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REVIEW ARTICLE OPEN

Extracellular matrix and its therapeutic potential for cancer

treatment
Jiacheng Huang1,2,3,4,5, Lele Zhang1,2,3,4,5, Dalong Wan1, Lin Zhou1,3,4,5, Shusen Zheng1,3,4,5, Shengzhang Lin2,6 and Yiting Qiao1,3,4,5

The extracellular matrix (ECM) is one of the major components of tumors that plays multiple crucial roles, including mechanical
support, modulation of the microenvironment, and a source of signaling molecules. The quantity and cross-linking status of ECM
components are major factors determining tissue stiffness. During tumorigenesis, the interplay between cancer cells and the tumor
microenvironment (TME) often results in the stiffness of the ECM, leading to aberrant mechanotransduction and further malignant
transformation. Therefore, a comprehensive understanding of ECM dysregulation in the TME would contribute to the discovery of
promising therapeutic targets for cancer treatment. Herein, we summarized the knowledge concerning the following: (1) major
ECM constituents and their functions in both normal and malignant conditions; (2) the interplay between cancer cells and the ECM
in the TME; (3) key receptors for mechanotransduction and their alteration during carcinogenesis; and (4) the current therapeutic
strategies targeting aberrant ECM for cancer treatment.

Signal Transduction and Targeted Therapy (2021)6:153 ; [Link]

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INTRODUCTION core elements of the “matrisome” for humans, accounting for 1%

Cancer is a leading cause of death which severely impedes the of the entire proteome.
health career for extension of life expectancy in the world. The Ever since the identification and characterization of collagen,
incidence and mortality of cancer are increasing year by year. the most abundant component of ECM, in the 1930s, the
According to the latest global cancer statistics in 2020, 19.3 million complicated network of ECM started to be gradually revealed
new cases were diagnosed and cancer contributed to 10.0 million through modern biochemistry methods3. Most of the proteins in
deaths1. Therefore, cancer is becoming one of the most serious the ECM can be classified into two groups, fibrous proteins, and
problems which threaten public health. The most striking glycosaminoglycan. The former include collagen, fibronectin,
attributes of cancer are uncontrolled proliferation, local invasion, elastin, and laminin, and the latter mainly consists of hyaluronic
and distant metastasis. Nowadays, the mainstream therapies for acid, chondroitin sulfate, keratan sulfate, and heparan sulfate.
cancer treatment include surgery, chemotherapy, radiotherapy, These molecules are crosslinked and distributed heavily in the
targeted therapy, and immunotherapy. Cancer-related death is ECM, forming the mesh structure for tissues. As early as the 1970s,
mainly caused by tumor recurrence and distant metastasis after the critical roles of ECM in the determination of cell morphology
systemic antitumor treatment. Although great advances have and responses to growth factors had been proven with solid
been achieved for cancer treatment in recent years, especially in empirical evidence4. Then the pursuit of discovering the
the field of targeted therapy and immune therapy, the pursuit for intermembrane signal transducers linking ECM and intercellular
converting this life-threatening disease into a manageable chronic signaling pathways produced many great works marked by the
condition has never stopped. The comprehensive understanding identification of integrins in 1980s5–9. Ever since then, the field of
of cancer cells, as well as the microenvironment supporting the ECM–cell interaction developed rapidly, and the vast signaling
malignant behavior of cancer cells, are of equal importance for network bridging extracellular environment and complicated cell
developing novel therapeutics against cancer. behaviors started to reveal itself gradually due to the continuous
The extracellular matrix (ECM), which comprises the interstitial efforts of researchers and technological advances. During the
elements within tissues or organs for all metazoan organisms, 2010s, the clinical application of Ibrutinib (a small molecular
plays vital roles for all biological processes by providing compound inhibiting integrin signaling) for the treatment of
architectural support, anchorage for cell adhesion, a reservoir for lymphoid leukemia and lymphoma was a hallmark event for the
water, and various growth factors, as well as inductions for successful translation of biological knowledge to practical
intracellular signaling pathways. According to a comprehensive medicines in this research area10,11. At the same time, bioengi-
study utilizing both proteomic analyses of the in vivo ECM neering of artificial and natural ECM materials also achieved great
composition and in silico prediction2, 278 genes were identified as success in multiple branches of medicine, such as osteology,

1
Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China; 2School of
Medicine, Zhejiang University, Hangzhou 310003, China; 3NHC Key Laboratory of Combined Multi-Organ Transplantation, Hangzhou 310003, China; 4Key Laboratory of the
Diagnosis and Treatment of Organ Transplantation, Research Unit of Collaborative Diagnosis and Treatment For Hepatobiliary and Pancreatic Cancer, Chinese Academy of
Medical Sciences (2019RU019), Hangzhou 310003, China; 5Key Laboratory of Organ Transplantation, Zhejiang Province, Hangzhou 310003, China and 6Shulan (Hangzhou)
Hospital Affiliated to Zhejiang Shuren University Shulan International Medical College, Hangzhou 310000, China
Correspondence: Shengzhang Lin (1311046@[Link]) or Yiting Qiao (yitingqiao@[Link])

Received: 24 July 2020 Revised: 17 February 2021 Accepted: 9 March 2021

© The Author(s) 2021

 Extracellular matrix and its therapeutic potential for cancer treatment
Huang et al.
2

Fig. 1 Schematic illustration of ECM components in normal tissue (left) and the TME (right). Matrix stiffness is mainly related to excessive
collagen and HA within TME. Both cancer cells and fibroblasts contribute to the remodeling of the ECM during its stiffness, fundamentally
influencing many critical biological processes during the development of cancer

odontology, dermatology, and ophthalmology. For example, an MAJOR ECM COMPONENTS: STRUCTURE AND FUNCTION
artificial dermal regeneration template has been invented for the Collagen
treatment of aplasia cutis congenital, a severer disorder char- Collagen makes up most of the ECM, accounting for approxi-
acterized by the congenital absence of skin12. mately 90% of the ECM and 30% of the total protein in humans13.
As one of the major components of the tumor microenviron- Currently, 28 types of collagens have been identified, encoded by
ment (TME), the dysregulation of ECM is a remarkable feature of 43 genes14. All collagens are homotrimers or heterotrimers of
cancer (Fig. 1). During the development of cancer, malignant cells three polypeptide chains (α chains), comprising numerous Gly-X-Y
contribute to ECM stiffness, and, in return, the stiffened ECM alters repeats, X and Y being frequently proline and 4-hydroxyproline,
the characteristics of cancer cells. The communication between respectively15. Glycine provides conformational flexibility, while
cancer cells and the ECM activates several vital pathways related to proline provides conformational rigidity. Therefore, the rod-
mechanotransduction. Therefore, a comprehensive understanding shaped triple helix is stabilized by interchain hydrogen bonds
of the dysregulation of the ECM in the TME would contribute to the and electrostatic interactions13. α Chains vary greatly in size
discovery of promising therapeutic targets for cancer treatment. In (ranging from 662 up to 3152 amino acids for the human α1
the present review, the structures and functions of multiple ECM (collagen type X) and α3 (collagen type VI) chains, respectively) as
components, such as collagen, fibronectin, elastin, and so on, were well as the frequencies of imperfections and interruptions of Gly-
introduced. Then we summarized their alterations and the X-Y repeats, resulting in differences in plasticity, flexibility and
underlying mechanisms during matrix stiffness in cancer. Mean- recognition patterns among various types of collagens13.
while, the downstream biological effects of matrix stiffness on both A more intensive collagen mesh is constructed based on the
cancer cells and other cells in TME were also discussed. posttranscriptional product for collagen maturation. Collagen
Subsequently, several pivotal receptors for ECM and their roles in forms macromolecules by intermolecular cross-linking16. The
malignant transformation were summarized. Afterward, both cross-linked collagen provides tissue intensity and tenacity. For
clinical and preclinical therapeutic applications of ECM-related example, the mechanical properties of fibril-forming collagen are
signaling for cancer treatment were discussed in-depth based on largely dependent on the extent of covalent cross-links within and
our current knowledge from basic researches and clinical studies. between triple helixes, including disulfide bonds, the Nε(γ-
Finally, the vision and several potential Gordian Knots for targeting glutamyl)lysine isopeptide, reducible and mature cross-links
ECM-related signaling for cancer treatment were summarized and produced via the lysyl oxidase pathway, advanced glycation end
discussed to call for more attention to this research field. products, hydroxylysine-methionine cross-links, and arginyl

