy. J Control Release. 2015;(207):18-30.44. Wang XY, Zhou Y, Ding KY. Roles of exosomes in cancer chemotherapy resistance,progression, metastasis and immunity, and their clinical applications (Review). Int JOncol. 2021;59(1).45. Whiteside TL. Tumor-Derived Exosomes and Their Role in Cancer Progression. AdvClin Chem. 2016;74:103-41.46. Szabo G, Momen-Heravi F. Extracellular vesicles in liver disease and potential asbiomarkers and therapeutic targets. Nat Rev Gastro Hepat. 2017;14(8):455-66.47. Jin XC, Chen YF, Chen HB, Fei SR, Chen DD, Cai XN, et al. Evaluation ofTumor-Derived Exosomal miRNA as Potential Diagnostic Biomarkers for Early-StageNon-Small Cell Lung Cancer Using Next-Generation Sequencing. Clin Cancer Res.2017;23(17):5311-9.48. Xue M, Chen W, Xiang A, Wang RQ, Chen H, Pan JJ, et al. Hypoxic exosomesfacilitate bladder tumor growth and development through transferring long non-codingRNA-UCA1. Molecular Cancer. 2017;16.49. Logozzi M, Angelini DF, Iessi E, Mizzoni D, Di Raimo R, Federici C, et al. IncreasedPSA expression on prostate cancer exosomes in in vitro condition and in cancer patients.Cancer Lett. 2017;(403):318-29.50. Puhka M, Takatalo M, Nordberg ME, Valkonen S, Nandania J, Aatonen M, et al.Metabolomic Profiling of Extracellular Vesicles and Alternative Normalization MethodsReveal Enriched Metabolites and Strategies to Study Prostate Cancer-Related Changes.Theranostics. 2017;7(16):3824-41.51. Johnson SM, Dempsey C, Chadwick A, Harrison S, Liu JZ, Di YJ, et al. Metabolicreprogramming of bone marrow stromal cells by leukemic extracellular vesicles in acutelymphoblastic leukemia. Blood. 2016;128(3):453-6.52. Yu X, Harris SL, Levine AJ. The regulation of exosome secretion: a novel function ofthe p53 protein. Cancer Res. 2006;66(9):4795-801.Cancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

Merve C¸ igdem ˘ OZGEL, S¸eref Bu ¨ gra TUNC¸ ER ˘ 6353. Wu F, Yin ZY, Yang L, Fan JS, Xu JJ, Jin Y, et al. Smoking Induced ExtracellularVesicles Release and Their Distinct Properties in Non-Small Cell Lung Cancer. J Cancer.2019;10(15):3435-43.54. Baumann K. Making more exosomes. Nat Rev Mol Cell Bio. 2021;22(4):242-.55. Adams SD, Csere J, D’angelo G, Carter EP, Romao M, Arnandis T, et al. Centrosomeamplification mediates small extracellular vesicle secretion via lysosome disruption.Curr Biol. 2021;31(7):140356. Lin YS, Dong HM, Deng WL, Lin W, Li K, Xiong X, et al. Evaluation of SalivaryExosomal Chimeric GOLM1-NAA35 RNA as a Potential Biomarker in EsophagealCarcinoma. Clin Cancer Res. 2019;25(10):3035-45.57. Hu YT, Qi CS, Liu X, Zhang C, Gao J, Wu Y, et al. Malignant ascites-derived exosomespromote peritoneal tumor cell dissemination and reveal a distinct miRNA signature inadvanced gastric cancer. Cancer Lett. 2019;457:142-50.58. Manier S, Liu CJ, Avet-Loiseau H, Park J, Shi JT, Campigotto F, et al. Prognostic roleof circulating exosomal miRNAs in multiple myeloma. Blood. 2017;129(17):2429-36.59. Ye SB, Zhang H, Cai TT, Liu YN, Ni JJ, He J, et al. Exosomal miR-24-3p impedesT-cell function by targeting FGF11 and serves as a potential prognostic biomarker fornasopharyngeal carcinoma. J Pathol. 2016;240(3):329-40.60. He L, Ping F, Fan ZN, Zhang C, Deng M, Cheng B, et al. Salivary exosomal miR-24-3pserves as a potential detective biomarker for oral squamous cell carcinoma screening.Biomed Pharmacother. 2020;121.61. Zou X, Zhu DX, Zhang H, Zhang SY, Zhou X, He X, et al. MicroRNA expressionprofiling analysis in serum for nasopharyngeal carcinoma diagnosis. Gene. 2020;727.62. Xu JF, Wang YP, Zhang SJ, Chen Y, Gu HF, Dou XF, et al. Exosomes containingdifferential expression of microRNA and mRNA in osteosarcoma that can predictresponse to chemotherapy. Oncotarget. 2017;8(44):75968-78.63. Fan Q, Yang L, Zhang XD, Peng XQ, Wei SB, Su DM, et al. The emerging role ofexosome-derived non-coding RNAs in cancer biology. Cancer Lett. 2018;414:107-15.64. Bobrie A, Colombo M, Raposo G, Thery C. Exosome Secretion: Molecular Mechanismsand Roles in Immune Responses. Traffic. 2011;12(12):1659-68.65. Li I, Nabet BY. Exosomes in the tumor microenvironment as mediators of cancer therapyresistance. Molecular Cancer. 2019;(18):32Cancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

64 EXOSOMES IN CANCER DEVELOPMENT AND METASTASIS66. Wortzel I, Dror S, Kenific CM, Lyden D. Exosome-Mediated Metastasis:Communication from a Distance. Dev Cell. 2019;49(3):347-60.67. Sung BH, Ketova T, Hoshino D, Zijlstra A, Weaver AM. Directional cell movementthrough tissues is controlled by exosome secretion. Nature Communications.2015;(6);716468. Milane L, Singh A, Mattheolabakis G, Suresh M, Amiji MM. Exosome mediatedcommunication within the tumor microenvironment. Journal of Controlled Release.2015;(219):278-94.69. Junttila MR, de Sauvage FJ. Influence of tumour micro-environment heterogeneity ontherapeutic response. Nature. 2013;501(7467):346-54.70. Hoshino A, Costa-Silva B, Shen TL, Rodrigues G, Hashimoto A, Tesic MarkM, et al. Tumour exosome integrins determine organotropic metastasis. Nature.2015;527(7578):329-35.71. Tsukamoto H, Fujieda K, Senju S, Ikeda T, Oshiumi H, Nishimura Y.Immune-suppressive effects of interleukin-6 on T-cell-mediated anti-tumor immunity.Cancer Science. 2018;109(3):523-30.72. Nishikawa H, Sakaguchi S. Regulatory T cells in cancer immunotherapy. Curr OpinImmunol. 2014;(27):1-7.73. Pace KR, Dutt R, Galileo DS. Exosomal L1CAM Stimulates Glioblastoma CellMotility, Proliferation, and Invasiveness. International Journal of Molecular Sciences.2019;20(16).74. Guo L, Zhu Y, Li LD, Zhou SF, Yin GH, Yu GH, et al. Breast cancer cell-derivedexosomal miR-20a-5p promotes the proliferation and differentiation of osteoclasts bytargeting SRCIN1. Cancer Med-Us. 2019;8(12):5687-701.75. Wang SH, Su XD, Xu MQ, Xiao X, Li XX, Li HL, et al. Exosomes secreted bymesenchymal stromal/stem cell-derived adipocytes promote breast cancer cell growthvia activation of Hippo signaling pathway. Stem Cell Res Ther. 2019;10.76. Lee FT, Mountain AJ, Kelly MP, Hall C, Rigopoulos A, Johns TG, et al. Enhancedefficacy of radioimmunotherapy with Y-90-CHX-A ”-DTPA-hu3S193 by inhibition ofepidermal growth factor receptor (EGFR) signaling with EGFR tyrosine kinase inhibitorAG1478. Clin Cancer Res. 2005;11(19):7080s-6s.Cancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

Merve C¸ igdem ˘ OZGEL, S¸eref Bu ¨ gra TUNC¸ ER ˘ 6577. Luo F SZ, Han Q, Xue C and Bai C. Effect of human hepatocellular carcinomaHepG2 Cell-derived exosome on the differentiation of mesenchymal stem cells andtheir interaction. Zhongguo Yi Xue Ke Xue Yuan Xue Bao. 2017;39:312-7.78. Amit M, Takahashi H, Dragomir MP, Lindemann A, Gleber-Netto FO, Pickering CR,et al. Loss of p53 drives neuron reprogramming in head and neck cancer. Nature.2020;578(7795):449-+.79. Lazar I, Clement E, Dauvillier S, Milhas D, Ducoux-Petit M, LeGonidec S, et al.Adipocyte Exosomes Promote Melanoma Aggressiveness through Fatty Acid Oxidation:A Novel Mechanism Linking Obesity and Cancer. Cancer Res. 2016;76(14):4051-7.80. Fang T, Lv H, Lv G, Li T, Wang C, Han Q, et al. Tumor-derived exosomal miR-1247-3pinduces cancer-associated fibroblast activation to foster lung metastasis of liver cancer.Nat Commun. 2018;9(1):191.81. Yan W, Wu XW, Zhou WY, Fong MY, Cao MH, Liu J, et al. Cancer-cell-secretedexosomal miR-105 promotes tumour growth through the MYC-dependent metabolicreprogramming of stromal cells. Nature Cell Biology. 2018;20(5):597-+.82. McAtee CO, Booth C, Elowsky C, Zhao L, Payne J, Fangman T, et al. Prostate tumorcell exosomes containing hyaluronidase Hyal1 stimulate prostate stromal cell motilityby engagement of FAK-mediated integrin signaling. Matrix Biol. 2019;78-79:165-79.83. Becker A, Thakur BK, Weiss JM, Kim HS, Peinado H, Lyden D. Extracellular Vesiclesin Cancer: Cell-to-Cell Mediators of Metastasis. Cancer Cell. 2016;30(6):836-48.84. Todorova D, Simoncini S, Lacroix R, Sabatier F, Dignat-George F. Extracellular Vesiclesin Angiogenesis. Circ Res. 2017;120(10):1658-73.85. Bao LL, You B, Shi S, Shan Y, Zhang QC, Yue HJ, et al. Metastasis-associated miR-23afrom nasopharyngeal carcinoma-derived exosomes mediates angiogenesis by repressinga novel target gene TSGA10. Oncogene. 2018;37(21):2873-89.86. Chen Y, Zeng C, Zhan Y, Wang H, Jiang X, Li W. Aberrant low expression of p85 alphain stromal fibroblasts promotes breast cancer cell metastasis through exosome-mediatedparacrine Wnt10b. Oncogene. 2017;36(33):4692-705.87. Akhtar M, Haider, A., Rashid, S., Al-Nabet, A.D.M.H. Paget’s “Seed and Soil” Theoryof Cancer Metastasis. Adv Anat Pathol. 2018;26:69-74.88. Hinshaw DC, Shevde LA. The Tumor Microenvironment Innately Modulates CancerProgression. Cancer Res. 2019;79(18):4557-66.Cancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

