Salivary Gland Development and Regeneration Advances in Research and Clinical Approaches To Functional Restoration 1st Edition Seunghee Cha (Eds.)
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Seunghee Cha Editor
Salivary Gland
Development and
Regeneration
123
Salivary Gland Development
and Regeneration
Seunghee Cha
Editor
Salivary Gland
Development and
Regeneration
Advances in Research and Clinical
Approaches to Functional
Restoration
Editor
Seunghee Cha
Oral and Maxillofacial Diagnostic Sciences
University of Florida
Gainesville, Florida
USA
Rome was not built in a day, as the English playwright John Heywood
famously wrote. Innovation and advancement in the field of salivary gland
regeneration is one of the great examples that reflects this sentiment. The first
research article available on this topic through the US National Library of
Medicine dates back to 1950. The article, entitled “Regeneration in the
Submaxillary Gland of the Rat,” by B.B. Milstein in 1950, cites Van
Podwyssozki as the first to describe regeneration of organs of small animals
as long ago as 1886 and regeneration of the salivary glands (Die Regeneration
an den Speicheldrusen) in 1887.
Since the 1950s, an ever-expanding literature and diversified approaches
aimed at functional restorations have mirrored strong interest and attention to
this particular subject of research. Journal articles dealing with autoimmune
Sjögren’s syndrome, effects of radiation, and ductal ligation models in rats
and mice appeared in the early 1980s, followed by research on neural regula-
tion of secretion and effectiveness of epidermal growth factor in wound heal-
ing models and glandular regeneration in the late 1980s through the
mid-1990s.
In 1995, the late Dr. Michael Humphreys published his well-known review
article entitled “Saliva and growth factors: the fountain of youth resides in us
all,” which emphasized the vital importance of growth factors in oral/sys-
temic health and glandular repair/regeneration. Histological analyses of glan-
dular architecture and development were established by Dr. Robert Redman,
the author of Chap. 4 of this volume. With the turn of a new century, molecu-
lar and cellular mechanisms of branching morphogenesis and glandular
development were further investigated and pioneered by Drs. Kenneth
M. Yamada and Matthew P. Hoffman, whose work provided foundations for
the application of tissue engineering concepts and methodologies to salivary
regeneration. Outstanding contributions by Dr. Bruce J. Baum to the field of
tissue engineering and gene therapy have ultimately been solidified in appli-
cations such as clinical trials involving AAV2-mediated human aquaporin-1
delivery in recent years. Investigation of ductal ligation models, irradiation
models, and Sjögren’s syndrome NOD models dominated interest in the field
until around 2010, when stem cell research in vitro and in vivo reignited
research interest and passion in salivary gland regeneration.
In the current era, the authors and coauthors in this book, who are renowned
researchers, dentists, and surgeons in the field, have spearheaded efforts to
discover the underlying pathogenesis of xerostomia and innovative approaches
v
vi Preface
cells for salivary gland regeneration. Current trends in salivary gland bioen-
gineering deliver great promise in functional restoration of the salivary glands
(Chap. 7, Dr. Baker).
To explore further the subject of bioengineering, factors and elements
needed for successful development of a functional salivary gland are dis-
cussed in detail in Chap. 8, emphasizing the dynamic nature of the basement
membrane and the significance of the extracellular matrix and cell polarity
in salivary gland development and reconstruction. In addition, studies utiliz-
ing the salivary-derived stem cells/gland progenitor and three-dimensional
(3D) biomimetic scaffolds encompassing decellularization methods, various
matrices, and polymers are summarized for 3D culture technique, which
underpins current knowledge on bioengineering of the salivary glands
(Chap. 8, Martinez et al.).
3D printing technology creates life-size body parts and tissues using living
cells as the ink. This technology has revolutionized the field of regenerative
and reconstructive medicine, enabling customized and personalized thera-
peutic approaches. In Chap. 9, Dr. Choi et al. describe basic principles and
different types of 3D technologies, patient-specific modeling, bioprinting,
and salivary gland regeneration (Chap. 9, Dr. Choi et al.).
A novel bioengineering method involves epithelial and mesenchymal stem
cell manipulation to generate a bioengineered organ germ. In Chap. 10,
Dr. Ogawa explains that the bioengineered glandular germs demonstrated
reciprocal interactions between epithelial and mesenchymal cells in one day
and invagination of epithelial tissue in three days in vitro. Once the germ was
engrafted into the parotid gland duct of salivary gland-defective mice, the
connection between the germ and the duct was established in a month, and
the mice exhibited restored salivary secretion after transplantation. This inno-
vative approach emphasizes that current advancement in the field promises a
therapeutic intervention for patients suffering from xerostomia (Chap. 10,
Drs. Ogawa and Tsuji).