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 Extracellular matrix and its therapeutic potential for cancer treatment
Huang et al.
3
ketoimine adducts called arginoline17. Moreover, the existence of can interact with the fibronectin domain57–60. FGF, vascular
noncollagenous domains in collagens that can assemble mutually endothelial growth factor (VEGF), and PDGF can bind to the
between collagens or even between collagens and other ECM heparin II domain in fibronectin58, and PDGF can attach to the
proteins increases the complexity of such supramolecules18. Thus, fibronectin first type III repeat (FNIII1)57. Moreover, extra domain A
collagens can form fibrils, beaded filaments, anchoring fibrils, and (EDA) in fibronectin can increase VEGF-C expression in colorectal
even networks19. carcinoma61. Therefore, although fibronectin is low in abundance
Collagens are long-lived proteins due to their high glycation in the ECM, it plays a vital role during malignant transformation.
level, but their degradation is still critical for both normal turnover
and pathological destruction of connective tissue20. Matrix Elastin and laminin
metalloproteinases (MMPs) participate in the physiological and Elastin is the primary component of elastic fibers and is mainly
pathological degradation of collagens. These zinc-dependent found in ligaments and vascular walls. Elastin maintains the
endopeptidases comprise a large family of 28 members21,22. For tenacity and intensity of tissues along with collagen by rebelling
example, MMP-1, MMP-8, MMP-13, and MMP-14 cleave fibril- against tissue deformation or rupture. Compared with collagen,
forming collagens I, II, and III, while MMP-2 and MMP-9 cleave elastin is highly resilient because of its amino constituents and
denatured collagens and collagen IV14. Sheddases are another dynamic three-dimensional (3D) structure. Glycine makes up one-
family of enzymes that digest collagens14,23. During the digestion third of the polypeptide, and proline accounts for approximately
of MMPs, signaling molecules such as endostatin and tumstatin 10%, while hydroxyproline accounts for less than 1%. The β-turn in
are released from collagens, simultaneously leading to the the polypeptide chain is produced based on the interaction of
alteration of mechanical characteristics as well as signaling Gly4 (N–H) and Gly1 (C = O) or Leu5 (N–H) and Val2 (C = O),
transduction in the microenvironment24,25. As the major compo- resulting in the resilience of elastin.
nent of the ECM, the amount and posttranslational modifications Laminin, together with collagen, makes up the constituents of the
of collagens often undergo tremendous alterations during the basement membrane. Therefore, laminin is involved in vasculariza-
development of cancer, resulting in a fundamental influence on tion, especially in the process of vessel maturation62. During re-
the behavior of cancer cells and other cells in the TME, features epithelialization in wound healing, laminin is upregulated to provide
that would be discussed later in this review. an interface for the adherence of epithelial cells to adhere and
stretch63. Laminin is polymerized by three different chains, one α
Fibronectin chain, one β chain, and one γ chain, which are encoded by separate
Fibronectin is low in abundance but has diverse functions in the genes64,65. Five forms of α chains (LAMA1-5) and three forms of β
ECM. Soluble fibronectin is secreted by hepatocytes and into the chains (LAMB1-3) and γ chains (LAMC1-3) can be found in
circulation26,27, while the insoluble form is produced by a variety laminins66. For example, laminin comprising α2β2γ1 is named
of mesenchymal cells, including fibroblast28 and endothelial cells. laminin-221. The laminin network is constructed along with collagen
In the vasculature, vascular smooth muscle cells are a major type IV, fibronectin, and perlecan in basement membranes63,67.
producer of fibronectin29.
Fibronectin is a type of dimer proteoglycan, which is interwoven Hyaluronic acid
with two subunits via a disulfide bond at the C-terminus30,31. A Hyaluronic acid (HA), another primary component in ECM, is a
fibronectin subunit weighs approximately between 220 and high-molecular-weight glycosaminoglycan comprising disacchar-
250 kD32. There are several structural domains in both subunits, ide repeats of N-acetylglucosamine and glucuronic acid68. HA is
and the structural domains mainly consist of three structural synthesized by the alternative addition of glucuronic acid and N-
modules, 12 repeat fibronectin type I, 2 repeat fibronectin type II, acetylglucosamine to the growing chain, using their activated
and 15–17 repeat fibronectin type III33–35. These structural nucleotide sugars (uridine diphosphate glucose (UDP) and UDP-N-
domains constitute the functional domains of fibronectin, includ- acetylglucosamine) as substrates. This reaction is mediated by
ing a domain that weighs 70 kD at the N-terminus (fibronectin hyaluronan synthase 1, 2, and 3 (HAS1–HAS3) localized on the cell
type I1–9), a central binding domain (CBD) that weighs 120 kD membrane. The enzymatic degradation of HA is mediated by
(fibronectin type III1–12), and a heparin-binding domain (HepII) hyaluronidase, b-D-glucuronidase, and β-N-acetyl-hexosamini-
(fibronectin type III12–14). dase69. The number of repeated disaccharides in a completed
Fibronectin has profound effects on cell adhesion, migration36, HA molecule can reach 10,000 or even more. Its long polymer
proliferation37,38, blood coagulation39,40, vascularization41–43, chains form random coils entangled in solution, and its numerous
clearance of bacteria by phagocytes44, and wound healing45,46, hydroxyls capture a huge quantity of water by forming hydrogen
among others. In the ECM, fibronectin connects various structural bonds70. Therefore, HA mechanically increases the elastoviscosity
proteins to form an integrated matrix, such as collagens47, in the ECM.
fibrillin48, and tenascin-C49,50. For example, the antibody targeting In addition to its unique viscoelastic nature, HA functions as an
the collagen-binding site in fibronectin could suppress the important “reservoir” for water, buffering ion exchange, water, and
fibrillogenesis of collagen, suggesting that type I collagen cannot osmotic balance within the ECM. Moreover, some substances and
assemble without fibronectin51. biomacromolecules are selectively permeable to HA due to their
Other than binding to multiple structural proteins to reinforce charged surface and selective domains. Therefore, HA can serve as
the ECM, fibronectin directly interacts with many other proteins to a sieve: particles with a huge molecular size are hindered and
exert regulatory functions52–54. First, fibronectin contains abun- immobilized, while smaller molecules tend to pass through HA
dant arginine–glycine–asparagine (RGD) sequences that can more efficiently71. Additionally, HA can be recognized by various
recognize and bind to integrins on the cell membrane55. types of cells through membrane receptors such as CD44 and
Therefore, fibronectin has a profound effect on intracellular receptor for hyaluronan-mediated motility (RHAMM), as well as
signaling transduction by inducing integrin attachment. For intracellular signaling transducers such as cell division cycle 37
example, the interaction of MMP-9-degraded fibronectin and (CDC37)72, P-3273, and hyaluronan binding protein 4 (HABP4)74.
integrin αvβ6 leads to aggressive migration and invasion via ERK1/ Such recognition plays vital role in many biological procedures,
2 and PI3K/AKT/Smad-1/5/8 pathways in breast cancer56. By including cell mobility, invasion, proliferation, and inflammation.
contrast, many growth factors can directly interact with fibronec-
tin. For example, insulin-like growth factor (IGF), fibroblast growth Chondroitin sulfate, keratan sulfate, and heparan sulfate
factor (FGF), transforming growth factor-beta (TGF-β), hepatocyte Chondroitin sulfate, keratan sulfate, and heparan sulfate are
growth factor (HGF), and platelet-derived growth factor (PDGF) heteropolysaccharides that also belong to the class of

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Huang et al.
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glycosaminoglycans75. Their molecular structures are similar to maintaining tissue homeostasis. For cancer, which is a compli-
that of HA and comprise repeated disaccharides. The difference cated disease involving active interaction between cells and their
among HA, chondroitin sulfate, keratan sulfate, and heparan microenvironment, ECM stiffness is a distinctive feature and a
sulfate lies in the carbohydrate of the monomer and sulfate ester promising therapeutic target (Fig. 1).
position. The carbohydrates that comprise chondroitin sulfate are
[→4GlcAb1→3GalNAcb1→], and the sulfated site could be
position 4 (CS A, chondroitin-4-sulfate) or position 6 (CS C, MATRIX STIFFNESS IN CANCER: PHENOMENA, MECHANISMS,
chondroitin-6-sulfate) of the repeating unit76,77. Keratan sulfate AND BIOLOGICAL EFFECTS
comprises [→3Galb1→4GlcNAcb1→], and sulfate esters can be Alterations of tissue stiffness in cancer
found at C-6 in one carbohydrate or both monosaccharides with a Stiffness is defined as the extent of deformation when the external
hydroxyl group78. Heparan sulfate comprises [→4GlcAb1→4Glc- force is applied to an object or material100,101. For most tissues
NAca1→]. O-sulfation modification of heparan sulfate mainly without bones, their stiffness is largely dependent on the quantity
occurs at C-2 of iduronic acid (IdoA) and C-6 of glucosamine, and and components of the ECM. Tumors frequently exhibit higher
sometimes at C-2 of GlcA and C-3 of glucosamine79. Various stiffness than normal tissues. For example, an elastography study
sulfate group sites lead to the heterogeneity of the glycosami- of breast cancer demonstrated that the stiffness of tumor tissue is
noglycan structures and functions75. higher than that of normal tissue102. In another study, in vivo
These three types of glycosaminoglycans described above have shear-wave elastography analysis of 337 breast cancer patients
the following characteristics. First, glycosaminoglycans bind to also revealed that tissue stiffness values are positively correlated
proteins by covalent bonds80. For example, chondroitin sulfate can with malignant phenotypes, including larger tumor sizes, higher
bind to matrix proteins, growth factors, cytokines, chemokines, histologic grades, and estrogen receptor (ER) status, with triple-
and protease inhibitors81–83. Second, the sulfate substituent on negative breast cancer tissues ranking stiffest103. Similarly, a study
the carbohydrate can mediate the coupling between glycosami- of 373 patients with focal liver lesions showed that the mean
noglycans and metal ions, thus preventing the formation of stiffness values of hepatocellular carcinoma, intrahepatic cholan-
peroxide catalyzed by metal ions. Finally, the hydrogen bond is giocarcinoma, and metastasis were 34 (range: 4.4–188), 25 (range:
formed when glycosaminoglycans interact with water, leading to 5.5–79), and 30 (range: 4.7–64), respectively, which are signifi-
the mechanical effect of viscoelasticity. cantly higher than those of hemangioma (9.3, range: 3.1–41), focal
nodular hyperplasia (10, range: 2.9–26) and cirrhotic nodules (11,
range: 4.4–49)104. In addition to breast cancer and liver cancer,
FIBROBLASTS pancreatic tumors are also stiffer than normal pancreatic tissue105–107.
Stromal cells, including fibroblasts and pericytes, are the major However, although tumors are macroscopically stiffer than
source of ECM84. Fibroblasts are widely distributed in most normal tissues, Plodinec et al.108 observed the existence of
connective tissues such as the bone marrow, lymph nodes, dispersed softened regions within human breast cancer biopsies
ovaries, and solid tumors85. Pericytes are specifically located and breast cancer tissues in mouse mammary tumor virus-
surrounding the endothelial cells on the interior surface of blood polyoma middle T antigen transgenic mice using an indentation-
vessels86,87. type atomic force microscopy method, and this finding might be
Fibroblasts are one of the major cell types within the TME in related to metastatic spreading.
terms of both number and function. Some studies have shown
that fibroblasts account for 70 to 90% of the whole tumor volume Mechanisms of matrix stiffness in cancer
of breast cancer and pancreatic cancer88–90. More importantly, Matrix stiffness mainly depends on the ECM components and
fibroblasts play a central role in the formation and turnover of proportion, which is a cardinal phenomenon in many cancers
ECM for two reasons. First, fibroblasts directly produce structural accompanying TME sclerosis. Generally, overabundant collagen
macromolecules, such as collagen, fibronectin, and laminin91. and HA are frequently observed throughout the tumor and are
Second, enzymes involved in the modification and degradation of responsible for its stiffness109–111. However, solid tumors are 3D
these structural macromolecules are also secreted by fibroblasts structures, whose periphery and interior parts show different
such as lysyl hydroxylases and metalloproteinases92,93. mechanical characteristics. The interior parts of solid tumors
Fibroblasts are regulated by many signals, including cytokines, mainly bear compressive stress from tumor cells and a stiffening
chemicals, and environmental signals, such as heat and mechan- matrix112, while the periphery of the tumor is subjected to tensile
ical forces, thus contributing to ECM remodeling. For example, stress from the tumor mass and surrounding tissues112. Thus, the
TGF-β can enhance the production of both collagen and primary components responsible for stiffness of the periphery and
fibronectin, as well as procollagen lysyl hydroxylase 2 (LOX2), interior of a tumor might be different. For example, excess
while tumor necrosis factor-alpha (TNF-α) can inhibit collagen collagen mostly contributes to the stiffness at the periphery of a
synthesis in fibroblasts92,94. Moreover, TNF-α and interleukin (IL)-1 tumor113. Superfluous HA mainly deposits at the interior of a
can induce the production of MMP-1, -3, and -9 by fibroblasts, tumor to counteract the compressive stresses exerted by the
leading to the degradation of collagen in the TME94. Interestingly, periphery layer of the tumor114.
primary human dermal fibroblasts proliferate faster and produce Overall, the excessive intratumoral deposition of collagen and
more collagen on amine-rich (NH3) surfaces when cultured in vitro HA can be attributed to accelerated synthesis and slowed
compared with surfaces coated with carboxyl acid (COOH) and catabolism. First, some tumor cells can synthesize components
hydrocarbon (CH3)95. Similarly, the collagen levels of human of the ECM such as collagen and HA, exhibiting some
patellar tendon fibroblasts, cardiac fibroblasts, and periodontal characteristics of fibroblasts. For example, Fang et al.115 showed
ligament fibroblasts are all enhanced by repeated mechanical that type I collagen could be produced by not only fibroblasts but
stretching96–98. Moreover, repeated mild heat shocks have been also by cancer cells in the lung and esophageal cancer. Similarly,
shown to increase dermal fibroblast activity and collagen HA-positive tumor cells can be identified in epithelial ovarian
production99. These lines of evidence suggest that fibroblasts cancer116, breast cancer117, colorectal cancer118, prostate can-
are highly flexible cells that convert signals from multiple sources cer119, and gastric cancer120. In addition to secreting components
into changes in ECM components. of the ECM, cancer cells can also produce enzymes involved in the
The ECM is an orchestration of many components, including but maturation of ECM proteins. For example, IHC analysis revealed
not limited to matrix proteins, glycosaminoglycans, growth that gastric cancer cells could produce LOX to enhance collagen
factors, enzymes, and fibroblasts, whose balance is critical to crosslinking121. It is worth mentioning that MMP-2 and MMP-9 are