66 EXOSOMES IN CANCER DEVELOPMENT AND METASTASIS89. Hanahan D, Weinberg RA. Hallmarks of Cancer: The Next Generation. Cell.2011;144(5):646-74.90. Liu Y, Cao XT. Characteristics and Significance of the Pre-metastatic Niche. CancerCell. 2016;30(5):668-81.91. Hu C, Chen MJ, Jiang RL, Guo YY, Wu MH, Zhang X. Exosome-related tumormicroenvironment. J Cancer. 2018;9(17):3084-92.92. Guo YX, Ji X, Liu JB, Fan DD, Zhou QB, Chen C, et al. Effects of exosomes onpre-metastatic niche formation in tumors. Molecular Cancer. 2019;18.93. Akoto T, Saini S. Role of Exosomes in Prostate Cancer Metastasis. Int J Mol Sci.2021;22(7).94. Yamamura Y, Asai N, Enomoto A, Kato T, Mii S, Kondo Y, et al. Akt-GirdinSignaling in Cancer-Associated Fibroblasts Contributes to Tumor Progression. CancerRes. 2015;75(5):813-23.95. Wang J-P, Tang, Y.-Y., Fan, C.-M., Guo, C., Zhou, Y.-H., Li, Z., Li, X.-L., Li, Y.,Li, G.-Y., Xiong, W. The role of exosomal non-coding RNAs in cancer metastasis.Oncotarget. 2018;9:12487-502.96. Muz B, de la Puente P, Azab F, Azab AK. The role of hypoxia in cancer progression,angiogenesis, metastasis, and resistance to therapy. Hypoxia. 2015;3:83-92.97. Abels ER, Breakefield XO. Introduction to Extracellular Vesicles: Biogenesis, RNACargo Selection, Content, Release, and Uptake. Cell Mol Neurobiol. 2016;36(3):301-12.98. Bade BC, Dela Cruz CS. Lung Cancer 2020 Epidemiology, Etiology, and Prevention.Clin Chest Med. 2020;41(1):1-+.99. Romaszko AM, Doboszynska A. Multiple primary lung cancer: A literature review.Adv Clin Exp Med. 2018;27(5):717-22.100. Li MY, Liu LZ, Dong M. Progress on pivotal role and application of exosome in lungcancer carcinogenesis, diagnosis, therapy and prognosis. Molecular Cancer. 2021;20(1).101. Wood SL, Pernemalm M, Crosbie PA, Whetton AD. The role of thetumor-microenvironment in lung cancer-metastasis and its relationship to potentialtherapeutic targets. Cancer Treat Rev. 2014;40(4):558-66.102. Siegel RL, Miller KD, Jemal A. Cancer Statistics, 2018. Ca-Cancer J Clin.2018;68(1):7-30.Cancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

Merve C¸ igdem ˘ OZGEL, S¸eref Bu ¨ gra TUNC¸ ER ˘ 67103. Hu CP, Meiners S, Lukas C, Stathopoulos GT, Chen J. Role of exosomal microRNAs inlung cancer biology and clinical applications. Cell Proliferat. 2020;53(6).104. Wu J, Shen ZJ. Exosomal miRNAs as biomarkers for diagnostic and prognosticin lungcancer. Cancer Med-Us. 2020;9(19):6909-22.105. Reclusa P, Taverna S, Pucci M, Durendez E, Calabuig S, Manca P, et al. Exosomes asdiagnostic and predictive biomarkers in lung cancer. J Thorac Dis. 2017;9:S1373-S82.106. Amiri A, Pourhanifeh MH, Mirzaei HR, Nahand JS, Moghoofei M, Sahebnasagh R, etal. Exosomes and Lung Cancer: Roles in Pathophysiology, Diagnosis and TherapeuticApplications. Current Medicinal Chemistry. 2021;28(2):308-28.107. Frydrychowicz M, Kolecka-Bednarczyk A, Madejczyk M, Yasar S, Dworacki G.Exosomes - Structure, Biogenesis and Biological Role in Non-Small- Cell Lung Cancer.Scand J Immunol. 2015;81(1):2-10.108. Chen R, Xu X, Qian ZJ, Zhang CC, Niu YJ, Wang ZX, et al. The biologicalfunctions and clinical applications of exosomes in lung cancer. Cell Mol Life Sci.2019;76(23):4613-33.109. Tian XY, Shen H, Li ZY, Wang TT, Wang SJ. Tumor-derived exosomes, myeloid-derivedsuppressor cells, and tumor microenvironment. Journal of Hematology Oncology.2019;12(1).110. Whiteside TL. Exosomes and tumor-mediated immune suppression. J Clin Invest.2016;126(4):1216-23.111. Chen G, Huang AC, Zhang W, Zhang G, Wu M, Xu W, et al. Exosomal PD-L1contributes to immunosuppression and is associated with anti-PD-1 response. Nature.2018;560(7718):382-+.112. Poggio M, Hu TY, Pai CC, Chu B, Belair CD, Chang A, et al. Suppression of ExosomalPD-L1 Induces Systemic Anti-tumor Immunity and Memory. Cell. 2019;177(2):414-+.113. Kim DH, Kim H, Choi YJ, Kim SY, Lee JE, Sung KJ, et al. Exosomal PD-L1 promotestumor growth through immune escape in non-small cell lung cancer. Exp Mol Med.2019;51.114. Berchem G, Noman MZ, Bosseler M, Paggetti J, Baconnais S, Le Cam E, et al. Hypoxictumor-derived microvesicles negatively regulate NK cell function by a mechanisminvolving TGF- and miR23a transfer. Oncoimmunology. 2016;5(4).Cancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

68 EXOSOMES IN CANCER DEVELOPMENT AND METASTASIS115. Huang SH, Li Y, Zhang J, Rong J, Ye S. Epidermal Growth Factor Receptor-ContainingExosomes Induce Tumor-Specific Regulatory T Cells. Cancer Invest. 2013;31(5):330-5.116. Greening DW, Gopal SK, Mathias RA, Liu L, Sheng JY, Zhu HJ, et al. Emerging rolesof exosomes during epithelial-mesenchymal transition and cancer progression. SeminCell Dev Biol. 2015;40:60-71.117. Blackwell RH, Foreman KE, Gupta GN. The Role of Cancer-Derived Exosomes inTumorigenicity Epithelial-to-Mesenchymal Transition. Cancers. 2017;9(8).118. Kim J, Kim TY, Lee MS, Mun JY, Ihm C, Kim SA. Exosome cargo reflects TGF-beta1-mediated epithelial-to-mesenchymal transition (EMT) status in A549 human lungadenocarcinoma cells. Biochem Bioph Res Co. 2016;478(2):643-8.119. Tang YT, Huang YY, Li JH, Qin SH, Xu Y, An TX, et al. Alterations in exosomalmiRNA profile upon epithelial-mesenchymal transition in human lung cancer cell lines.Bmc Genomics. 2018;19.120. Rahman MA, Barger JF, Lovat F, Gao M, Otterson GA, Nana-Sinkam P. Lungcancer exosomes as drivers of epithelial mesenchymal transition. Oncotarget.2016;7(34):54852-66.121. Peinado H, Zhang HY, Matei IR, Costa-Silva B, Hoshino A, Rodrigues G, etal. Pre-metastatic niches: organ-specific homes for metastases. Nat Rev Cancer.2017;17(5):302-17.122. Cheng Y, Dai X, Yang T, Zhang N, Liu ZZ, Jiang YG. Low Long Noncoding RNAGrowth Arrest-Specific Transcript 5 Expression in the Exosomes of Lung Cancer CellsPromotes Tumor Angiogenesis. J Oncol. 2019;2019.123. Mao SS, Lu ZL, Zheng SF, Zhang H, Zhang GC, Wang F, et al. Exosomal miR-141promotes tumor angiogenesis via KLF12 in small cell lung cancer. J Exp Clin Canc Res.2020;39(1).124. Liu M, Sun X, Shi S. MORC2 Enhances Tumor Growth by Promoting Angiogenesisand Tumor-Associated Macrophage Recruitment via Wnt/beta-Catenin in Lung Cancer.Cell Physiol Biochem. 2018;51(4):1679-94.125. Zhou L, Lv TF, Zhang Q, Zhu QQ, Zhan P, Zhu SH, et al. The biology, function andclinical implications of exosomes in lung cancer. Cancer Lett. 2017;407:84-92.126. Iqbal MA, Arora S, Prakasam G, Calin GA, Syed MA. MicroRNA in lung cancer: role,mechanisms, pathways and therapeutic relevance. Mol Aspects Med. 2019;70:3-20.Cancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