Currently, functional restoration of the salivary glands is still challenging
to accomplish even with successful reconstruction of salivary cellular compo-
nents. Therefore, understanding the mechanisms of saliva secretion becomes
critical for positive clinical outcomes that we desire. Chapter 11 covers con-
siderations for establishing functional secretion by providing information on
stimuli for secretion, neural connection along with neurotransmitters and
receptors, protein secretion, and studies of neural agonists and antagonists.
The chapter also clarifies myths surrounding this topic with recent research
data (Chap. 11, Drs. Carpenter and Carvalho).
Thought-provoking renderings of the past, current, and future of gene
therapy in salivary gland diseases are provided by Dr. Passineau in Chap. 12.
In this chapter, current challenges in the field of salivary gland gene therapy,
along with the author’s proposals to circumvent or overcome the hurdles, are
forthrightly discussed (Chap. 12, Dr. Passineau).
Last, but not least, the chapter on surgical management of salivary gland
disease reveals the critical considerations for glandular regeneration from the
perspectives of otolaryngologists and surgeons (Chap. 13, Drs. Varadarajan
and Dziegielewski). The extensive description in this chapter includes, but is
viii Preface
not limited to, glandular anatomy, pathology, surgical advances for neoplastic
and nonneoplastic diseases of salivary glands, and recent discoveries in the
field such as salivary gland transfer and salivary duct repositioning. The
importance of understanding the expected sequelae in human patients follow-
ing radiation or surgery cannot be overemphasized as none of the existing
laboratory approaches would come to fruition for patients without such
knowledge.
Based on the cutting-edge information offered in this book, it is undoubt-
able that many more innovative strategies for salivary gland regeneration will
emerge in upcoming years. Research that unlocks the complex processes of
organ development would be fundamental to develop such approaches. With
the current enthusiasm and growing interest in the field, it will just be a matter
of time before we build another Rome.
ix
x Contents
xi
xii Contributors
Abstract
The convergence of the fields of tissue engineering and regenerative
medicine provides a potential blueprint to repair damaged tissues.
Accordingly, a range of therapeutic applications have emerged that hold
great potential to regenerate branching organs, such as salivary glands.
This unique saliva-secreting organ is required for proper oral health,
lubrication, immunity, and food digestion but is susceptible to damage
either by co-irradiation as a side effect of radiotherapy cancer treatment,
autoimmune-related Sjögren syndrome, disease-related medications, or
surgical resection. This chapter focuses on fundamental cellular and
molecular processes occurring during organ ontogenesis and in develop-
ing branching glands. We cover the growth of the epithelial compart-
ment, which is the major functional component of the gland, but also
how surrounding niches such as mesenchymal, endothelial, and neuronal
cells communicate, intertwine, and influence the formation of glands
and other branching organs. Finally, we highlight how this key informa-
tion has created new regenerative-related approaches and how these
impact future clinical translation.
1.1 Introduction
a c
Fig. 1.1 Developing salivary glands in mice. (a) Bright (arrow). Confocal image of E-cadherin stained epithelia
field picture represents E13 submandibular (SMG) and and Tubbulin-3 stained PSG. (c) Different niches sur-
sublingual gland (SLG). The epithelial compartment is rounding the epithelium in adult mouse submandibular
comprised of a distal endbud and proximal duct area. (b) gland. Confocal 30 μm projected image of stained SMG
Epithelia (blue) innervated by the parasympathetic with epithelial marker E-cadherin (blue), neuronal
nerves (PSG, red) during embryonic SMG development. marker Tubbulin-3 (red), and endothelial protein CD31
The PSG releases neurotransmitters via varicosities (green)
1 Implications of Salivary Gland Developmental Mechanisms for the Regeneration of Adult Damaged Tissues 5
major glands, which provide 90 % of total saliva, they are not yet fully functional and must still
becomes established by tightly controlled mecha- undergo specific acinar-lineage maturation so that
nisms of cellular interactions. by birth, in both humans and mice, the organ is
comprised of functional secretory compartments.