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upregulated in human colorectal cancer122, and it might partly In addition to the direct mechanisms described above, tumor
attribute to the compensatory responses to matrix stiffness so that cells could secrete growth factors to attract fibroblasts to migrate
the local matrix is degraded, which further enhances the motility towards the TME and then transform normal fibroblasts into
of cancer cells. cancer-associated fibroblasts (CAFs) with a stronger ability to
Unfortunately, the production of ECM components and proliferate and promote ECM accumulation. In turn, a stiffened
enzymes could be further accelerated when tumor cells receive ECM accelerates the growth of tumor cells. Such communication
external signals from growth factors123. For example, HAS mRNA between cancer cells and fibroblasts forms a positive loop feeding
transcription can be stimulated by epidermal growth factor (EGF), the rapid progression of this disease (Fig. 2). During the process of
keratinocyte growth factor (KGF), and PDGF in keratinocytes124–126, this bidirectional interaction, the TGF-β/Smad2/3 and C–X–C motif
and these growth factors are frequently overexpressed in cancer. chemokine ligand 12 (CXCL12)/C–X–C motif chemokine receptor 4
By contrast, some enzymes catalyzing the degradation of the (CXCR4) signaling pathways are most critical (Fig. 3). Specifically,
ECM tend to be suppressed in the TME. For example, hyalur- TGF-β, which could be derived from cancer cells129, acts potently
onidase activity decreases in ovarian cancer compared with that in on fibroblasts to enhance the synthesis of collagen and
normal ovarian tissue127. Moreover, MMP-28, namely epilysin, is fibronectin130 as well as chemokines related to tumor promotion,
significantly downregulated in lung squamous cell carcinoma and such as CXCR3, CXCR4, C–C motif chemokine receptor 9 (CCR9),
adenocarcinoma128. CXCL10, CXCL12, C–C motif chemokine ligand 21 (CCL21), and
CCL25131. These chemokines enhance tumor cell invasion and
eventually the occurrence of organ-specific metastases132. More-
over, macrophages are lured into the TME by tumor cells133 and
are further transformed towards the M2 type of macrophages134.
Next, these M2 macrophages contribute to the activation of CAFs
by secreting more TGF-β into the TME135,136, feeding more fuel
into this positive loop and leading to malignant transformation
(Fig. 2).

The biological effect of matrix stiffness on cancer cells

A stiffened ECM has fundamental influences on critical biological
processes of cancer development, including uncontrolled
proliferation, metastasis, angiogenesis, resistance against ther-
apeutics, genome instability (GIN), and immunosuppressive TME
(Fig. 4). The mechanisms by which ECM stiffness remodels these
key processes will be discussed in-depth in this chapter.

Fig. 2 The signaling loop formed by cancer cells, macrophages and ECM and growth factors
fibroblasts contributes to ECM stiffness, in which TGF-β plays a ECM are important modifiers for the function of many growth
central role factors. Firstly, accumulated ECM can function as a reservoir of

Fig. 3 Intracellular signaling network triggered by TGF-β and CXCL12, two critical factors inducing ECM stiffness

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growth factors, thus creating a niche with concentrated signaling colorectal cancer122, and growth factors released from ECM
molecules for the sustained malignant transformation. For cleaved by MMPs would promote tumor progression. For example,
instance, Somasundaram et al. proved that PDGF bound to the VEGF is released when heparan sulfate is degraded, and such
collagen to accumulate in ECM137. Heparin-binding growth factor- process promotes angiogenesis in colorectal carcinoma145.
1, a growth factor associated with angiogenesis, also binds to type
I and type IV collagens138. What’s more, Paralkar et al.139 found Effects on the proliferation of cancer cells
that TGF-β bound to type IV collagen in the basement membrane. Tumor cells proliferate more slowly in a soft matrix, and matrix
It is also reported that ECM contains IGFs140. Secondly, ECM stiffness contributes to cancerous proliferation by multiple
facilitates the presentation of growth factors to their receptors. For signaling pathways (Fig. 5)146–149. For example, the superfluous
example, glypican-3, a heparan sulfate proteoglycan, promotes collagens bind to integrin on the cell membrane, leading to its
the interaction between Wnts and Frizzled through complexing allosteric alteration. In addition, the intracellular domain of the
with Wnts, thus stimulating the growth of hepatocellular integrin β subunit recruits the cytoskeletal protein talin and other
carcinoma cells both in vitro and in vivo141. Interestingly, cytoskeletal linker proteins, leading to the formation of focal
glypican-3 also directly binds Frizzled through the glycosamino- adhesions and activation of Src family kinases (SFKs). Thereafter,
glycan chains142. Furthermore, ECM degradation contributes to assembly of the actin cytoskeleton increases cytoskeletal tension,
the release of growth factors and cytokines143,144. During influencing the myocardin-related transcription factor (MRTF)/
tumorigenesis, MMP-2 and MMP-9 are upregulated in human serum response factor (SRF) complex. With the help of MRTF/SRF,
the signals from the cytoskeleton are transmitted into the nucleus.
In addition, activated focal adhesion kinase (FAK) enhances the
activity of PI3K100,150. Downstream proteins, such as AP-1
(oncogene c-Jun/c-Fos) are activated via Rac/PAK/MEK/ERK, and
target of rapamycin is inhibited, eventually contributing to the
proliferation of tumor cells. Another important pathway involved
in cancer cell proliferation on hard surfaces is the Hippo pathway.
This pathway comprises three components, mammalian Ste20-like
kinases 1/2 (MST1/2), large tumor suppressor 1/2 (LATS1/2), and
yes-associated transcriptional regulator/tafazzin (YAP/TAZ). When
matrix stiffness occurs, the activated integrin linked kinase (ILK)-
integrin signaling enhances the phosphorylation of myosin
phosphatase target subunit 1 and inhibits its activity151, leading
to the suppression of a signaling cascade comprising Merlin,
MST1/2, and LATS1/2151. The blockade of upstream signals results
in the translocation of YAP/TAZ from the cytoplasm to the
nucleus152, where they initiate the transcription of genes involved
in cell proliferation, such as cyclin D1 and forkhead box M1153. In a
Fig. 4 Crucial biological processes affected by ECM stiffness for cancer prospective cohort study in 528 patients with chronic hepatitis B

Fig. 5 Schematic summary of key membrane receptors recognizing ECM components and their downstream signaling networks