Merve C¸ igdem ˘ OZGEL, S¸eref Bu ¨ gra TUNC¸ ER ˘ 69127. Wang YZ, Yi J, Chen XG, Zhang Y, Xu M, Yang ZX. The regulation of cancer cellmigration by lung cancer cell-derived exosomes through TGF-beta and IL-10. OncolLett. 2016;11(2):1527-30.128. Wu CF, Andzinski L, Kasnitz N, Kroger A, Klawonn F, Lienenklaus S, et al. The lackof type I interferon induces neutrophil-mediated pre-metastatic niche formation in themouse lung. Int J Cancer. 2015;137(4):837-47.129. Liu YF, Gu Y, Han YM, Zhang Q, Jiang ZP, Zhang X, et al. Tumor Exosomal RNAsPromote Lung Pre-metastatic Niche Formation by Activating Alveolar Epithelial TLR3to Recruit Neutrophils. Cancer Cell. 2016;30(2):243-56.130. Hood JL, Roman SS, Wickline SA. Exosomes Released by Melanoma Cells PrepareSentinel Lymph Nodes for Tumor Metastasis. Cancer Res. 2011;71(11):3792-801.131. Peinado H, Aleckovic M, Lavotshkin S, Matei I, Costa-Silva B, Moreno-Bueno G, etal. Melanoma exosomes educate bone marrow progenitor cells toward a pro-metastaticphenotype through MET. Nat Med. 2012;18(6):883-+.132. Weidle UH, Birzele F, Kollmorgen G, Ruger R. The Multiple Roles of Exosomes inMetastasis. Cancer Genom Proteom. 2017;14(1):1-15.133. Zeng ZC, Li YL, Pan YJ, Lan XL, Song FY, Sun JB, et al. Cancer-derived exosomalmiR-25-3p promotes pre-metastatic niche formation by inducing vascular permeabilityand angiogenesis. Nature Communications. 2018;9.134. Kucharzewska P, Christianson HC, Welch JE, Svensson KJ, Fredlund E, Ringner M, etal. Exosomes reflect the hypoxic status of glioma cells and mediate hypoxia-dependentactivation of vascular cells during tumor development. P Natl Acad Sci USA.2013;110(18):7312-7.135. Rak J. Microparticles in Cancer. Semin Thromb Hemost. 2010;36(8):888-906.136. Chalmin F, Ladoire S, Mignot G, Vincent J, Bruchard M, Remy-Martin JP, et al.Membrane-associated Hsp72 from tumor-derived exosomes mediates STAT3-dependentimmunosuppressive function of mouse and human myeloid-derived suppressor cells. JClin Invest. 2010;120(2):457-71.137. Benito-Martin A DGA, Ceder S, Peinado H. The new deal: a potential role for secretedvesicles in innate immunity and tumor progression. Front Immunol. 2015;6:66.138. Bobrie A, Krumeich S, Reyal F, Recchi C, Moita LF, Seabra MC, et al.Rab27a Supports Exosome-Dependent and -Independent Mechanisms That ModifyCancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

70 EXOSOMES IN CANCER DEVELOPMENT AND METASTASISthe Tumor Microenvironment and Can Promote Tumor Progression. Cancer Res.2012;72(19):4920-30.139. Ludwig S, Floros T, Theodoraki MN, Hong CS, Jackson EK, Lang S, et al. Suppressionof Lymphocyte Functions by Plasma Exosomes Correlates with Disease Activity inPatients with Head and Neck Cancer. Clin Cancer Res. 2017;23(16):4843-54.140. Czernek L, Duchler M. Functions of Cancer-Derived Extracellular Vesicles inImmunosuppression. Arch Immunol Ther Ex. 2017;65(4):311-23.141. Plebanek MP, Angeloni NL, Vinokour E, Li J, Henkin A, Martinez-Marin D, et al.Pre-metastatic cancer exosomes induce immune surveillance by patrolling monocytesat the metastatic niche. Nature Communications. 2017;8.142. Pritchard A, Tousif S, Wang Y, Hough K, Khan S, Strenkowski J, et al. Lung TumorCell-Derived Exosomes Promote M2 Macrophage Polarization. Cells. 2020;9(5).143. Clark DJ, Fondrie WE, Yang A, Mao L. Triple SILAC quantitative proteomic analysisreveals differential abundance of cell signaling proteins between normal and lungcancer-derived exosomes. J Proteomics. 2016;133:161-9.144. Zhang N, Nan AR, Chen LJ, Li X, Jia YY, Qiu MY, et al. Circular RNA circSATB2promotes progression of non-small cell lung cancer cells. Molecular Cancer. 2020;19(1).145. Qi YJ, Zha WJ, Zhang W. Exosomal miR-660-5p promotes tumor growth and metastasisin non-small cell lung cancer. J Buon. 2019;24(2):599-607.146. Hong WJ, Xue M, Jiang J, Zhang YJ, Gao XW. Circular RNA circ-CPA4/let-7miRNA/PD-L1 axis regulates cell growth, stemness, drug resistance and immuneevasion in non-small cell lung cancer (NSCLC). J Exp Clin Canc Res. 2020;39(1).147. Wu DM, Deng SH, Liu T, Han R, Zhang T, Xu Y. TGF-beta-mediated exosomallnc-MMP2-2 regulates migration and invasion of lung cancer cells to the vasculature bypromoting MMP2 expression. Cancer Med-Us. 2018;7(10):5118-29.148. Yao J LX, Wang Y, Li J, Ni B. Long noncoding RNAs AC026904.1 is essential forTGF--induced migration and epithelial-mesenchymal transition through functioning asan enhancer of slug in lung cancer cells. Environ Toxicol. 2020;9:942-51.149. Li C, Wan L, Liu ZY, Xu GQ, Wang SJ, Su ZY, et al. Long non-coding RNAXIST promotes TGF-beta-induced epithelial-mesenchymal transition by regulatingmiR-367/141-ZEB2 axis in non-small-cell lung cancer. Cancer Lett. 2018;418:185-95.Cancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

Merve C¸ igdem ˘ OZGEL, S¸eref Bu ¨ gra TUNC¸ ER ˘ 71150. Chen LT, Xu SD, Xu H, Zhang JF, Ning JF, Wang SF. MicroRNA-378 is associated withnon-small cell lung cancer brain metastasis by promoting cell migration, invasion andtumor angiogenesis. Med Oncol. 2012;29(3):1673-80.151. Kim DH, Park S, Kim H, Choi YJ, Kim SY, Sung KJ, et al. Tumor-derived exosomalmiR-619-5p promotes tumor angiogenesis and metastasis through the inhibition ofRCAN1.4. Cancer Lett. 2020;475:2-13.152. Taverna S, Pucci M, Giallombardo M, Di Bella MA, Santarpia M, Reclusa P, et al.Amphiregulin contained in NSCLC-exosomes induces osteoclast differentiation throughthe activation of EGFR pathway. Sci Rep-Uk. 2017;7.153. Yang XR, Pi C, Yu RY, Fan XJ, Peng XX, Zhang XC, et al. Correlation of exosomalmicroRNA clusters with bone metastasis in non-small cell lung cancer. Clin ExpMetastas. 2021;38(1):109-17.154. Xu ZH, Miao ZW, Jiang QZ, Gan DX, Wei XG, Xue XZ, et al. Brain microvascularendothelial cell exosome-mediated S100A16 up-regulation confers small-cell lungcancer cell survival in brain. Faseb Journal. 2019;33(2):1742-57.155. Wei CH, Zhang RG, Cai Q, Gao XC, Tong F, Dong JH, et al. MicroRNA-330-3p promotesbrain metastasis and epithelial-mesenchymal transition via GRIA3 in non-small cell lungcancer. Aging-Us. 2019;11(17):6734-61.156. Leong HS, Robertson AE, Stoletov K, Leith SJ, Chin CA, Chien AE, et al. InvadopodiaAre Required for Cancer Cell Extravasation and Are a Therapeutic Target for Metastasis.Cell Rep. 2014;8(5):1558-70.157. Wang LQ, Tong X, Zhou ZY, Wang SJ, Lei Z, Zhang TZ, et al. CircularRNA hsacirc0008305 (circPTK2) inhibits TGF-beta-induced epithelial- mesenchymaltransition and metastasis by controlling TIF1 gamma in non-small cell lung cancer.Molecular Cancer. 2018;17.158. You J, Li M, Cao LM, Gu QH, Deng PB, Tan Y, et al. Snail1-dependent cancer-associatedfibroblasts induce epithelial-mesenchymal transition in lung cancer cells via exosomes.Qjm-Int J Med. 2019;112(8):581-90.159. Esfandyari S, Elkafas H, Chugh RM, Park HS, Navarro A, Al-Hendy A. Exosomesas Biomarkers for Female Reproductive Diseases Diagnosis and Therapy. InternationalJournal of Molecular Sciences. 2021;22(4).160. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2019. Ca-Cancer J Clin.2019;69(1):7-34.Cancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

72 EXOSOMES IN CANCER DEVELOPMENT AND METASTASIS161. Leskela S, Perez-Mies B, Rosa-Rosa JM, Cristobal E, Biscuola M, Palacios-BerraqueroML, et al. Molecular Basis of Tumor Heterogeneity in Endometrial Carcinosarcoma.Cancers. 2019;11(7).162. Carvalho MJ, Laranjo M, Abrantes AM, Torgal I, Botelho MF, Oliveira CF.Clinical translation for endometrial cancer stem cells hypothesis. Cancer Metast Rev.2015;34(3):401-16.163. Muinelo-Romay L, Casas-Arozamena C, Abal M. Liquid Biopsy in Endometrial Cancer:New Opportunities for Personalized Oncology. International Journal of MolecularSciences. 2018;19(8).164. Maida Y, Takakura M, Nishiuchi T, Yoshimoto T, Kyo S. Exosomal transfer of functionalsmall RNAs mediates cancer-stroma communication in human endometrium. CancerMed-Us. 2016;5(2):304-14.165. Li BL, Lu W, Qu JJ, Ye L, Du GQ, Wan XP. Loss of exosomal miR-148b fromcancer-associated fibroblasts promotes endometrial cancer cell invasion and cancermetastasis. J Cell Physiol. 2019;234(3):2943-53.166. Zhang N, Wang YH, Liu HB, Shen WJ. Extracellular vesicle encapsulatedmicroRNA-320a inhibits endometrial cancer by suppression of the HIF1 alpha/VEGFAaxis. Exp Cell Res. 2020;394(2).167. Song Y, Wang, M., Tong, H., Tan, Y., Hu, X., Wang, K., Wan, X. . Plasma exosomesfrom endometrial cancer patients contain LGALS3BP to promote endometrial cancerprogression. Oncogene. 2021;40:633-46.168. Xiao L, He YM, Peng F, Yang JL, Yuan CF. Endometrial Cancer Cells Promote M2-LikeMacrophage Polarization by Delivering Exosomal miRNA-21 under Hypoxia Condition.J Immunol Res. 2020;2020.169. Che XX, Jian FF, Chen C, Liu C, Liu GD, Feng WW. PCOS serum-derivedexosomal miR-27a-5p stimulates endometrial cancer cells migration and invasion. JMol Endocrinol. 2020;64(1):1-12.170. Srivastava A, Moxley K, Ruskin R, Dhanasekaran DN, Zhao YD, Ramesh R. ANon-invasive Liquid Biopsy Screening of Urine-Derived Exosomes for miRNAs asBiomarkers in Endometrial Cancer Patients. Aaps J. 2018;20(5).171. Shi S, Tan Q, Feng FQ, Huang HP, Liang JJ, Cao DR, et al. Identification of coregenes in the progression of endometrial cancer and cancer cell-derived exosomes by anintegrative analysis. Sci Rep-Uk. 2020;10(1).Cancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