might not serve a similar role during adult to significantly increased saliva levels [58, 62, 72,
homeostasis. Recent studies observed active pro- 103]. This does not, however, exclude the poten-
liferation of cells within specific compartments, tial of other SG-specific epithelial cells, non-SG
such as acini and intercalated, striated, and excre- specific cells, and/or their bioactive cell lysate to
tory ducts, wherein these cells self-duplicate to contribute to the repair of damaged SGs. These
replenish their own entity, as reviewed in [4]. To options will be surveyed in following chapters,
what extent these adult compartmental “reser- and their impact on when to use them in different
voir” cells contribute to recovery after injury is damaging situations has been recently reviewed
a focus of ongoing research. At least after severe [61]. In this chapter, we will further outline our
radiation-induced damage, which leads to irre- current understanding of how SGs are structur-
versible hyposalivation, there is no active repair ally built by various cell types (Fig. 1.1b, c) and
initiated by remaining SG cells. This is often a how their continuous interactions are informing
combinatorial result of (a) drastic loss of acinar the design of current and future therapies.
and duct “reservoir” cells or stem/progenitor
cells, (b) decrease in signaling pathways required
to activate surviving “reservoir” or stem/pro- 1.2.3 essons from Developmental
L
genitor cells, and/or (c) severely damaged cells Regulatory Mechanisms
that can no longer contribute to self-duplication Guiding the Epithelium
or differentiation. In such cases, multiple strat-
egies ranging from constructing a new gland to Often disorders in humans and genetic rodent
gene therapy and stem/progenitor cell transplan- model systems can provide critical information
tations may aid in restoring the functional and on what signaling pathways are essential for epi-
morphological components of the gland. Thus thelial cell survival, proliferation, differentiation,
far, transplantations of cells selected for their and movement (Fig. 1.2). Major examples are
expression of receptor KIT, EPCAM, CD24, and/ Fgf10−/− and Fgfr2b−/− mice, which are related to
or CD29 (Integrin β1, ITGβ1) were shown to human loss-of-function mutations in FGF10 and
restore acinar and ductal compartments, leading FGFR2 that result in hereditary diseases including
1 Implications of Salivary Gland Developmental Mechanisms for the Regeneration of Adult Damaged Tissues 7
lacrimal and SG-related aplasia of lacrimal and branching via epithelial ITGβ1 [84]. MMPs also
salivary glands (ALSG), lacrimo-auriculo-dento- cleave pro-HB-EGF into an N-terminal and
digital (LADD) syndrome, and lung- related C-terminal fragment at the membrane so that the
chronic obstructive pulmonary disease (COPD). latter fragment can move to the nucleus to acti-
In these conditions, SG development is stalled, as vate cell proliferation via cyclin A [95].
FGFR2b+ epithelium no longer receives survival Conversely, another member of the EGF family,
and proliferative cues from the surrounding neuregulin (NRG), binds ERBB3 on endbuds to
FGF10-producing mesenchyme [80]. Thus, when aid in their local expansion [70]. NRG1 is further
invading oral epithelial cells at gland ontogenesis essential for innervation as Nrg1−/− mice are
receive FGF10, they initiate an endbud and duct devoid of nerves and show aberrant duct forma-
formation. From then on, FGFR2b signaling tion and lumenization [73].
expands KIT+ progenitors in the continuously Similar to FGF10, Fgf8 hypomorphic and
clefting endbuds in combination with stem cell Fgfr2c heterozygous mice exhibit hypoplastic
factor (SCF)/KIT signaling [57]. As FGF10 has a glands due to reduced communication between
heparan-binding (HB) core, it evokes and expands FGF8-producing epithelia and FGFR2c-receiving
more rapid responses once it is bound to specific mesenchyme. In both FGF-deficient mice, initial
3-O-sulfated heparin sulfate (3-O-HS). This HS epithelial invagination occurs, but subsequent SG
belongs to a group of heparan sulfate proteogly- growth does not occur. To date, FGF8 has been
cans (HSPGs) located in the basement membrane described as a potential target of the EDA path-
or at cell surfaces. Interestingly, KIT+ endbud way. Human mutations in ectodysplasin-A
progenitors highly express HS3ST3, the 3-O-HS- (EDA) or its receptor EDAR result in hypohi-
specific modifying enzyme 3-O-sulfotransferase, drotic ectodermal dysplasia (HED). Defects in
to rapidly increase their expansion during devel- teeth, hair, sweat, and salivary glands are notice-
opment [80]. A similar function remains during able due to reduced cell proliferation and differ-
adult homeostasis. Regulating this FGFR2b sig- entiation [45, 74]. In SGs, EDA and downstream
naling pathway is of crucial importance so that target NF-kB aid in ductal lumenization and end-
every epithelial cell does not undergo extensive bud branching, presumably by inducing ductal
proliferation. Ductal cells therefore express FGF maturation within the center of endbuds. Early
antagonists, Sprouty 1 and 2, to lower FGFR2b on, mesenchyme-produced EDA is downstream
signaling and upregulate WNT [48]. Both canon- of mesenchymal WNT and upstream of epithelial
ical WNT/β-catenin and noncanonical WNT5b SHH (sonic hedgehog) signaling. As such, SHH
pathways drive ductal formation via upregulation treatment can rescue SGs deprived of EDA [100].