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Huang et al.
7
patients, those with a higher liver stiffness (≥10 kPa) showed a chemotherapies and immune therapies in many circumstances181.
significantly higher possibility of developing hepatocellular First, a stiffened matrix forms physical barriers for drug infiltration
carcinoma than those showing lower liver stiffness (<10 kPa)154. into tumor tissue, and researchers have shown that decreasing HA
deposited in tumor tissues benefited systemic chemotherapy in
Effects on the mobility of cancer cells colorectal cancer patients with liver metastasis182. Second, besides
Cancer cells also tend to exhibit higher mobility on a stiffened the physical barrier, a stiff matrix compresses micro blood vessels,
ECM for many reasons. First, the stiffness of ECM can directly making it difficult for drugs to access core tumor tissues via the
activate several signaling transduction pathways involved in cell vasculature. Third, ECM stiffness induces hypoxia in the tumor
migration (Fig. 5). For example, Rho/Rho-associated coiled-coil microenvironment183,184, further inducing neovascular chaos,
containing protein kinase signaling is activated when cytoskeletal resulting in disorganized and perforated intratumoral microves-
tension is increased in a stiffened matrix155,156. Simultaneously, sels. This leaky vasculature negatively influences the transport
collagen-induced integrin clustering induces the recruitment of efficiency of chemotherapeutic drugs185. Finally, ECM stiffness is
focal adhesion signaling molecules, such as FAK, Src, paxillin, Rac, involved in the transformation of tumor cells to cancer stem cells
Rho, and Ras, eventually promoting the contraction and progres- (CSCs), which have the ability to proliferate in a hypoxic
sion of cancer cells157,158. As mentioned previously, PI3K is also environment. Many lines of evidence have shown that CSCs are
activated when matrix stiffness occurs150,159,160, and the down- more resistant to anti-cancer drugs than bulk cells186–188.
stream molecules AP-1 promotes the migration and invasion of Matrix stiffness also plays a role in radiation resistance for
tumor cells. Moreover, the stiffness of the ECM can regulate the tumors189–192. β1 integrins are upregulated in several types of
expression level of key elements of signaling pathways, indirectly cancer, such as lung cancer193 and colorectal carcinoma191, and
leading to their dysregulation. Gkretsi et al.161 reported that Ras several studies have demonstrated that the upregulation of β1
suppressor-1 (RSU-1), a cell-ECM protein, is overexpressed in integrins contribute to the survival of tumor cells in pancreatic,
breast cancer cells embedded in stiffer 3D collagen I gels, and prostate, glioblastoma, melanoma, and colorectal carcinoma after
silencing RSU-1 led to the inhibition of urokinase plasminogen the treatment of radiation190,193–195. Mechanically, the down-
activator (UPA) and MMP-13, resulting in reduced invasion activity stream signals of β1 integrins would be activated in response of
in breast cancer cells. radiation, such as ILK, FAK, paxillin194, c-Jun N2-terminal kinase
(JNK), PI3K, and AKT/protein kinase B (PKB)196. The activation of
Effects on tumor vascularity PI3K/AKT leads to the radiation resistance197, and inhibition of
Vascularization is an indicator of tumor development and integrin signaling attenuates the insensitivity of cancer cells
progression162. During angiogenesis, vascular loops are formed exposed to radiation189,196.
which link the parental vessels and neovessels, and the matrix of
basement membrane is synthesized to reinforce the elasticity and Effects on genome stability
tenacity of blood vessel163. Basement membrane, mainly com- Recently, some researchers have reported that GIN could also be
posed of collagen, laminin, fibronectin, often exhibit several enhanced by matrix stiffness, whose detailed mechanisms remain
abnormal characteristics in tumors, such as disconnection with under investigation. Some researchers speculate that matrix
endothelial cells, disorder of layer and structure, and extensively stiffness would promote cell mitosis, during which spontaneous
infiltration into tumor stroma164. Vascularization decreases with the mutations would accumulate accompanied by fast DNA replica-
increasing matrix density in both collagen and fibrin matrix165–168. tion198,199. In addition, matrix stiffness increases the probability of
Matrix stiffness also interrupts endothelial cell–cell junction so that nucleus envelope rupture200. Nucleus envelope rupture would
the integrity of barrier breaks down and leads to the leaky cause the leakage of nuclear contents into the cytoplasm, such as
vascular169. Mechanically, several mechanosensors are in the nucleic acid and nuclease, ultimately causing DNA damage and
employ of endothelial cells to convert the mechanical clues into GIN201. Finally, the pore size of the matrix is smaller under stiffer
cells so that intracellular biochemical signaling cascades can be conditions202 due to the overabundant deposition of matrix
activated, such as integrins, actin cytoskeleton, cell-cell adhesion proteins such as collagen203. While cancer cells invade, they need
receptors, and other membrane proteins such as ion channels and to squeeze through smaller pores and undergo more physical
G-protein-coupled receptors. Taking the mechanical sensor com- damage204. Such squeezing movement would isolate some
plex of endothelial cells as an example, which is composed of mobilizable nuclear proteins away from DNA205, such as DNA
platelet and endothelial cell adhesion molecule 1 (PECAM1), repair proteins (e.g., BRCA1), thus increasing the possibility of GIN.
vascular endothelial cadherin (VE–cadherin), and VEGF receptor
(VEGFR), PECAM1 functions as a direct mechanosensory, and Effects on infiltrated immune cells and immune therapies
VE–cadherin serves as an adapter, and VEGFR activates intracellular During the development of cancer, immune cells infiltrate into
signaling which consumes energy from GTPase170–172. In addition, TME and play either anti-tumor and pro-tumor roles. For example,
upregulation of MMP activity in stiffened TME also augments CD8+ T cells, CD4+ Th1 cells, dendritic cells (DC), natural killer (NK)
vascular hyperplasia, intrusion, and neovascular branching169. cells, and M1 macrophages mainly exhibited inhibitory effects on
ECM also affects vascularization indirectly through hypoxia. cancer progression, while regulatory T cells (Tregs), CD4+ Th2 cells,
Overgrowth of cancer cells, as well as a structural and functional myeloid-derived suppressor cells (MDSCs) and M2 macrophages
abnormality of ECM both, contributes to the hypoxia of solid mainly show pro-tumor effects206. These cells are constantly
tumor173. In turn, the hypoxia circumstance affects the vascular- influenced by the physical, chemical, and biological signals
ization via multiple mechanisms, the most well understood of emitted by ECM in TME.
which is the activation of hypoxia-inducible factors (HIFs)174. T cells, especially CD8+ T cells, are the major players in the
Overexpression of HIF-1α has been reported in many malignan- immune response against cancerous cells, and they are also the
cies175,176. In addition, multiple studies have demonstrated the primary targets for checkpoint inhibitor (CPI) therapy currently.
involvement of HIF-1/VEGF signaling in breast cancer177, gastric The intratumoral ECM contributed to both exclusion and
cancer178, bladder cancer179, ovarian cancer180, and so on. inactivation of T cells in TME by multiple mechanisms. Firstly,
the center-axial infiltration of T cells towards chemotaxis gradients
Effects on the therapeutic efficacy of chemotherapies, is interrupted by the haptotaxis signals from altered ECM207–209.
radiotherapies, and targeted therapies Instead of entering TME, some T cells migrate along ECM-rich
The stiffened matrix in tumors also decreases drug sensitivity, encapsulation of tumors due to the gradients of substrate rigidity
which can partially explain the poor therapeutic efficacy of and adhesion molecules such as aligned collagen fibers210,211.