Merve C¸ igdem ˘ OZGEL, S¸eref Bu ¨ gra TUNC¸ ER ˘ 73172. Dziechciowski M, Zapala B, Skotniczny K, Gawlik K, Pawlica-Gosiewska D, PiwowarM, et al. Diagnostic and prognostic relevance of microparticles in peripheral and uterineblood of patients with endometrial cancer. Ginekol Pol. 2018;89(12):682-7.173. Casali PG, Bielack S, Abecassis N, Aro HT, Bauer S, Biagini R, et al. Bone sarcomas:ESMO-PaedCan-EURACAN Clinical Practice Guidelines for diagnosis, treatment andfollow-up. Ann Oncol. 2018;29:79-95.174. Rozeman LB, Cleton-Jansen AM, Hogendoorn PCW. Pathology of primary malignantbone and cartilage tumours. Int Orthop. 2006;30(6):437-44.175. Stiller CA, Trama A, Serraino D, Rossi S, Navarro C, Chirlaque MD, et al. Descriptiveepidemiology of sarcomas in Europe: Report from the RARECARE project. Eur JCancer. 2013;49(3):684-95.176. Eyre R, Feltbower RG, Mubwandarikwa E, Eden TOB, McNally RJQ. Epidemiology ofBone Tumours in Children and Young Adults. Pediatr Blood Cancer. 2009;53(6):941-52.177. Grunewald TGP, Cidre-Aranaz F, Surdez D, Tomazou EM, de Alava E, Kovar H, et al.Ewing sarcoma. Nat Rev Dis Primers. 2018;4.178. Kansara M, Teng MW, Smyth MJ, Thomas DM. Translational biology of osteosarcoma.Nat Rev Cancer. 2014;14(11):722-35.179. Gaspar N, Hawkins DS, Dirksen U, Lewis IJ, Ferrari S, Le Deley MC, et al. EwingSarcoma: Current Management and Future Approaches Through Collaboration. J ClinOncol. 2015;33(27):3036-U140.180. Zhuo BB, Li Y, Gu F, Li ZW, Sun QZ, Shi YC, et al. Overexpression of CD155 relatesto metastasis and invasion in osteosarcoma. Oncol Lett. 2018;15(5):7312-8.181. Xu HY, Zhu XJ, Bao H, Shek TW, Huang ZW, Wang YQ, et al. Genetic andclonal dissection of osteosarcoma progression and lung metastasis. Int J Cancer.2018;143(5):1134-42.182. Mu XD, Isaac C, Greco N, Huard J, Weiss K. Notch signaling is associated with ALDHactivity and an aggressive metastatic phenotype in murine osteosarcoma cells. FrontOncol. 2013;3.183. Potratz J, Tillmanns A, Berning P, Korsching E, Schaefer C, Lechtape B, et al. Receptortyrosine kinase gene expression profiles of Ewing sarcomas reveal ROR1 as a potentialtherapeutic target in metastatic disease. Mol Oncol. 2016;10(5):677-92.Cancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

74 EXOSOMES IN CANCER DEVELOPMENT AND METASTASIS184. Li GQ, Zhang P, Zhang WK, Lei Z, He JM, Meng JH, et al. Identification of keygenes and pathways in Ewing’s sarcoma patients associated with metastasis and poorprognosis. Oncotargets Ther. 2019;12:4153-65.185. Luo W, Xu C, Ayello J, Dela Cruz F, Rosenblum JM, Lessnick SL, et al. Proteinphosphatase 1 regulatory subunit 1A in ewing sarcoma tumorigenesis and metastasis.Oncogene. 2018;37(6):798-809.186. Choo S, Wang P, Newbury R, Roberts W, Yang J. Reactivation of TWIST1 contributesto Ewing sarcoma metastasis. Pediatr Blood Cancer. 2018;65(1).187. Hatano M, Matsumoto Y, Fukushi J, Matsunobu T, Endo M, Okada S, et al.Cadherin-11 regulates the metastasis of Ewing sarcoma cells to bone. Clin Exp Metastas.2015;32(6):579-91.188. Mendoza-Naranjo A, El-Naggar A, Wai DH, Mistry P, Lazic N, Ayala FRR, et al. ERBB4confers metastatic capacity in Ewing sarcoma. Embo Mol Med. 2013;5(7):1087-102.189. El-Naggar AM, Veinotte CJ, Cheng HW, Grunewald TGP, Negri GL, Somasekharan SP,et al. Translational Activation of HIF1 alpha by YB-1 Promotes Sarcoma Metastasis.Cancer Cell. 2015;27(5):682-97.190. Krook MA, Nicholls LA, Scannell CA, Chugh R, Thomas DG, Lawlor ER.Stress-Induced CXCR4 Promotes Migration and Invasion of Ewing Sarcoma. MolCancer Res. 2014;12(6):953-64.191. Chow WA. Chondrosarcoma: Biology, genetics, and epigenetics. F1000Research.2018;7.192. Wu CML, T.M.; Hsu, S.F.; Su, Y.C.; Kao, S.T.; Fong, Y.C.; Tang, C.H. IGF-I enhances51 integrin expression and cell motility in human chondrosarcoma cells. J Cell Physiol.2011;226:3270-7.193. Lai TH, Fong YC, Fu WM, Yang RS, Tang CH. Stromal Cell-Derived Factor-1 Increasealpha v beta 3 Integrin Expression and Invasion in Human Chondrosarcoma Cells. JCell Physiol. 2009;218(2):334-42.194. Valery PC, Laversanne M, Bray F. Bone cancer incidence by morphological subtype: aglobal assessment. Cancer Cause Control. 2015;26(8):1127-39.195. Mirabello LT, R.J.; Savage, S.A. Osteosarcoma incidence and survival improvement.Cancer-Am Cancer Soc. 2009;115:1531-43.Cancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

Merve C¸ igdem ˘ OZGEL, S¸eref Bu ¨ gra TUNC¸ ER ˘ 75196. Abarrategi A, Tornin J, Martinez-Cruzado L, Hamilton A, Martinez-Campos E, RodrigoJP, et al. Osteosarcoma: Cells-of-Origin, Cancer Stem Cells, and Targeted Therapies.Stem Cells Int. 2016;2016.197. Bayani J, Zielenska M, Pandita A, Al-Romaih K, Karaskova J, Harrison K, et al. Spectralkaryotyping identifies recurrent complex rearrangements of chromosomes 8, 17, and 20in osteosarcomas. Gene Chromosome Canc. 2003;36(1):7-16.198. Stephens PJ, Greenman CD, Fu BY, Yang FT, Bignell GR, Mudie LJ, et al. MassiveGenomic Rearrangement Acquired in a Single Catastrophic Event during CancerDevelopment. Cell. 2011;144(1):27-40.199. Daw NC, Chou AJ, Jaffe N, Rao BN, Billups CA, Rodriguez-Galindo C, et al. Recurrentosteosarcoma with a single pulmonary metastasis: a multi-institutional review. Brit JCancer. 2015;112(2):278-82.200. Isakoff MS, Bielack SS, Meltzer P, Gorlick R. Osteosarcoma: Current Treatment and aCollaborative Pathway to Success. J Clin Oncol. 2015;33(27):3029-U127.201. Jerez S, Araya H, Hevia D, Irarrazaval CE, Thaler R, van Wijnen AJ, et al. Extracellularvesicles from osteosarcoma cell lines contain miRNAs associated with cell adhesionand apoptosis. Gene. 2019;710:246-57.202. Gong LZ, Bao QY, Hu CZ, Wang J, Zhou Q, Wei L, et al. Exosomal miR-675 frommetastatic osteosarcoma promotes cell migration and invasion by targeting CALN1.Biochem Bioph Res Co. 2018;500(2):170-6.203. Raimondi LDL, A.; Gallo, A.; Costa, V.; Russelli, G.; Cuscino, N.; Manno, M.;Raccosta, S.; Carina, V.; Bellavia, D. Osteosarcoma cell-derived exosomes affect tumormicroenvironment by specific packaging of microRNAs. Carcinogenesis. 2019:1-12.204. Baglio SR, Lagerweij T, Perez-Lanzon M, Ho XD, Leveille N, Melo SA, et al. BlockingTumor-Educated MSC Paracrine Activity Halts Osteosarcoma Progression. Clin CancerRes. 2017;23(14):3721-33.205. Shimbo K, Miyaki S, Ishitobi H, Kato Y, Kubo T, Shimose S, et al. Exosome-formedsynthetic microRNA-143 is transferred to osteosarcoma cells and inhibits theirmigration. Biochem Bioph Res Co. 2014;445(2):381-7.206. Delattre O, Zucman J, Plougastel B, Desmaze C, Melot T, Peter M, et al. Gene Fusionwith an Ets DNA-Binding Domain Caused by Chromosome-Translocation in HumanTumors. Nature. 1992;359(6391):162-5.Cancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