of Tfcp2l1 while inhibiting endbud development. After E13, EDA does not seem to correlate with
In turn, endbuds repress duct development by WNT anymore, based on their different expres-
FGF-mediated Wnt5b repression and secretion of sion pattern located in the epithelial or mesen-
WNT ligand-sequestering protein SFRP1 [78]. chymal compartment [31, 78]. SHH’s important
Evidently, a tight FGF-WNT gradient allows for role in SG development has been confirmed, as
KIT+ progenitor expansion in endbuds, while SHH-deficient SGs are hypoplastic with unpolar-
ductal cells prepare for upcoming lumenization ized epithelial cells and underdeveloped lumen
and maturation. In this process, ERBB1 (EGFR)+ formation [36, 43]. SHH is also linked to FGF8
ductal K5+ progenitors proliferate in response to as both can upregulate each other [43]. Therefore,
HB-EGF to give rise to maturing K19+ cells [50]. FGF8 is able to rescue Hedgehog inhibition but
One mechanism of action is via induction of surprisingly not EDA deficiency [43]. As such,
membrane-type-2 matrix metalloproteinase EDA-FGF8’s precise signaling interaction still
(MT2-MMP) and FGFR expression in epithelial needs to be determined.
cells. MT2-MMP is crucial to release bioactive FGF signaling, in particular via FGFR1 (vari-
NC1 domains from extracellular matrix (ECM) ant b in the epithelium and c in the mesenchyme),
protein collagen IV, which in turn promotes can also upregulate bone morphogenetic protein
8 I.M.A. Lombaert
(BMP) ligands. BMPs are part of the TGFβ sig- spatial proliferation, differentiation, and clefting.
naling family and signal via BMP receptors. Initiation of some of those embryonic signaling
FGFR1 signaling regulates BMP7 directly and pathways has been observed in active repair situ-
BMP4 indirectly to regulate epithelial growth. ations, such as ductal ligation settings where aci-
BMP4, which is mesenchyme specific, inhibits nar atrophy and hyposalivation is temporarily
epithelial branching, while BMP7, released by induced by restricting salivary flow from the
both epithelium and mesenchyme, increases it major duct [17]. We can thereby try to manipu-
[90]. The role of another member of the TGF late the activation and/or repression of specific
family, TGFβ1, is still inconclusive. While developmental pathways to stimulate in vivo
TGFβ1-deficient mice have normal SGs, over- repair of damaged SGs, as is outlined further in
stimulation of TGFβ1 results in acinar loss, elon- this chapter.
gated ducts, and/or fibrosis [35, 42].
Additionally, ECM and epithelial integrin cell
interactions are just as essential for branching 1.3 Environmental Cues
morphogenesis. These ECM molecules line up Patterning Epithelial
the basement membrane (BM) separating the epi- Branching and Maturation
thelium from mesenchyme. Interestingly, iso-
lated epithelial cells can easily grow without the SGs are highly vascularized and innervated, all of
physical presence of mesenchymal cells but not which integrate within a condensed mesenchyme.
without ECM component(s), such as laminin, Developmentally, SG epithelia invade a con-
fibronectin, perlecan, collagen, or mouse densed mesenchymal placode already containing
sarcoma- derived reconstituted BM “Matrigel.” a complex endothelial network and parasympa-
Deposition of unique ECM components along thetic neuronal bodies awaiting cues for innerva-
the clefting endbuds and elongating ducts plays a tion [48]. Both signals for epithelial invasion into
role in correct branching. Impairing these con- the mesenchyme and subsequent branching are
nections will lead to reduced clefting, endbud transmitted via direct cell-cell contact and/or
number, cell movement, and/or growth. Detailed indirect paracrine signaling pathways, which are
descriptions of disruptive ECM cell outcomes discussed below.
were recently reviewed in [79].