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Huang et al.
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Such an accumulation of T cells on the periphery of cancerous adhesion of prostatic cancer cells could be attenuated by silencing
tissues are reported in many kinds of cancers such as colorectal CUB domain-containing protein-1 (CDCP1) due to the reduction of
cancer and lung cancer212,213. Secondly, ECM-rich tumors exhibit inside-out signaling mediated by integrin β1 subunit. Interestingly,
poor diffusion and hypoxia. The retarded exchange of substances the metastatic adhesion of circulating cancer cells may be
enhances glycolytic metabolism and acidification, which sup- upregulated by the inside-out signaling via FAK/integrin232.
presses the activation of T lymphocytes through the specific Much research has shown that several integrin proteins are
interaction between V-domain immunoglobulin suppressor of T highly expressed in solid tumors and are involved in tumor
cell activation and co-inhibitory receptor P-selectin glycoprotein progression. For example, integrin αvβ3 is upregulated in prostate
ligand-1 in acidic TME214. Moreover, the hypoxic microenviron- cancer and promotes cell migration via activation of the PI3K/AKT
ment increases the production of immunosuppressive factors like pathway233. Similarly, immunohistochemistry (IHC) analysis con-
TGF-β in favor of Treg differentiation, and it also induces ducted by Desgrosellier JS revealed that the positive rate of
neovascularization with abnormal structure and reduced expres- integrin αvβ3 was significantly higher in metastasis than in
sion of surface glycoproteins and cell adhesion molecules which primary tumors of pancreatic and breast cancer, and integrin αvβ3
are critical for the extravasation of T lymphocytes215. Thereby, enhanced tumor migration and metastasis by the recruitment of
poor diffusion due to stiffened ECM contributes remarkably to the Src kinase234. Furthermore, several studies have demonstrated
suppression of anti-tumor responses mediated by T lymphocytes that the upregulation of integrin αvβ3 is correlated with a poor
in TME. Thirdly, ECM proteins are directly involved in the prognosis for patients with oral squamous carcinoma235–238,
regulation of T lymphocytes. For example, CD8+ T cells are breast cancer239, gastric cancer240,241, colorectal cancer242, pan-
suppressed by collagen through leukocyte associated Ig-like creatic ductal adenocarcinoma243, and cervical squamous carci-
receptor-1 (LAIR-1)/SH2-containing inositol phosphatase signaling noma244. Other than integrin αvβ3, integrin αvβ6 is overexpressed
axis in murine cancer models216, and high molecular weight HA in oral squamous carcinoma235,237, breast carcinoma239,245, gastric
could enhance the activity of Tregs in vitro217. Lung cancer cells cancer240,246, pancreatic ductal adenocarcinoma243,247, ovarian
also express more PD-L1 in response to ECM stiffness to shut cancer248, colorectal cancer242,249,250, cholangiocarcinoma251,252,
down the anti-tumor immune response mediated by CD8+ and non-small cell lung cancer253.
T cells218. Fourthly, stiffened ECM impairs the efficacy of immune
therapies. For example, two important obstacles for the applica- Discoidin domain receptors
tion of chimeric antigen receptor (CAR)-engineered T cells therapy DDRs can spontaneously bind to collagen and are not regulated
in non-hematopoietic malignancies are the low infiltration rate by intracellular or extracellular signals. The structure of DDRs
and the immunosuppressive TME, both of which are directly includes collagen-binding the discoidin domain at the N-terminus,
associated with intratumoral ECM accumulation219. Similarly, CPI extracellular juxtamembrane domain, transmembrane domain,
therapies mediated by blocking antibodies are also less pene- intracellular juxtamembrane domain, and tyrosine kinase domain
trable for tumors with high rigidity220. at the C-terminus254. There are two types of DDRs, namely, DDR1
Tumor-associated macrophages are the most frequent immune and DDR2. DDR1 is commonly expressed in epithelial cells, and
cells found in the TME221. ECM components are able to regulate DDR2 is generally present in mesenchymal cells such as
the polarization of macrophages. For example, collagen and HA fibroblasts255. Specifically, DDR1 interacts with collagen type I
are able to drive M2 polarization in vitro222,223, while fibronectin and IV, while DDR2 binds to collagen type I, II, and X. When the
enhances cytotoxicity of macrophages against tumor cells, collagen-binding discoidin domain interacts with collagen, the
resembling the M1 polarization224. Other than macrophages, NK conformation of DDRs changes and the phosphorylation of the
cells have also been shown to be functionally suppressed by tyrosine kinase domain leads to the recruitment of adapter
transmembrane collagens like Collagen type XVII via LAIR-1225. proteins (e.g., ShcA and Nck2) to the cytoplasmic domain of
DDRs256. Both integrin and DDRs can sense ECM stiffness and then
Receptors for ECM in normal and cancer cells transmit this signal into cells. However, ECM cell signal transduc-
Many receptor proteins play an important role in the interaction tion mediated by DDRs is unidirectional, while the one mediated
between ECM and cells, such as integrin, discoidin domain by integrin is bidirectional.
receptors (DDRs), CD44, RHAMM, LAIR-1, and the mannose Although heterogeneity remains regarding the expression of
receptor family, including urokinase plasminogen activator DDRs in multiple cancers, many studies have reported that DDRs
receptor-associated protein226. Next, we will focus mainly on are overexpressed in cancers. For example, DDR1 overexpression
integrin, DDRs, CD44, and RHAMM, which are frequently discussed has been observed in breast cancer257–260, nonsmall cell lung
in the context of cancer (Fig. 5). carcinomas261–264, glioblastoma265, ovarian tumor266–269, endo-
metrial tumors270, esophageal carcinoma271, head and neck
Integrin squamous cell carcinomas260, hepatocellular carcinoma272, cho-
Integrins are transmembrane heterodimers comprising α subunits langiocarcinoma273, and prostate cancer274. Similarly, DDR2 over-
and β subunits. In mammals, 18 α subunits and 8 β subunits expression is reported in nasopharyngeal carcinoma275,
combine into 24 integrin heterodimers. Among the 24 integrins, cholangiocarcinoma273, thyroid cancer276, Hodgkin’s lym-
four (α1β1, α2β1, α10β1, and α11β1) can bind collagen226. phoma277,278, and acute myelocytic leukemia279. In addition,
Moreover, integrins can bind to various proteins that contain DDR1 overexpression is significantly correlated with a poor
the RGD sequence, such as fibronectin, fibrinogen, laminin, and prognosis in pancreatic ductal adenocarcinoma280, gastric can-
vitronectin227–230. Other than functioning as an anchor, integrins cer281, and nonsmall cell lung cancer263,282, while increased DDR2
serve as switching points that connect the ECM to the intracellular levels could function as an independent indicator of a worse
actin cytoskeleton. Specifically, integrins perceive the ECM clinical outcome in breast cancer283.
mechanical force and then transfer such signals to intracellular
proteins such as FAK and Src tyrosine kinases, a process called CD44
mechanotransduction. In addition to outside-in signal transduc- CD44 mainly functions as a receptor for HA, collagen, fibronectin,
tion, integrins also transmit signals from the inside to the outside and growth factors. CD44 comprises an extracellular domain, a
of the cell when intracellular stimulating molecules bind to β transmembrane domain, and a cytoplasmic domain284, whose
subunits, further influencing the affinity between integrins and the isoform heterogeneity is mainly due to the alternative splicing of
ECM so that cell adhesion, migration, and ECM characteristics premRNA and posttranscriptional modifications such as glycosyla-
might change. For example, Pollan et al.231 reported that the tion (N- and O-glycosylations). HA–CD44 interaction activates

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Huang et al.
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multiple cell receptors, such as c-MET, EGF receptor (EGFR), erb-b2 carcinoma389, and head and neck cancers390. Recently, Choi
receptor tyrosine kinase 2 (ErbB2), and TGF-β, which then et al.391 reported that RHAMMB isoform was crucial for in vivo
promotes oncogenic pathways. In addition to membrane recep- metastatic capacity of mouse and human pancreatic cancer while
tors, the HA–CD44 interaction also activates intracellular signal RHAMMA, carrying an extra 15-amino acid-stretch, did not
transducers, such as Grb2, Gab-1, Src, and Rac GTPase families. promote metastasis in spontaneous and experimental metastasis
Thus, many aspects of malignant transformation, such as mouse models.
uncontrolled proliferation, migration and drug resistance could
be induced by the HA-CD44 interaction284,285. In addition, the
binding of lymphocytes to fibronectin is also mediated by MATRIX COMPONENTS AS THERAPEUTIC TARGETS FOR
CD44286, which is pivotal for the infiltration of lymphocytes into CANCER
the TME. A phase I clinical trial demonstrated that recombinant Therapies targeting collagen
fibronectin CH296 (FN-CH296) stimulates T cells to achieve strong Collagen is one of the most fundamental components in the ECM,
tumor inhibitory effects in patients with advanced cancer287. the breaking of which could facilitate the penetration of many
Overexpression of CD44 standard (CD44s) and CD44 variant conventional chemotherapeutic agents and nanoparticles through
(CD44v) isoforms is widely reported in many types of cancer288. In the barrier of the stiffened matrix in the TME. To alleviate the
gastric cancer, Yansu Chen et al.289 performed a meta-analysis excessive deposition of collagen in solid tumors with TME
comprising 2403 cases and identified that higher CD44 expression sclerosis, several therapeutic strategies have been developed,
is correlated with a poor overall survival rate and serves as an mostly focusing on the synthesis, degradation, and cross-linking of
independent risk factor. A similar observation regarding the collagen (Table 1).
prognostic value of CD44 is also reported in other types of cancer, Considering TGF-β’s crucial role during collagen synthesis, TGF-
including renal cell carcinoma290–295, prostate cancer296–298, β signaling is the most promising target to inhibit collagen
pancreatic cancer299–301, lung cancer302–307, breast cancer308, synthesis392,393. For example, an anticoccidial named halofugi-
colorectal cancer309–318, and hepatocellular carcinoma319–322. none has been shown to reduce collagen synthesis by inhibiting
Recently, CD44s and CD44v isoforms have been identified as TGF-β signaling in animal models of pancreatic cancer394, lung
surface biomarkers for CSCs in pancreatic cancer323, salivary gland cancer395, melanoma396, and breast cancer397, and tumor migra-
tumor324, laryngeal and nasopharyngeal carcinoma325–327, head tion396,397. Moreover, the therapeutic effect of fresolimumab, a
and neck malignancy328–335, gastric cancer336–341, colon can- monoclonal antibody targeting TGF-β, is currently actively
cer312,342–346, glioma347–349, lung cancer306,350,351, breast cancer352, evaluated in several clinical trials ([Link] identifier:
ovarian cancer353, prostate cancer296,354–356, and leukemia/ NCT01401062 and NCT02581787) to treat cancer398. However, a
lymphoma357. treatment target involving TGF-β should be regarded cautiously
because of its extensive roles in both inflammatory and
Receptor for hyaluronan-mediated motility tumorigenesis399. In addition to therapies targeting TGF-β, some
RHAMM is a unique ECM receptor which lacks a transmembrane pilot studies have also found that the classic anti-hypertensive
domain, and it exhibits both intracellular (cytoplasmic and drug losartan contributes to the inhibition of collagen synthesis in
nuclear) and extracellular (membrane-bound or soluble) localiza- both animal models400,401 and clinical trials ([Link]
tions358–361. RHAMM exhibits highly diverse functions in different identifier: NCT01821729). Although its molecular mechanism still
subcellular compartments. On cell membrane, HA is the major requires further investigation, its safety profile makes losartan a
ligand for membrane-bound RHAMM362. RHAMM couples with promising choice for designing new therapies targeting collagen
integral cell surface receptor proteins such as CD44 and growth synthesis in cancer.
factor receptors, and HA-RHAMM–CD44 coupling is necessary for Collagenases can degrade collagen, which could attenuate the
the activation of Src/Ras/ERK and FAK/Ras/ERK signaling pathways stiffness of the matrix and simultaneously contribute to more
mediated by CD44363–366. Antibodies blocking RHAMM-HA recog- efficient drug delivery into solid tumors402. Due to their chemical
nition would completely inhibit HA-mediated locomotion, while nature as proteins, several strategies have been developed to
antibodies blocking CD44-HA recognition failed to change overcome their problem of large molecular sizes to achieve
locomotion, suggesting that RHAMM plays a central role for cell effective transport of collagenases into tumors, such as the
motility along HA fibers367,368. Moreover, intracellular RHAMM oncolytic herpes simplex virus vector403 and collagozome (a
forms direct interaction with MEK/ERK366, and it also localizes to liposomal formulation of collagenase type I)404. For example,
multiple subcellular structures including actin filaments, podo- Zinger A et al. found that the tumor size was reduced by 87%
somes, the centrosome, microtubules and the mitotic spin- when mice bearing pancreatic tumor xenografts were sequentially
dle364,369. During cell migration, spectrin-α (an actin-associated treated with collagozome and paclitaxel compared with mice
protein) and RHAMM interact in a complex at the nodes of the treated with empty liposomes and paclitaxel404. More importantly,
actin net to coordinate microtubule polarization370. In the the researchers found no evidence of the existence of tumor cells
centrosome, RHAMM interacts with dynein and maintains spindle in the circulatory system, suggesting that the process of ECM
pole stability369. In the nucleus RHAMM is able to regulate HA- degradation did not trigger tumor metastasis404. Interestingly, a
induced activation of the Aurora A kinase (AURKA) by associating hormone named relaxin could improve the penetration of
with TPX2 (TPX2 microtubule nucleation factor), a critical protein antitumor drugs by indirectly promoting the synthesis of
for AURKA recruiting and activating371. During mitosis, RHAMM collagenase in osteosarcoma tumor models405. In addition to
regulates mitotic spindle formation through interacting with collagenases, a few studies showed that strategies aimed at
tubulin, ERK and TPX2 to recruit and activate AURKA360,369,372,373. regulating the quantity or activity of MMPs could also be helpful
In mammary epithelium, RHAMM works in concert with TPX2, for cancer treatment, such as marimastat (BB-2516), prinomastat
BRCA1, and AURKA to regulate the apicobasal polarization374. (AG3340), tanomastat (BAY 12-9566), and neovastat406,407.
As a dual oncogenic protein promoting proliferation and However, two major concerns exist regarding the application of
migration both on cell membrane and intracellularly, RHAMM is collagenase during cancer therapy. First, the process of collagen
overexpressed and correlated with poor prognosis in many kinds degradation might lead to the release of growth factors and
of solid tumors, including but not limited to breast cancer375–377, cytokines anchored in collagens, which would initiate a cascade of
colorectal cancer378,379, stomach cancer380, prostate cancer381,382, inflammatory signals and tumor progression408. Second, the
hepatocellular carcinoma383,384, pancreatic ductal adenocarci- breakdown of collagen might facilitate tumor migration and
noma385, lung cancer386,387, bladder cancer388, oral squamous cell invasion409,410. Therefore, the best time point for the application