76 EXOSOMES IN CANCER DEVELOPMENT AND METASTASIS207. Peter M, Gilbert E, Delattre O. A multiplex real-time PCR assay for the detection ofgene fusions observed in solid tumors. Lab Invest. 2001;81(6):905-12.208. Pinto AD, P.; Parham, D. Pathobiologic markers of the Ewing sarcoma family of tumors:State of the art and prediction of behaviour. Sarcoma. 2011.209. Kreppel M, Aryee DNT, Schaefer KL, Amann G, Kofler R, Poremba C, et al. Suppressionof KCMF1 by constitutive high CD99 expression is involved in the migratory ability ofEwing’s sarcoma cells. Oncogene. 2006;25(19):2795-800.210. Rocchi A, Manara MC, Sciandra M, Zambelli D, Nardi F, Nicoletti G, et al. CD99inhibits neural differentiation of human Ewing sarcoma cells and thereby contributes tooncogenesis. J Clin Invest. 2010;120(3):668-80.211. Balamuth NJ, Womer RB. Ewing’s sarcoma. Lancet Oncol. 2010;11(2):184-92.212. Rodriguez-Galindo C. Treatment of Ewing sarcoma family of tumors: Current statusand outlook for the future (vol 40, pg 276, 2003). Med Pediatr Oncol. 2003;41(6):594-.213. Miller IV, Raposo G, Welsch U, da Costa OP, Thiel U, Lebar M, et al. First identificationof Ewing’s sarcoma-derived extracellular vesicles and exploration of their biologicaland potential diagnostic implications. Biology of the Cell. 2013;105(7):289-303.214. Tsugita M, Yamada N, Noguchi S, Yamada K, Moritake H, Shimizu K, et al.Ewing Sarcoma Cells Secrete EWS/Fli-1 Fusion mRNA via Microvesicles. Plos One.2013;8(10).215. Villasante A, Marturano-Kruik A, Ambati SR, Liu Z, Godier-Furnemont A, Parsa H,et al. Recapitulating the Size and Cargo of Tumor Exosomes in a Tissue-EngineeredModel. Theranostics. 2016;6(8):1119-30.216. Ventura S, Aryee DNT, Felicetti F, De Feo A, Mancarella C, ManaraMC, et al. CD99 regulates neural differentiation of Ewing sarcoma cellsthrough miR-34a-Notch-mediated control of NF-kappa B signaling. Oncogene.2016;35(30):3944-54.217. De Feo A, Sciandra M, Ferracin M, Felicetti F, Astolfi A, Pignochino Y, et al. Exosomesfrom CD99-deprived Ewing sarcoma cells reverse tumor malignancy by inhibiting cellmigration and promoting neural differentiation. Cell Death Dis. 2019;10.218. Kim MJC, K.J.; Ayala, A.G.; Ro, J.Y. . Chondrosarcoma: With updates on moleculargenetics. Sarcoma. 2011.Cancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

Merve C¸ igdem ˘ OZGEL, S¸eref Bu ¨ gra TUNC¸ ER ˘ 77219. Cintra FF, Etchebehere M, Goncalves JCB, Cassone AE, Amstalden EMI. VascularPattern in Enchondroma and Chondrosarcoma: Clinical and Immunohistologic Study.Appl Immunohisto M M. 2014;22(8):600-5.220. Liu GT, Chen HT, Tsou HK, Tan TW, Fong YC, Chen PC, et al. CCL5 promotesVEGF-dependent angiogenesis by down-regulating miR-200b through PI3K/Aktsignaling pathway in human chondrosarcoma cells. Oncotarget. 2014;5(21):10718-31.221. Liu GT, Huang YL, Tzeng HE, Tsai CH, Wang SW, Tang CH. CCL5 promotes vascularendothelial growth factor expression and induces angiogenesis by down-regulatingmiR-199a in human chondrosarcoma cells. Cancer Lett. 2015;357(2):476-87.222. Sun XJ, Charbonneau C, Wei L, Chen Q, Terek RM. miR-181a Targets RGS16 toPromote Chondrosarcoma Growth, Angiogenesis, and Metastasis. Mol Cancer Res.2015;13(9):1347-57.223. Lu N, Lin T, Wang L, Qi M, Liu ZY, Dong HY, et al. Association of SOX4 regulated bytumor suppressor miR-30a with poor prognosis in low-grade chondrosarcoma. TumorBiol. 2015;36(5):3843-52.224. Horng CT, Shieh PC, Tan TW, Yang WH, Tang CH. Paeonol SuppressesChondrosarcoma Metastasis through Up-Regulation of miR-141 by Modulating PKCdelta and c-Src Signaling Pathway. International Journal of Molecular Sciences.2014;15(7):11760-72.225. Tsai CH, Yang DY, Lin CY, Chen TM, Tang CH, Huang YL. Sphingosine-1-phosphatesuppresses chondrosarcoma metastasis by upregulation of tissue inhibitor ofmetalloproteinase 3 through suppressing miR-101 expression. Mol Oncol.2017;11(10):1380-98.226. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2020. CA Cancer J Clin.2020;70(1):7-30.227. Cancer Genome Atlas N. Comprehensive molecular portraits of human breast tumours.Nature. 2012;490(7418):61-70.228. Liang Y, Zhang H, Song X, Yang Q. Metastatic heterogeneity of breast cancer: Molecularmechanism and potential therapeutic targets. Semin Cancer Biol. 2020;60:14-27.229. Tan Y, Luo X, Lv W, Hu W, Zhao C, Xiong M, et al. Tumor-derived exosomalcomponents: the multifaceted roles and mechanisms in breast cancer metastasis. CellDeath Dis. 2021;12(6):547.Cancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

78 EXOSOMES IN CANCER DEVELOPMENT AND METASTASIS230. Rodriguez M, Silva J, Herrera A, Herrera M, Pena C, Martin P, et al. Exosomes enrichedin stemness/metastatic-related mRNAS promote oncogenic potential in breast cancer.Oncotarget. 2015;6(38):40575-87.231. Piao YJ, Kim HS, Hwang EH, Woo J, Zhang M, Moon WK. Breast cancer cell-derivedexosomes and macrophage polarization are associated with lymph node metastasis.Oncotarget. 2018;9(7):7398-410.232. Kong X, Zhang J, Li J, Shao J, Fang L. MiR-130a-3p inhibits migration and invasion byregulating RAB5B in human breast cancer stem cell-like cells. Biochem Biophys ResCommun. 2018;501(2):486-93.233. Li Y, Liang Y, Sang Y, Song X, Zhang H, Liu Y, et al. MiR-770 suppresses thechemo-resistance and metastasis of triple negative breast cancer via direct targetingof STMN1. Cell Death Dis. 2018;9(1):14.234. Du J, Fan JJ, Dong C, Li HT, Ma BL. Inhibition effect of exosomes-mediated Let-7a onthe development and metastasis of triple negative breast cancer by down-regulating theexpression of c-Myc. Eur Rev Med Pharmacol Sci. 2019;23(12):5301-14.235. Wang M, Zhang H, Yang F, Qiu R, Zhao X, Gong Z, et al. miR-188-5p suppresses cellularproliferation and migration via IL6ST: A potential noninvasive diagnostic biomarker forbreast cancer. J Cell Physiol. 2020;235(5):4890-901.236. Wu Q, Sun S, Li Z, Yang Q, Li B, Zhu S, et al. Breast cancer-released exosomes triggercancer-associated cachexia to promote tumor progression. Adipocyte. 2019;8(1):31-45.237. Feng Y, Wang L, Wang T, Li Y, Xun Q, Zhang R, et al. Tumor cell-secreted exosomalmiR-22-3p inhibits transgelin and induces vascular abnormalization to promote tumorbudding. Mol Ther. 2021;29(6):2151-66.238. Pan S, Zhao X, Shao C, Fu B, Huang Y, Zhang N, et al. STIM1 promotes angiogenesisby reducing exosomal miR-145 in breast cancer MDA-MB-231 cells. Cell Death Dis.2021;12(1):38.239. Di Modica M, Regondi V, Sandri M, Iorio MV, Zanetti A, Tagliabue E, et al. Breastcancer-secreted miR-939 downregulates VE-cadherin and destroys the barrier functionof endothelial monolayers. Cancer Lett. 2017;384:94-100.240. Zhou W, Fong MY, Min Y, Somlo G, Liu L, Palomares MR, et al. Cancer-secretedmiR-105 destroys vascular endothelial barriers to promote metastasis. Cancer Cell.2014;25(4):501-15.Cancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

Merve C¸ igdem ˘ OZGEL, S¸eref Bu ¨ gra TUNC¸ ER ˘ 79241. Feng T, Zhang P, Sun Y, Wang Y, Tong J, Dai H, et al. High throughput sequencingidentifies breast cancer-secreted exosomal LncRNAs initiating pulmonary pre-metastaticniche formation. Gene. 2019;710:258-64.242. Wang J, Zhang Q, Zhou S, Xu H, Wang D, Feng J, et al. Circular RNAexpression in exosomes derived from breast cancer cells and patients. Epigenomics.2019;11(4):411-21.243. Yang SJ, Wang DD, Zhou SY, Zhang Q, Wang JY, Zhong SL, et al. Identification ofcircRNA-miRNA networks for exploring an underlying prognosis strategy for breastcancer. Epigenomics. 2020;12(2):101-25.244. Deng Z, Cheng Z, Xiang X, Yan J, Zhuang X, Liu C, et al. Tumor cell cross talkwith tumor-associated leukocytes leads to induction of tumor exosomal fibronectin andpromotes tumor progression. Am J Pathol. 2012;180(1):390-8.245. Didiasova M, Zakrzewicz D, Magdolen V, Nagaraj C, Balint Z, Rohde M, et al.STIM1/ORAI1-mediated Ca2+ Influx Regulates Enolase-1 Exteriorization. J BiolChem. 2015;290(19):11983-99.246. Sethuraman A, Brown M, Krutilina R, Wu ZH, Seagroves TN, Pfeffer LM, et al.BHLHE40 confers a pro-survival and pro-metastatic phenotype to breast cancer cellsby modulating HBEGF secretion. Breast Cancer Res. 2018;20(1):117.247. Szajnik M, Czystowska-Kuzmicz M, Elishaev E, Whiteside TL. Biological markers ofprognosis, response to therapy and outcome in ovarian carcinoma. Expert Rev MolDiagn. 2016;16(8):811-26.248. Dorayappan KDP, Wallbillich JJ, Cohn DE, Selvendiran K. The biologicalsignificance and clinical applications of exosomes in ovarian cancer. Gynecol Oncol.2016;142(1):199-205.249. Runz S, Keller S, Rupp C, Stoeck A, Issa Y, Koensgen D, et al. Malignant ascites-derivedexosomes of ovarian carcinoma patients contain CD24 and EpCAM. Gynecol Oncol.2007;107(3):563-71.250. Nakamura K, Sawada K, Kinose Y, Yoshimura A, Toda A, Nakatsuka E, et al.Exosomes Promote Ovarian Cancer Cell Invasion through Transfer of CD44 to PeritonealMesothelial Cells. Mol Cancer Res. 2017;15(1):78-92.251. Li QL, Bu N, Yu YC, Hua W, Xin XY. Exvivo experiments of human ovarian cancerascites-derived exosomes presented by dendritic cells derived from umbilical cord bloodfor immunotherapy treatment. Clin Med Oncol. 2008;2:461-7.Cancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

80 EXOSOMES IN CANCER DEVELOPMENT AND METASTASIS252. Kobayashi M, Salomon C, Tapia J, Illanes SE, Mitchell MD, Rice GE. Ovarian cancercell invasiveness is associated with discordant exosomal sequestration of Let-7 miRNAand miR-200. J Transl Med. 2014;12:4.253. Wyciszkiewicz A, Kalinowska-Lyszczarz A, Nowakowski B, Kazmierczak K,Osztynowicz K, Michalak S. Expression of small heat shock proteins in exosomesfrom patients with gynecologic cancers. Sci Rep. 2019;9(1):9817.254. Liang T, Guo Q, Li L, Cheng Y, Ren C, Zhang G. MicroRNA-433 inhibits migration andinvasion of ovarian cancer cells via targeting Notch1. Neoplasma. 2016;63(5):696-704.255. Wurz K, Garcia RL, Goff BA, Mitchell PS, Lee JH, Tewari M, et al. MiR-221and MiR-222 alterations in sporadic ovarian carcinoma: Relationship to CDKN1B,CDKNIC and overall survival. Genes Chromosomes Cancer. 2010;49(7):577-84.256. Huh JH, Kim TH, Kim K, Song JA, Jung YJ, Jeong JY, et al. Dysregulation ofmiR-106a and miR-591 confers paclitaxel resistance to ovarian cancer. Br J Cancer.2013;109(2):452-61.257. Sorrentino A, Liu CG, Addario A, Peschle C, Scambia G, Ferlini C. Role of microRNAsin drug-resistant ovarian cancer cells. Gynecol Oncol. 2008;111(3):478-86.258. Azmi AS, Bao B, Sarkar FH. Exosomes in cancer development, metastasis, and drugresistance: a comprehensive review. Cancer Metastasis Rev. 2013;32(3-4):623-42.259. Zhu X, Shen H, Yin X, Yang M, Wei H, Chen Q, et al. Macrophages derived exosomesdeliver miR-223 to epithelial ovarian cancer cells to elicit a chemoresistant phenotype.J Exp Clin Cancer Res. 2019;38(1):81.260. Pan CS, I.; M¨uller, V.; Ni, Q.; Oliveira-Ferrer, L.; Pantel, K.; Schwarzenbach, H.. Exosomal micro RNA s as tumor markers in epithelial ovarian cancer. Mol Oncol.2018;12:1935-48.261. Kan CW, Hahn MA, Gard GB, Maidens J, Huh JY, Marsh DJ, et al. Elevated levelsof circulating microRNA-200 family members correlate with serous epithelial ovariancancer. BMC Cancer. 2012;12:627.262. Zuberi M, Mir R, Das J, Ahmad I, Javid J, Yadav P, et al. Expression of serum miR-200a,miR-200b, and miR-200c as candidate biomarkers in epithelial ovarian cancer and theirassociation with clinicopathological features. Clin Transl Oncol. 2015;17(10):779-87.263. Yoshida K, Yokoi A, Kato T, Ochiya T, Yamamoto Y. The clinical impact of intra- andextracellular miRNAs in ovarian cancer. Cancer Sci. 2020;111(10):3435-44.Cancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

Merve C¸ igdem ˘ OZGEL, S¸eref Bu ¨ gra TUNC¸ ER ˘ 81264. He L, Zhu W, Chen Q, Yuan Y, Wang Y, Wang J, et al. Ovarian cancer cell-secretedexosomal miR-205 promotes metastasis by inducing angiogenesis. Theranostics.2019;9(26):8206-20.265. Masoumi-Dehghi S, Babashah S, Sadeghizadeh M. microRNA-141-3p-containingsmall extracellular vesicles derived from epithelial ovarian cancer cells promoteendothelial cell angiogenesis through activating the JAK/STAT3 and NF-kappaBsignaling pathways. J Cell Commun Signal. 2020;14(2):233-44.266. Liang B, Peng P, Chen S, Li L, Zhang M, Cao D, et al. Characterization and proteomicanalysis of ovarian cancer-derived exosomes. J Proteomics. 2013;80:171-82.267. Li SD, Zhang JR, Wang YQ, Wan XP. The role of microRNAs in ovarian cancer initiationand progression. J Cell Mol Med. 2010;14(9):2240-9.268. Cappellesso R, Tinazzi A, Giurici T, Simonato F, Guzzardo V, Ventura L, et al.Programmed cell death 4 and microRNA 21 inverse expression is maintained incells and exosomes from ovarian serous carcinoma effusions. Cancer Cytopathol.2014;122(9):685-93.269. Vaksman O, Trope C, Davidson B, Reich R. Exosome-derived miRNAs and ovariancarcinoma progression. Carcinogenesis. 2014;35(9):2113-20.270. Mahmoud EH, Fawzy A, RA AE. Serum MicroRNA-21 Negatively Relates toExpression of Programmed Cell Death-4 in Patients with Epithelial Ovarian Cancer.Asian Pac J Cancer Prev. 2018;19(1):33-8.271. Bisht S, Feldmann G. Novel Targets in Pancreatic Cancer Therapy - Current Status andOngoing Translational Efforts. Oncol Res Treat. 2018;41(10):596-602.272. Deplanque G, Demartines N. Pancreatic cancer: are more chemotherapy and surgeryneeded? Lancet. 2017;389(10073):985-6.273. Costa-Silva B, Aiello NM, Ocean AJ, Singh S, Zhang H, Thakur BK, et al. Pancreaticcancer exosomes initiate pre-metastatic niche formation in the liver. Nat Cell Biol.2015;17(6):816-26.274. Hoshino A, Costa-Silva B, Shen TL, Rodrigues G, Hashimoto A, Mark MT, et al. Tumourexosome integrins determine organotropic metastasis. Nature. 2015;527(7578):329-+.275. Ma Y, Yu S, Zhao W, Lu Z, Chen J. miR-27a regulates the growth, colonyformation and migration of pancreatic cancer cells by targeting Sprouty2. Cancer Lett.2010;298(2):150-8.Cancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

82 EXOSOMES IN CANCER DEVELOPMENT AND METASTASIS276. Shang D, Xie C, Hu J, Tan J, Yuan Y, Liu Z, et al. Pancreatic cancer cell-derivedexosomal microRNA-27a promotes angiogenesis of human microvascular endothelialcells in pancreatic cancer via BTG2. J Cell Mol Med. 2020;24(1):588-604.277. Adhyam M, Gupta AK. A Review on the Clinical Utility of PSA in Cancer Prostate.Indian J Surg Oncol. 2012;3(2):120-9.278. DeRita RM, Zerlanko B, Singh A, Lu H, Iozzo RV, Benovic JL, et al. c-Src,Insulin-Like Growth Factor I Receptor, G-Protein-Coupled Receptor Kinases and FocalAdhesion Kinase are Enriched Into Prostate Cancer Cell Exosomes. J Cell Biochem.2017;118(1):66-73.279. Ramteke A, Ting H, Agarwal C, Mateen S, Somasagara R, Hussain A, et al. Exosomessecreted under hypoxia enhance invasiveness and stemness of prostate cancer cells bytargeting adherens junction molecules. Mol Carcinog. 2015;54(7):554-65.280. McAtee CO, Booth C, Elowsky C, Zhao L, Payne J, Fangman T, et al. Prostate tumorcell exosomes containing hyaluronidase Hyal1 stimulate prostate stromal cell motilityby engagement of FAK-mediated integrin signaling. Matrix Biol. 2019;78-79:165-79.281. Abd Elmageed ZY, Yang Y, Thomas R, Ranjan M, Mondal D, Moroz K, et al. Neoplasticreprogramming of patient-derived adipose stem cells by prostate cancer cell-associatedexosomes. Stem Cells. 2014;32(4):983-97.282. Honeywell DR, Cabrita MA, Zhao H, Dimitroulakos J, Addison CL. miR-105 inhibitsprostate tumour growth by suppressing CDK6 levels. Plos One. 2013;8(8):e70515.283. Ault KA. Epidemiology and natural history of human papillomavirus infections in thefemale genital tract. Infect Dis Obstet Gynecol. 2006;2006 Suppl:40470.284. Barchuk A, Bespalov A, Huhtala H, Chimed T, Laricheva I, Belyaev A, et al. Breast andcervical cancer incidence and mortality trends in Russia 1980-2013. Cancer Epidemiol.2018;55:73-80.285. Luo X, Wei J, Yang FL, Pang XX, Shi F, Wei YX, et al. Exosomal lncRNAHNF1A-AS1 affects cisplatin resistance in cervical cancer cells through regulatingmicroRNA-34b/TUFT1 axis. Cancer Cell Int. 2019;19:323.286. Zhang J, Liu SC, Luo XH, Tao GX, Guan M, Yuan H, et al. Exosomal Long NoncodingRNAs are Differentially Expressed in the Cervicovaginal Lavage Samples of CervicalCancer Patients. J Clin Lab Anal. 2016;30(6):1116-21.Cancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

Merve C¸ igdem ˘ OZGEL, S¸eref Bu ¨ gra TUNC¸ ER ˘ 83287. Guo Y, Wang X, Wang K, He Y. Appraising the Value of Serum and Serum-DerivedExosomal LncRNA-EXOC7 as a Promising Biomarker in Cervical Cancer. Clin Lab.2020;66(7).288. Lei L, Mou Q. Exosomal taurine up-regulated 1 promotes angiogenesis and endothelialcell proliferation in cervical cancer. Cancer Biol Ther. 2020;21(8):717-25.289. Bhat A, Sharma A, Bharti AC. Upstream Hedgehog signaling components are exportedin exosomes of cervical cancer cell lines. Nanomedicine (Lond). 2018;13(17):2127-38Cancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