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Huang et al.
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Table 1. ECM as a therapeutic target in cancer

Drug illustration Function Characteristic

Halofuginone Inhibiting TGF-β signaling pathway and collagen synthesis Anticoccidial drug
Fresolimumab Inhibiting collagen synthesis Monoclonal antibody targeting TGF-β
Collagenases Collagen degradation Enzyme
Relaxin Promoting the synthesis of collagenase Hormone
MMPs Collagen degradation Enzyme
GS-6624 Inhibition of collagen cross-linking Monoclonal antibody targeting LOXL2
SB-431542 and SB-505124 Inhibiting ALK4/5/7 kinase to block TGF-β pathway Imidazole analog
Ki26894 Inhibitor of TGFβR1 Small-molecule inhibitor
Candesartan Angiotensin receptor blockers Long-acting angiotensin receptor
antagonist
4-methylumbelliferone (4-MU) Inhibitor of HA synthesis Umbelliferone derivatives
Hyaluronidase HA degradation Enzyme
BC-1 Targeting fibronectin for drug delivery Monoclonal antibody
L19 Targeting fibronectin for delivering drugs and radionuclide Monoclonal antibody
APTEDB Targeting fibronectin for drug delivery High-affinity peptides
Vitaxin Targeting integrin and preventing angiogenesis Monoclonal antibody targeting integrin
αvβ3
Volociximab Targeting integrin and inhibiting neoangiogenesis Monoclonal antibody targeting α5β1
integrin
1a-RGD Targeting the RGD-integrins interaction Small-molecule integrin antagonist
Cilengitide Inhibitor of αvβ3 and αvβ5 integrins Specific peptide antagonist
Imatinib, nilotinib, and dasatinib Inhibiting tyrosine kinase and DDR signaling pathway Benzene ammonia pyrimidine derivatives
Bivatuzumab Blocking CD44-HA interaction Monoclonal antibody against CD44v6
Verbascoside Inhibitor for CD44 dimerization phenylpropanoids
Tranilast Suppressing TGF-β signaling and expression of extracellular matrix Derivative of the amino acid tryptophan
components
Pirfenidone Inhibiting TGF-β/Smad and anti-inflammation Pyridones
Fasudil Rho-kinase inhibitor Isoquinoline sulfonamide derivatives
Metformin Reducing TGF-β signaling, IL-1β, and M2 tumor-associated Biguanides
macrophages infiltration
Dexamethasone Suppressing angiogenesis and normalizes vessel morphology Glucocorticoid steroid
Hydroxychloroquine Macropinocytosis inhibitors Derivatives of 4-aminoquinoline
All-trans retinoic acid Retinoic acid receptor agonists Vitamin
Defactinib FAK inhibitors and antiangiogenic effect Benzamides
Ibrutinib Inhibitor of Bruton tyrosine kinase to interrupt BCR signaling in CLL Benzene ammonia pyrimidine derivatives
RG7356 Blocking the signaling of CD44 in CLL Humanized monoclonal antibody
for CD44

of such treatment should be considered cautiously and validated of the adapters such as Smad2 and Smad3 phosphorylates. These
experimentally. Theoretically, collagenase-based therapies should adapters, together with Smad4, translocate into the cell nucleus,
be applied to early detected cancer with obvious matrix stiffness finally binding to transcription factors so that the transcription of
that has shown no signs of invasion or metastasis. target genes is activated or suppressed416–418. TGF-β plays a dual
Inhibition of collagen cross-linking is another strategy to target role in cancer. It is a tumor suppressor during the initiating stage
ECM stiffness in cancer. For example, studies have found that LOXs early stage of cancer, while it functions as an oncoprotein in
are frequently upregulated in many cancers, including thyroid advanced stages of cancer419. Mechanically, the direct effect when
cancer and colorectal cancer411–413. Inhibition of LOXs has been TGF-β binds to TGFβR is proapoptotic420, so TGFβR is down-
shown to enhance chemotherapeutic drug delivery in mouse regulated or mutant in various types of cancer. However, tumor
models of pancreatic cancer414 and breast cancer415. Theoretically, cells themselves overexpress TGF-β, which is excreted into TME
LOX inhibition might be beneficial during the development phase and targets nonparenchymal cells421 like fibroblasts and Treg cells.
of cirrhotic cancer. However, it might not work for tumors with an TGF-β promotes fibroblasts to produce ECM components, and
existing mature collagen mesh, greatly limiting its application. enhances the differentiation and function of Treg cells to induce
immunosuppressive TME422.
Therapies targeting TGFβR Therapies targeting TGF-β have been discussed in the section
TGF-β receptor (TGFβR) is a tetramer which consists of two “Therapies Targeting Collagen” earlier in this review. Small
different transmembrane kinase, namely type I receptor (TGFβR1) molecules which target TGFβR are widely used in experiments
and type II receptor (TGFβR2), and both of them have the ability to of cancer therapies423 (Table 1). SB-431542 and SB-505124 have
lead to the phosphorylation of serines, threonines, and tyro- been shown to suppress proliferation, motility, and vascularization
sines416. When TGF-β binds to TGFβR, the seine at the C-terminal in mice models of glioma and renal carcinoma424–426. SB-431542