CANCER: FROM GENOMICS TO PHARMACEUTICSCHAPTER 4METHYLATION BIOMARKERS AND LIQUID BIOPSYSTUDIES IN CANCERSeval TURNA1,2, Semra DEMOKAN31PhD Candidate, ˙Istanbul University, Institute of Graduate Studies in Health Sciences, ˙Istanbul, T¨urkiye2˙Istanbul University, Oncology Institute, Department of Basic Oncology, Experimental and Molecular OncologyDivision, ˙Istanbul, T¨urkiyeE-mail: [email protected]., ˙Istanbul University, Oncology Institute, Department of Basic Oncology, Experimental and MolecularOncology Division, ˙Istanbul, T¨urkiyeE-mail: [email protected]: 10.26650/B/LSB28LSB48LSB56.2024.019.004ABSTRACTEarly detection of cancer can prevent the progression of the disease, significantly improve treatment’s successand quality of patient’s life, while reducing treatment costs. Molecular markers are needed to detect the malignancyearlier, to reduce the recurrences and cancer-related deaths and to manage the treatment regimens. In the developmentof malignancies, epigenetic changes play important roles as well as genetic mutations. Sporadic cancers mostly occuras a result of aberrant epigenetic alterations caused by environmental conditions, such as lifestyle, diet and exposure tovarious carcinogens. The most studied epigenetic mechanism, DNA methylation is observed as hypermethylation inthe promoter regions of tumor suppressor genes which leads to suppression of expression, and/or as hypomethylation ofoncogenes/repeated sequences throughout the genome which contributes to carcinogenesis by increasing oncogenes’expressions. In addition, due to the reversible nature of methylation, pharmacological demethylation approach andepigenomics/transcriptomics studies for the discovery of reliable methylation biomarkers and epidrug studies for thedevelopment of successful therapeutic strategies have been accelerated. Methylation biomarkers can be validated inbody fluid samples by using liquid biopsy and epigenetic analysis methods. In this section, we summarized studieson methylation-based biomarkers previously validated using primary tumors and subsequently body fluid samplesobtained from cancer patients via liquid biopsy as a non-invasive/minimally invasive method.Keywords: Cancer, methylation, biomarker, liquid biopsyCancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

Seval TURNA, Semra DEMOKAN 851. IntroductionMolecular biomarkers can contribute to the early diagnosis of cancer, and predictthe progression and recurrences of the disease, and also guide treatment strategies, andsignificantly improve quality of life (1-3). In addition, screening of asymptomatic peoplewith screening tests utilizing molecular markers may ensure that people at risk of developingmalignancy may be identified, detected at an early stage, thus reducing morbidity (2,4). Asseen in the example of colon cancer, the 5-year survival rate remains around 90% with earlydiagnosis, whereas this rate reduces to 13% at the advanced stages (5). For this reason, itis necessary to determine biomarkers with reliable accuracy from samples that can be takenfrom patients with non-invasive/minimally invasive methods, both for screening purposes,early diagnosis, treatment, and even the development of new biomarkers (6). Cancer is acomplex disease that arises as a result of defects in the mechanisms regulating cell functionssuch as excitation, differentiation, life and death (7). Tumor development is controlled by bothgenetic and epigenetic changes affecting especially tumor suppressor genes and oncogenes(8,9). In 1942, Waddington defined epigenetics for the first time as a branch of science dealingwith events that occur as a result of gene-environment interaction and cannot be explainedby genetic principles (10). In an international symposium organized by the World HealthOrganization in 1950, attention was drawn to the types of cancer seen in the geographicalregions of the people who migrated to different parts of the world, where they migrated fromtheir own countries, and it was suggested that this is a disease related to mostly environmentalfactors rather than genetic factors for many cancer types (11). Cytosine methylation wasdefined for the first time in 1975, and studies in the field of epigenetics continued rapidlyin the following years. Although it has become very popular with the Human EpigenomeProject, which started in 1999 and continued in the 2000s, and had led to the accumulationof huge epigenomic data by increasing the number of studies, there are still unexplainedmechanisms underlying epigenetic background of carcinogenesis (12). Today non mutationalepigenetics as a new hallmark of cancer cells was reported in the Hanahan ‘s review in2022 (13). Sporadic cancers mostly occur as a result of aberrant epigenetic alterationscaused by environmental conditions, as models representing gene-environment associations(14). Epigenetic modifications of genetic material, unlike genomic mutations, are defined asheritable changes that cause gene expression changes without changes in the DNA sequence(15,16). One of the most important features of epigenetic changes is that, in addition tohereditary changes in the formation of cells or individuals (mitotic/meiotic inheritance), aswell as not transcriptionally inherited under the influence of environmental factors, but causestable, long-term and phenotypic differences (12,16,17). The most known mechanisms ofepigenetic changes include DNA methylation, histone modifications, chromatin remodeling,and RNA interference (18). The best described and the most studied epigenetic mechanism,DNA methylation is observed as hypermethylation in the promoter regions of tumor suppressorCancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

86 METHYLATION BIOMARKERS AND LIQUID BIOPSY STUDIES IN CANCERgenes which leads to silencing of expression, and/or as hypomethylation of oncogenes and/orrepeated sequences throughout the genome which contributes to development of neoplasticcells by causing upregulation of oncogenes (17). DNA hypermethylation occurs in the earlystages of cancer and accumulates progressively towards the advanced stages (19). Differentcharacterizations of cancer cells and differences in genotype and phenotype have complicatedthe study of the molecular mechanisms of cancer and, accordingly, have led to difficultiesin conducting the research necessary for the diagnosis, treatment, and follow-up of cancer(20). Strategies to detect DNA methylation are a promising and rapidly evolving area ofresearch for epigenetics-based biomarker development and drug development and delivery(19). The development of non-invasive epigenetic analysis methods in order to detect themethylation biomarker candidates is essential to identify and unravel the complex mechanismsthat control the underlying signaling pathways (21). DNA methylation biomarkers discoveredor tested in tissue samples can be validated in body fluids such as serum, plasma, saliva, feces,urine, sputum, pericardial fluid, ascitic fluid, cerebrospinal and bronchial fluids obtainedfrom the patients by invasive/non-invasive techniques (22). By the liquid biopsy capturingctDNAs determined to have the same mutations and methylation patterns (23,24) as tumorcells using methylation markers in plasma provides some advantages over methods based ongenetic variations (25). First, methylation analysis of an individual’s cfDNA facilitates thedetermination of tissue origin, detection and monitoring of pathological conditions, takingadvantage of the high tissue specificity of DNA methylation patterns and the similarity incertain tissue types among different individuals (26,27). Secondly, it has been determinedthat the probability of different individuals carrying the same mutation, even in the sametissue type, is very low due to the heterogeneity in the mutation processes (28), but theepigenetic changes are quite similar (25,27). In addition, due to the heterogeneity in tumors,some researchers aimed to identify biomarkers in normal tissues rather than tumors, therebydistinguishing patients with cancer. For example, Gai et al. performed methylome analysis innormal liver and colon tissues and discovered DNA methylation biomarkers of both tissues.They then used the results to differentiate between cancer patients and healthy individuals,showing that tissue-specific biomarkers liquid biopsy plasma ctDNA methylation tests werehighly consistent among sick individuals (25). In a study conducted with methylation datafrom The Cancer Genome Atlas (TCGA) and The International Cancer Genome Consortium(ICGC) databases, specific methylation markers in lung cancer tissues had found with 83.3%specificity and 82.5% sensitivity when compared to ctDNA methylation levels in plasma(29). Finally, studies have shown that by targeting DNA methylation biomarkers for cancerdetection and treatment follow-up, an easier and general method can be developed for thepatient compared to the classical method. Liquid biopsy approach as a precision cancer-relatedmethylation biomarker validation method, can detect the methylated ctDNA of tumor at theCancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

Seval TURNA, Semra DEMOKAN 87earlier stages and is also a promising, tool for continuously monitoring disease progression,treatment efficacy and the treatment response make them promising biomarkers for cancer(30).However, more and more people are diagnosed with cancer every year due to theincrease in the elderly population, exposure to physical, biological and chemical carcinogenswith developing technology, increased opportunities to benefit from diagnosis and healthinstitutions, obesity and physical inactivity (31).2. Relationship between Methylation, Environment and CancerAlthough cancer is the result of accumulated aberrant genetic and epigenetic alterations,familial syndromes and environmental factors play an important role in the developmentof malignancies (32). Approximately 90-95% of cancers are sporadic cancers due toenvironmental factors (33). Epigenetic changes occur when environmental factors (age,alcohol, exposure to carcinogens, chronic inflammation, diet, hormones, tobacco, infectiousagents, sunlight, radiation, obesity, and immuno-suppression) affect the expression andfunction of genes without causing mutations (34). Inappropriate maintenance of inheritedepigenetic marks can lead to abnormal activation or inhibition of various signaling pathways.In addition, it is reported that the number of epigenetic alterations in the process oftumorigenesis is much higher than the number of genetic alterations (35). Carcinogenicrisk factors due to environmental conditions can be grouped under three headings as physical,chemical and biological factors (36). Physical carcinogens include sun rays (UV and ultravioletrays), ionizing radiation, X-Rays, high and low temperatures, air pollution, etc., while chemicalcarcinogens include agents such as aromatic amines, natural carcinogens, cigarette smoke andalcohol. Epigenetic and genetic changes occurring in genes by chemical substances provento be carcinogenic can be used as a biomarker in the identification of tumors (37). Biologicalcarcinogens include viral, bacterial and protozoal carcinogens known in microbiota associatedwith cancer (38).2.1. Physical Carcinogens2.1.1. RadiationIonizing radiation causes DNA damage and its effects persist for a long time (39,40). Inaddition, studies have shown that it causes DNA methylation changes (40). In a study byKoturbash et al., it was reported that X-rays caused hypomethylation in LINE-1 sequenceswhile down-regulating DNMTs and MeCP2 protein in experimental animal models. In adifferent study investigating the relationship between radiation sensitivity and methylation, itwas reported that ionizing radiation caused hypermethylation of p16? ? ?4?and ATM tumorsuppressor gene promoters in tumor cells not treated with pharmacological demethylationmethods (41).Cancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