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also enhances the activity of DC and CD8+ T cells423,427. The fatal chemoresistance in animal models of ovarian cancer460. Moreover,
weakness of these two inhibitors lies in their instability and low Kohli et al.461 demonstrated that liposomes containing 4-MU
specificity which causes severe systematic toxicity. Ki26894 has could potently suppress HA synthesis, eventually facilitating the
been reported to suppress bone metastasis in mice models of penetration of more liposome drugs into breast cancer xenografts.
breast cancer and gastric cancer428–430. Other small molecules that Hyaluronidase has exhibited beneficial effects for diseases such
inhibit TGFβR, such as LY-2109761431–435, SD-093436, SD-208436, as bladder cancer, brain cancer, and gastrointestinal cancer by
and LY-580276436, have also been tested in various kinds of degrading HA within the TME402,462. A few clinical trials are
cancer. currently evaluating the therapeutic effects of combining hyalur-
In consideration of the complex role of TGF-β and TGFβR in onidase and chemotherapeutic agents such as gemcitabine and
tumors, the therapeutic strategy targeting them should be really fluorouracil463,464. Currently, the long-term effects of hyaluroni-
cautious. Agonist of TGFβR directly inhibits the growth of tumor dase on cancer therapy remain under investigation.
cells, but also promotes stromal cells to produce ECM components
and contributes to immunosuppression. As for advanced tumors, Therapies targeting fibronectin
inhibition of TGFβR suppresses the metastasis and invasion of The researches regarding the application of fibronectin in cancer
tumor. Therefore, a comprehensive understanding of tumor traits, treatment are mainly focused on its application as a target for
disease stage, and TME are prerequisites when applying a precise drug delivery (Table 1). EDA and extra domain B (EDB) of
therapeutic strategy targeting TGF-β signaling. fibronectin are frequently upregulated in tumor neovascula-
ture465–467. Therefore, several targeted cancer therapies have
Therapies targeting AT1R been developed targeting EDB. For example, the murine mono-
Angiotensin II type 1 receptor (AT1R) and Angiotensin II type 2 clonal antibody against the cryptic domain adjacent to human
receptor (AT2R) are both receptors for Angiotensin II (AngII)437. fibronectin EDB, BC-1 was fused with murine IL12 (huBC-1-mIL-12)
They belong to the family of G-protein-coupled receptors, which and showed inhibitory effects on various kinds of cancer
are seven-span transmembrane proteins. AT1R is considered as xenografts in immunocompetent severe combined immune
the leading receptor for AngII to exert vasoconstriction functions, deficiency mice, including colon cancer, skin tumor, and prostate
while AT2R tends to be a counter-regulatory factor. The down- cancer468,469. A clinical trial of huBC-1-mIL-12 was conducted, and
stream signaling of AT1R, directly or indirectly, includes MAPK, c- 46% of patients were in stable condition after 6 or more cycles of
Src, Tyk2, Pyk2, Jak2, Ras, AKT, receptor tyrosine kinases, and treatments470. Another antibody that targets EDB, L19, was fused
redox-sensitive transcription factors such as nuclear factor kappa B with IL-2 (L19-IL-2) and significantly improved the tumor-
(NFκB) and HIF-1α438–441. The phosphorylation of tyrosine in inhibitory efficiency of IL-2 in tumor-bearing mice471,472. Patients
growth factor receptors, integrins, and adhesion-associated who received L19-IL-2 treatment showed stable condition without
adapter proteins such as paxillin, tensin, and Grb2 all promotes treatment-related death during its clinical trial in renal cell
the function of AngII, eventually enhancing the phosphorylation carcinoma and melanoma patients473,474. Other than cytokines,
of MEK and ERK1/2 induced by EGFR442–446. EDB also serves as the delivery target for antibody-mediated
AT1R plays important roles in promoting cell proliferation, radioisotopes. A fusion protein of L19 and small immunoprotein
angiogenesis, and inflammation in TME. Firstly, AT1R activates (SIP) marked with 131I not only slowed tumor growth, but also
EGFR in breast cancer447 and prostate cancer448, contributing to prolonged the survival of mice bearing F9 teratocarcinoma and
the activation of ERK and signal transducer and activator of head and neck carcinoma xenografts475,476. In addition, 131I-
transcription 3 (STAT3) phosphorylation, and protein kinase C labeled L19-SIP could be applied to visualize the tumor lesions in
(PKC) activation, thus promoting the proliferation of cancer cells. lymphoma477 and prostate cancer478 patients. However, no
Secondly, the activating of EGFR by AT1R leads to the increased curative effect was observed in these patients. Moreover, EDB
expression of VEGF in both cancer cells and endothelial cells, and binding peptides have also been applied for the delivery of
intratumoral endothelial cells are activated in either paracrine or chemotherapeutic agents. Saw et al.479 developed APTEDB, a novel
autocrine manner, which contributes to angiogenesis in class of high-affinity peptides targeting EDB, and doxorubicin-
TME449,450. Lastly, AT1R promotes the transcription of cytokines containing APTEDB liposomes reduced 55% of tumor size while the
and chemokines, such as IL-6, IL-12, IL-8, and monocyte free doxorubicin reduced 20% of tumor size in tumor allograft
chemoattractant protein-1 through activating NFκB and AP-1451, mice model. Similarly, APTEDB-decorated nanoparticles encapsu-
thus resulting in inflammation. Dysregulations of AT1R and AT2R lating paclitaxel has been applied for the inhibition of neovascu-
has been reported in the breast in situ carcinoma452, invasive lature in a mice model of glioma tumor, and such modification
breast carcinoma453, skin squamous cell carcinoma454, cervical significantly enhanced the intratumoral accumulation of paclitaxel
cancer455, ovarian cancer456, and prostate cancer448. and prolonged the survival time480.
Angiotensin receptor blockers (ARBs) are widely used as
traditional antihypertension drugs, and recent research revealed Therapies targeting sensors of matrix stiffness
that they could suppress growth and metastasis of cancer (Table 1). Integrin is a promising drug target due to its crucial role in both
Candesartan, a long-acting angiotensin receptor antagonist, mechanotransduction and other oncogenic processes for malig-
inhibits lung metastasis in mice intravenously injected with 3LL nancy transformation (Table 1). Integrin α11β1, α5β1, α9β1, and
cells457. Moreover, tumor growth and angiogenesis are inhibited αvβ3 are widely expressed by tumor cells and tumor stromal cells,
by candesartan in mouse melanoma model457,458 and xenograft including fibroblasts, endothelial cells, and tumor-associated
models of human prostate and ovarian cancer cells448,456. macrophages, substantially influencing the characteristics of the
Losartan, another angiotensin receptor blocker, is able to inhibit TME481–484. Many preclinical studies have demonstrated that the
the release of growth factors like VEGF and suppresses tumor inhibition of integrin could strongly suppress disease progres-
growth of glioma cells both in vivo and in vitro459. sion485. For example, Vitaxin, a humanized monoclonal antibody
targeting integrin αvβ3, showed therapeutic potential in breast,
Therapies targeting HA lung, and colon cancer patients by preventing intratumoral
Similar to collagen, two types of therapeutic strategies targeting angiogenesis during clinical trials486. Similarly, volociximab, an
HA are under investigation, including the inhibition of HA antibody that binds specifically to integrin α5β1, also exhibited
synthesis and enhancement of HA degradation (Table 1). remarkable therapeutic efficacy in clinical trials involving ovarian
4-Methylumbelliferone (4-MU) is an inhibitor of HAS. 4-MU has cancer, peritoneal cancer, pancreatic cancer and renal cancer
been shown to suppress the activation of CSCs and attenuate patients487–490. In addition, Paolillo et al.491 found that 1a-RGD, a

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small-molecule integrin antagonist that targets the RGD–integrin matrix stiffness in tumors. In addition, traditional drugs, such as
interaction, could augment detachment-mediated anoikis while hydroxychloroquine527, retinoic acid receptor agonists527, and FAK
suppressing cell migration in glioma cancer cell lines. Cilengitide, a inhibitors399, have the potential to attenuate matrix stiffness in
specific peptide antagonist targeting the binding between tumors. More mechanistic studies are urgently required to exploit
integrin αvβ3 and RGD, shows a good safety profile and clinical these drugs for cancer therapy.
improvement for patients with head and neck tumors492–495.
However, it should be cautioned that the binding of cilengitide Cell–ECM interaction as therapeutic targets in leukemia—chronic
with integrin is accompanied by conformation alteration, leading lymphocytic leukemia as an example
to adverse effects such as agonist-like activities496. In the previous paragraphs of this review, we mainly focused on
Emerging studies have demonstrated the role of DDR1 in the ECM of solid tumors. However, cell–ECM interactions also play
cancer progression and metastasis497–499 (Table 1). Aguilera nonnegligible roles in leukemia which are often referred to as
et al.500 knocked down DDR1 by siRNA and found that migration “liquid cancer”. Even though ECM molecules are relatively sparse
was inhibited in pancreatic ductal adenocarcinoma cells. The in blood, intensive but temporary cell-ECM interactions occur
combination of DDR1 inhibitors and classical chemotherapeutic within the bone marrow and peripheral lymphatic organs where
drugs has been reported to reduce the tumor burden in both hematopoietic cells receive signals for proliferation and differ-
orthotopic xenografts and autochthonous pancreatic cancer entiation. Similar to solid tumors, collagens, proteoglycans, and
models500. Moreover, an in vivo study showed that the knockdown glycoproteins form ECM in the bone marrow and lymph nodes.
of DDR1 suppressed tumor growth and multiorgan metastasis in However, unlike solid tumors in which most cancer cells are
breast cancer mouse models497. Similarly, in a KRAS-mutant lung permanently embedded in stiffened ECM, leukemia cells only form
adenocarcinoma mouse model, inhibition of DDR1 attenuated temporary connections with ECM in structured niches within bone
tumor aggression501. The signal transduction triggered by DDRs marrow and lymphoid organs.
could be blocked by tyrosine kinase inhibitors (TKIs), such as Leukemia can be classified as acute or chronic, according to the
imatinib, nilotinib, and dasatinib, some of which have been applied degree of cell differentiation, and as myelogenous or lymphocytic,
as a cancer treatment for more than a decade502–506. For example, according to the predominant type of cell involved. Generally,
nilotinib, a second-generation TKI, suppresses tumor metastasis of leukemia can be categorized as acute lymphocytic leukemia,
colorectal cancer cells by inhibiting the DDR signaling pathway in chronic lymphocytic leukemia (CLL), acute myelogenous leukemia
an intrasplenic tumor mouse model507. Moreover, lung squamous (AML), and chronic myelogenous leukemia (CML). In this section,
cell carcinoma patients with a DDR2 mutation were more sensitive CLL would be the most frequently used example since remarkable
to dasatinib than those with wild-type DDR2508. Other than TKIs, 3- breakthroughs have been made in managing this disease by
(2-(pyrazolo[1,5-a]pyrimidin-6-yl) ethynyl)benzamides have been targeting cell-ECM interactions in the past decade.
identified as selective DDR1 inhibitors with a relatively low IC50 In the cortex of lymph nodes, a network of fibroblastic reticular
and could potently attenuate cancer invasion, adhesion, and cells (FRCs) secretes type III collagen that produces reticular fibers
tumorigenesis in vitro509. which are highly stretchable, which allows lymph nodes to enlarge
Considering the importance of the CD44-HA and RHAMM-HA rapidly to accommodate fast-dividing lymphocytes in the
interactions in tumor cells, they might be promising therapeutic circumstances of infections or leukemia. On the apical surface of
targets for cancer treatment (Table 1). Efforts have been made by FRC (the side that faces the cavity where lymphocytes reside),
many research groups to evaluate the antitumor effect of CD44 integral membrane proteins (such as vascular cell adhesion
antibodies. For example, bivatuzumab (e.g., the first humanized molecule, VCAM-1) and other macromolecules tethered to FRC
monoclonal antibody against CD44v6 underwent clinical trials), membranes (such as HA) provide abundant anchorage points for
displayed a moderate antitumor effect in patients with advanced lymphocytes and antigen-presenting cells528–530. CLL cells actively
squamous cell carcinoma of the head and neck or esophagus510. proliferate inside the lymphoid tissues, but they would stop
Subsequently, more CD44 antibodies entered clinical trials, such as proliferation during their circulation in blood531. Therefore,
RO5429083 ([Link] identifier: NCT01358903 and lymphadenopathy is typically observed in CLL patients. Bruton
NCT01641250). Moreover, another siRNA-based strategy has been tyrosine kinase (BTK), a key element of B-cell antigen receptor
developed to inhibit the mRNA transcription of CD44 or CD44v511–516. (BCR) signalosome, plays vital roles for CLL homing and retention
However, due to the lack of a comprehensive understanding of all in lymph nodes by controlling integrin α4β1-mediated adhesion
CD44 isoforms and the consequences of knocking down a mixture to fibronectin and VCAM-1, as well as chemotaxis signals
of CD44 isoforms, some challenges persist for the clinical mediated by CXCL12-, CXCL13-, and CCL19-induced signaling532.
applications of a siRNA-based strategy targeting CD44. Recently, CLL patient cells expressed higher BTK mRNA compared to normal
verbascoside has been identified as small molecular-weight B cells533. BTK inhibitor Ibrutinib (PCI-32765) treatment can
inhibitors for CD44 dimerization, and it showed inhibitory effects achieve rapid (within days) and sustained reduction of lympha-
on the growth of intracranial tumors in a mouse model denopathy accompanied by transient lymphocytosis due to early
of glioma517. DNA aptamer targeting the HA-binding domain of exiting of CLL cells from lymph nodes534,535. Ibrutinib has been
CD44 also exhibited suppressive effects on the invasiveness of approved for patients with previously treated mantle cell
breast cancer cell line MDA-MB-231518. Several strategies targeting lymphoma, CLL, and several other B-cell-related diseases, and
RHAMM-HA interaction are also under preclinical studies in more BTK inhibitors are in the pipeline536.
multiple kinds of cancer. For example, small interfering RNA- Other than BCR signaling, cell-HA interactions in the bone
mediated suppression of RHAMM has been shown to sensitize marrow and lymph nodes are also critical for hematological
lung adenocarcinoma A549 cells to radiotherapy519. A soluble malignancies. For example, CD44v6 expression in diffuse large B-
peptide containing the HA-binding domain of RHAMM inhibited cell lymphoma (DLBCL) correlates with advanced disease stage,
both proliferation and migration of multiple glioma cell lines368. and coexpression of any of the CD44 isoforms with RHAMM could
Several shorter blocking peptides (7 to 15mer) for RHAMM-HA identify a subgroup of DLBCL patients with a very poor prognosis
interactions have been screened out, but their therapeutic efficacy independent of the International Prognostic Index537. RHAMM-HA
has not been evaluated in the cancer models yet520,521. interaction promotes directional cell locomotion538–540. For
example, B cells could mobilize along HA molecules through
Other therapeutic strategies alleviating matrix stiffness in cancer RHAMM-HA interaction upon activation by chemokines such as
A few studies have reported that tranilast522, pirfenidone523, CCL21 and IL-8, which is critical for proper B-cell positioning within
fasudil524, metformin525, and dexamethasone526 could alleviate the lymph nodes541,542. RHAMM is highly expressed on B-cell CLL

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(B-CLL) cells and considered as a promising tumor-associated elucidated, which also raises new cautions regarding the safety
antigen543–545. RHAMM-R3 peptide vaccination could trigger an and workability of translating knowledge obtained in animal
anticancer immune response in CLL patients546. On the other models to human patients.
hand, the N-linked glycosylated CD44 variant (CD44v6) forms Thirdly, researches of tumor ECM contribute to the develop-
high-avidity interaction with HA under the stimulation of the CD40 ment of effective tools for tumor diagnosis and imaging.
ligand, thus producing an adhesive force to stop CLL mobility, Traditional imaging heavily relies on radionuclide and single
thus retaining CLL cells in specialized compartments of lymph fluorescence, which are limited by the adverse reactions and the
node where they would encounter intensive survival and accessibility of imaging medium into dense solid tumors.
proliferation-inducing signals542. Moreover, engagement of CD44 Santimaria et al.562 labeled L19, a monoclonal antibody targeting
would activate the intercellular PI3K/AKT and MAPK/ERK path- EDB fibronectin, with 123I for imaging of colorectal cancer, lung
ways, and increase the expression level of myeloid cell leukemia cancer, and brain cancer. Novel imaging materials and methods
sequence 1 protein to suppress spontaneous and drug-induced are springing up these days, and they are safer and more
apoptosis in CLL cells547. These biological functions are in convenient for tumor imaging with lower toxicity. For instance,
consistent with the observations that CD44 is highly expressed gold nanoparticles (AuNPs), whose diameter ranges from 1 to
and negatively correlated with prognosis in CLL548,549. Zhang 100 nm, possess the traits of sensitivity, specificity, and low
et al.550 reported that a humanized monoclonal antibody specific clearance, and therefore are designed for coupling tumor-specific
for CD44 (RG7356) was directly cytotoxic for CLL cells both in vitro RNA563,564. Researchers applied second-harmonic generation
and in vivo, but had little effects on normal B cells. (SHG) and two-photon excited fluorescence for high contrast
Other than CLL, CD44-HA interaction plays similar tissue homing imaging of tumors in the deep positions of the body based on the
and pro-survival roles in AML and CML. Several CD44 antibodies SHG signature of ECM components565. In addition, radiomics
have been shown to suppress AML cells, such as RG7356, HI44a, based on machine learning algorithms are more and more
A3D8, and ARH460-16-2551–554. In the Phase I clinical study of capable of identifying early malignancies, whose combination
RG7356 in AML patients, one complete response (CR) with with detection reagents targeting intratumoral ECM might be a
incomplete platelet recovery (CRp) and one partial response (PR) powerful method for the early detection of cancer. What’s more,
were recorded, suggesting its potential as an effective therapy for noninvasive liquid biopsy testing ECM components or fragments
AML551. Inhibition of HA synthesis with 4-MU enhanced the anti- could be another direction strategy for cancer at its early stage.
proliferative effect of imatinib and doxorubicin in CML555,556. Moon et al.566 performed liquid biopsy of fibronectin on
The success of Ibrutinib and RG7356 in hematological circulating extracellular vesicles for early detection of breast
malignancies suggests that cell–ECM interactions, as well as the cancer, and the area under the curves reached 0.70.
signaling network involved in the tissue homing process, are Fourthly, ECM normalization can serve as a powerful adjuvant
highly workable and druggable targets for combating hematolo- for conventional chemotherapy and immunotherapy. After apply-
gical malignancies. ing the nanoparticles loaded with pheophorbide a (PPa, a
photosensitiser that induced immunogenetic cell death) and
NLG919 (an inhibitor of indoleamine 2,3-dioxygenase 1 which
CONCLUSION AND OUTLOOK enhanced the proliferation of cytotoxic T lymphocytes and
Cancer is a complex systematic disease involving constant inhibited regulatory T cells) targeting MMP-2/9 in ECM, the effect
interactions between cancer cells, the ECM, and other cell types of immunotherapy would be greatly enhanced567. The advances
present in the TME. Therefore, ECM stiffness plays a vital role of nanotechnology provide opportunities for the spatial and
during the process of cancer progression, making it a promising temporal regulation of drug release in TME. Several clinical trials of
therapeutic target for cancer management. nanoparticles loaded with albumin-bound (NAB)-paclitaxel is
Firstly, ECM serves as a promising and direct therapeutic target ongoing in early breast cancer568,569, advanced biliary tract
for cancer treatment. One of the most successful cases is the cancer570,571, pancreatic cancer572, and so on. Nanoparticle loaded
application of TKIs in non-small cell lung cancer with EGFR with multiple drugs targeting ECM is now a research hotspot that
mutation557 and chronic myeloid leukemia558, which is partially is promising to achieve low toxicity and high efficiency for their
mediated by the blockage of the signal transduction stimulated by precisely controlled combination of different therapeutic agents.
DDRs. Therefore, it is urgent for us to identify more cancer-specific However, some challenges also remain for clinical translation up
ECM targets with the potential of inhibiting cell proliferation, to now. The most obvious problem lies in the complexity of
migration, and angiogenesis in the future, thus effectively chemical composition during the in vivo metabolism of such
suppress cancer progression without hurting healthy tissues. nanoparticles loaded with multiple drugs. Moreover, drug delivery
Secondly, intratumoral ECM could be the antigens for the efficiency, tumor-targeting efficacy, drug toxicity, and controllable
design of tumor vaccine and CAR therapy. Lin et al. showed that drug release in time and in place are all issues that need to be
vaccination targeting EDA domain of fibronectin enhanced considered.
macrophages infiltration, inhibited tumor vasculature, decreased Lastly, there are still Gordian Knots for developing cancer
pulmonary metastases559 in a polyoma middle T oncoprotein treatment targeting ECM in the field of both scientific research
mouse breast cancer model560. Zhang et al.561 applied CAR and clinical practices. Currently, there is a lack of materials that can
macrophage therapy which recognized tumor antigen ErbB2 so accurately simulate the ECM in vitro. Although Matrigel is widely
that CD147 signaling was simulated and MMPs was increased in a applied in 3D culture and Gelatin Methacryloyl is frequently used
breast cancer mice model. Such CAR therapy softened the ECM, in 3D print, the physical and biological properties, as well as the
enhanced T cells infiltration, and inhibited tumor growth in mice. interaction between different components of ECM is very difficult
However, tumor vaccine and CAR therapy targeting ECM for an in vitro system to compare with. In addition, ECM stiffness is
components is relatively more difficult for clinical translation, rarely fully simulated in mice models of solid tumors. Mice have
compared to directly targeting ECM components and related the advantages of quick reproduction, stable genetic background,
signaling pathways with small molecular compounds or anti- and low cost. However, it is not very accurate to compare ECM
bodies. The main challenge lies in the scarcity of effective and characteristics in tumor-bearing mice whether subcutaneously or
specific ECM targets in cancer. Another problem is how to orthotopically with real human tumors, due to the great
accurately predict the host responses to tumor vaccine and CAR differences in scales and histology. For example, a large
therapy in real patients. The complex immune responses in proportion of liver cancer is accompanied by cirrhosis, but the
human and animal models in vivo have not been not fully subcutaneous and orthotopic liver cancer models, which are

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