88 METHYLATION BIOMARKERS AND LIQUID BIOPSY STUDIES IN CANCER2.1.2. Air PollutionIn environments where polluting particulate matter, black carbon, ozone, nitrogenoxides, exhaust fumes and polyaromatic hydrocarbons are present in the air, abnormal DNAmethylation changes cause lung malignancies (42). In addition, exposure to air pollutants NOand NOx causes DNA hypomethylation (43).2.1.3. Physical ExerciseRegular or long-term physical exercises cause changes in DNA methylation patterns,especially in striated muscle cells, and gene expression levels to change. In addition, it isthought that hypermethylation increases in muscle cells’ DNA due to aging and this plays a rolein triggering metabolic diseases (44). Protein expression levels of proinflammatory cytokinessuch as Creatine Kinase, Interleukin-6 and Tumor Necrosis Factor-? (TNF-?) increase as aresult of methylation changes that occur with exercise (45).2.2. Chemical Carcinogens2.2.1. Tobacco and Alcohol ConsumptionOne of the most important factors for DNA methylation is tobacco/cigarette smokeexposure. Chemicals of cigarette, containing approximately 400 carcinogens includingpolycyclic hydrocarbons, nitrosamines, formaldehyde, nicotine, and arsenic identified incarcinogenic group, causes DNA damage, abnormal activation of DNMTs, abnormalactivation of DNA binding factors, modulation of gene expression and DNA methylationby hypoxia (46,47). Although smoking-related DNA methylation is most common in headand neck cancers (48), smoking is the main risk factor for many other types of cancer, includinglung (49), prostate (50) and bladder cancer (51) by causing DNA methylation. Cigarette smokecondensation may play a role in pancreatic cancer by causing overexpression of the METTL3gene via hypomethylation, and aberrant miR-25-3p maturation with m6A modification (52).It has been reported that the risk of developing cancer when smoking and alcohol areused together is higher than the use of alcohol or cigarette alone (53). While the effect ofcigarette consumption is associated with the amount of cigarettes consumed per day and theduration of use, the effect of alcohol is thought to play a role in the formation of cancer bybeing associated with the fact that acetaldehyde in the content of alcohol binds to cell DNAand causes DNA damage (54). In the United States, 15.5% of adults are smokers, while 7%of them are reported to be alcohol consumers (55,56). According to 2019 data in Turkey, 28%of the population smokes regularly every day. This usage rate was 14.9% in women and wasreported as 41.3% in men. According to the World Health Organization 2021 statistics, theprevalence of smoking in our country was 29.3% in 2018 (57).2.2.2. Nutritional FactorsUnhealthy diets such as inadequate protein consumption and high-fat diets are known tocause changes in DNA methylation that may increase the risk of various metabolic disordersCancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

Seval TURNA, Semra DEMOKAN 89and cancer by changing the metabolic pathways (58). Caloric restriction, on the other hand,positively affects DNA methylation and shows a different methylation pattern, especially inadipose tissue, preventing obesity and delaying chronic diseases (59). It has been reportedthat the DNA methylation pattern in the loci of genes involved in carcinogenesis, such as WT1and TNF-?, transitions to a normal state as a result of global caloric restriction, especiallyin obese individuals (58). It is also known that high-fat diets cause DNA methylation byaffecting the expression of genes involved in metabolic processes and tumor development,especially due to obesity (60). It has been shown that hypermethylated SFRP2 gene may beassociated with body mass index (BMI) in colorectal cancer (CRC) and DNA methylationlevels decrease and become hypomethylated in obese patients (BMI≻25 kg/m2) (61).2.2.3. Endocrine Disrupting ChemicalsEndocrine disruptors damaging the endocrine system cause abnormalactivation/deformation of hormones by exerting their effects through nuclear receptors,non-nuclear steroid hormone receptors, non-steroid receptors, complex enzymatic pathwaysor DNA methylation of hormone receptors (60,62). Especially prostate cancers andendometrial cancers can occur as a result of abnormal hormonal activity (62). Pesticidessuch as Switch, Corit, Frupica, Steward, Reldan, Cantus, Teldor and Scala have an endocrinedisrupting effect even if used within allowed limits and change the balance of ER?, ARand aryl hydrocarbons in breast cancer and PCa by activating the signaling pathways whichmaintain hormonal balance, (63).2.3. Biological Carcinogens2.3.1. Viral Carcinogenes2.3.1.1. Hepatit B VirusIt has been stated that hepatitis B virus DNA is affected by the level of methylation(hypermethylated CpG islands or hypomethylated promoter region) in the host DNA to whichit is integrated and takes the characteristics of the region to which it binds. It has beenreported that when the gene is integrated into the hypomethylated promoter region, it remainshypomethylated and plays a role in carcinogenesis (64). In addition, in the comparativeanalysis of hepatitis B virus (HBV) positive cancerous tissue, tumor microenvironment andblood serum, common GSTP1 gene in all three sample types, p16 and APC genes in serum,and p16, RASSF1A, GSTP1, APC, p15 and SFRP1 genes in tissue were hypermethylated (65).2.3.1.2. Hepatit C VirusIt plays a role in liver cancer by causing DNA hypomethylation in LINE and Alu elements,which are known as repeating elements in the genome (66). Moreover, in hepatitis C virus(HCV) positive liver cancer, similar to HBV positive tumor tissues, p16, GSTP1, APC andRUNX3 genes are hypermethylated compared to HCV negative tumors, thereby silencingtumor suppressor genes and making an important contribution to carcinogenesis (67).Cancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

90 METHYLATION BIOMARKERS AND LIQUID BIOPSY STUDIES IN CANCER2.3.1.3. Epstein Barr VirusEpstein Barr Virus, which is known to be responsible especially for nasopharyngeal andlymphoid tissue cancers, can remain latent for many years after infecting the host cells. Duringthis time, most of the CpG islands of early virus gene promoters are methylated and escapethe immune system (68). EBV infection causes abnormal epigenetic changes in host DNA aswell as viral DNA. In addition, EBV plays an important role in carcinogenesis by triggeringhypermethylation of CDKN2A and RASSF1A genes in nasopharyngeal cancer (69).2.3.2. Bacterial CarcinogenesAlthough the effect of bacteria on carcinogenesis has been ignored for many years, theirimportance has increased in the last few years and they have been associated with many typesof cancer. Bacterial fauna cause tumor initiation by affecting various cellular functions ofthe host cell (70). They are also involved in cancer development and progression by causingabnormal DNA methylation in bacteria, just like in viruses (71). Numerous bacteria havebeen associated with various cancers, including Fusobacterium nucleatum (F. nucleatum),Helicobacter pylori (H. pylori) (72).2.3.2.1. Fusobacterium nucleatumGram negatif, anaerobic, opportunistic Fusebacterium bacteria found in the normal flora oforal and colonic mucosa have been associated with progressive disease and many tumor types(73). In addition, it plays a role in carcinogenesis by altering the host immune response andmethylation pattern (74,75). In colorectal carcinoma, F. nucleatum has been associated withpoor prognosis by downregulating METTL3, causing demethylation of m6A modifications(76). In addition, F. nucleatum causes downregulation of p16 protein through promoterhypermethylation of the CDKN2A gene in CRC patients with high microsatellite instability(77).2.3.2.2. Helicobacter PyloryIn the etiology of gastric cancer, H. pylori which carries specific virulence factors such asCagA and VacA, plays important roles and it causes tumorigenesis by inducing cancer-derivedinflammatory cytokines, promoting hypermethylation of some genes such as GATA4, p41???,CDH1, p16? ? ?4?, MGMT and RUNX 3 (71,78).While methylation is also involved in the regulation of normal biological processes,changes in the methylation pattern play a crucial role in tumor development as they cause theactivation of oncogenes (79, 80). For this reason, it has begun to attract more attention in theearly diagnosis of cancer (81, 82).3. How Different Types of Methylation Work?Epigenetic changes allow cells to have different identities while containing the same geneticinformation (17). The inheritance of gene expression patterns is mediated by epigeneticCancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.

Seval TURNA, Semra DEMOKAN 91mechanisms (83). Inappropriate maintenance of inherited epigenetic marks can result inabnormal activation or inhibition of various signaling pathways and lead to disease states suchas cancer (84). In the process of tumorigenesis, the number of epigenetic changes is likelyto be much greater than the number of genetic changes (85). Epigenetic changes are usuallyobserved in earlier stages of tumorigenesis (85).Although methylation, which is defined as a biochemical reaction that occurs as a resultof the replacement of a hydrogen atom with a methyl group, is generally understood as DNAmethylation, there is also available RNA methylation as a type of RNA modification (86,87).Methylation can be observed in the N4-methylcytosine (4mC) and N6-methyladenine (6mA)regions of RNA (88).3.1. DNA MethylationMethylation process is a fundamental epigenetic modification involved in the regulationof gene expression, cellular proliferation, differentiation, and stem cell maintenance, as wellas influencing transcriptional regulation (89,90). Methylation sites include intergenic regions,CpG islands that make up about 70% of gene promoters, and gene bodies, which are the firstexon transition region of the gene (91). However, approximately 98% of DNA methylationoccurs in CpG islands in somatic cells, while about a quarter of all methylation occurs innon-CpG regions of embryonic stem cells (ESCs) (92). DNA methylation is regulated by aclass of enzymes called DNMTs: DNMT1, DNMT2, DNMT3A, DNMT3B and DNMT3L(88). Covalent transfer of the methyl (-CH3) group to cytosine at position 5’, catalyzed byDNA methyltransferases (DNMTs), causes DNA methylation resulting in 5-methylcytosine(5mC) (91). DNMT1 binds to hemi-methylated DNA formed after DNA replication and isresponsible for de novo methylation by playing a role in the formation of methylation patternsin the unmethylated chain.It has been stated that especially DNMT1 and DNMT3 play a very important role inDNA methylation (92,93). DNMT3A and DNMT3B are responsible for both the methylationof hemi-methylated DNA and the pro-DNA methylation observed during early development(94,95). In addition to DNA methylation, DNMT2 is defined as tRNA transferase I, whichmethylates the 38? ℎ position in tRNAAspGUC in RNA modification (96). The function ofDNMT3L may be interacting with the other two enzymes and is also involved in maternalgenomic imprinting (97). In addition, abnormal methylation of certain genes has beenassociated with the development of various tumor types, as DNA methylation changes exhibita high degree of concordance among many cancer tissues or within the tissue of origin (98,99).Regions methylated at different levels of DNA methylation, which differ betweenphenotypes, are called differentially methylated regions (DMRs) and have different types,such as tissue, cancer, and allele-specific DMRs (100-102). However, it has been found inthe literature that DMRs occur especially in areas close to CGIs and are important for diseasedevelopment (100,103).Cancer: from Genomics to Pharmaceutics, edited by Zeynep Karakas, et al., Istanbul University Press, 2024. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uitm-ebooks/detail.action?docID=31789562.Created from uitm-ebooks on 2025-12-02 14:42:18. Copyright © 2024. Istanbul University Press. All rights reserved.