Finally, an underexplored area contributing to
SG formation are microRNAs (miRNAs), which 1.3.1 Guiding Neurons
are small, noncoding RNAs that specifically tar-
get mRNAs to globally regulate gene expression. Different cranial nerves innervate the pre- and
Epithelial endbud progenitors highly express postnatal SG where they exert different func-
miR200c to reduce FGFR-dependent prolifera- tions. While the autonomic nervous system regu-
tion. miR200c downregulates the autocrine ree- lates the SG at an unconscious level and in stress
lin/very low-density lipoprotein receptor conditions, sensory neurons respond to mechani-
(VLDLR) pathway, which positively regulates cal, thermic, and light signals.
FGFR signaling [83]. Additionally, it was found For decades, both the parasympathetic and
that EGF can specifically induce mesenchymal sympathetic nervous system have been acknowl-
production of miR-21, which decreases multiple edged as the driving stimulant to release saliva
target mRNA candidates. One of these, RECK, from acinar cells into ducts. While parasympa-
inhibits MMPs, which subsequently influences thetic stimulation results in serous secretion and
ECM degradation to enhance SG branching [37]. ion release, sympathetic activation stimulates
In conclusion, various signaling pathways mucous or protein-containing saliva and can also
instruct different cell types within the epithelial play role in local inflammation and blood flow
compartment and not surprisingly interact with [23, 67]. Both parasympathetic and sympathetic
and regulate each other to safeguard temporal- nerves are part of the autonomic nervous system,
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1 Implications of Salivary Gland Developmental Mechanisms for the Regeneration of Adult Damaged Tissues 9
and their neuronal guidance is ensured by axons initiating SG epithelia to localize into ganglia
that sprout along unique paths within the tissue. around the primary duct and send out axons
While the former innervates along the epithelia, toward the endbuds [48]. Sympathetic nerves
the latter follows the vasculature. This directional innervate SGs along the blood vessels during
guidance is driven by neurotrophic factors, later stages of development when final epithelial
secreted by cells in the periphery, as well as the maturation is needed. As such, developmental
presence of specific receptors on the axons that experiments can clearly dissect the role of neu-
allow or block their adhesion to the adjacent rotransmitters and neurotrophic factors affecting
ECM. The most notable trophic molecules include the PSG. It is now well appreciated that the PSG
neurotrophins (e.g., NGF, BDNF, NT-3), netrins, establishes a communication loop with specific
semaphorins, ephrins, and myelin inhibitors. epithelial cells to allow outgrowth of both com-
Similarly, axons secrete neurotransmitters in their partments. When the PSG is absent, the pool of
proximity, exerting a variety of effects through K5-expressing epithelial progenitors is signifi-
specific receptors on their target cells (Fig. 1.3). cantly reduced [50], which influences down-
Parasympathetic nerves signal via the cholinergic stream K19+ ductal luminal differentiation and
acetylcholine (ACh) pathway, targeting musca- subsequent epithelial outgrowth. This is medi-
rinic receptors on neighboring cells, as well as ated via a loss in ACh-CHRM1 (muscarinic
water channels such as aquaporin 5 (AQP5). In receptor 1) signaling from the PSG to K5+ cells
contrast, sympathetic nerves release epinephrine and resulting in a subsequent reduction of
and norepinephrine (i.e., noradrenaline, NA) that HB-EGF/EGFR pathway signaling that initiates
bind to β-adrenergic receptors (adrenoceptors) on maintenance and differentiation of K5+ progeni-
acini. Other non-ACh, non-NA neurotransmitters tors. Lumenization, which marks further ductal
can be produced by both parasympathetic and maturation, is also coordinated by the PSG but
sympathetic nerves and may include vasoactive not via the ACh pathway. The neurotransmitter
intestinal peptide (VIP), substance P (SP), neuro- VIP activates a cAMP/protein kinase A (PKA)
peptide Y (NPY), neurokinin A, pituitary adenyl- pathway to induce epithelial duct cell prolifera-
ate cyclase-activating peptide (PACAP), and tion and formation of a single lumen by the fusion
calcitonin gene-related peptide (CGRP). of multiple microlumens. After initial lumen for-
Developmentally, parasympathetic ganglia mation, VIP remains essential to expand the
(PSG) neuron cell bodies migrate along the lumen size via the cystic fibrosis transmembrane
branches of mandibular arteries [91] to cues from (CFTR) pathway [73].
10 I.M.A. Lombaert
Organ development also requires proper bidi- does lead to hypoplasia of the gland [82] and
rectional communication. Feedback signaling thus must involve a direct or indirect role for
from epithelial cells toward the PSG stimulates sympathetic nerves in either epithelial cell main-
cell survival, migration, and innervation. At SG tenance or maturation. In the adult gland, RET
ontogenesis, WNT-producing epithelia, particu- signaling is also known to be essential for sym-
larly K5+ progenitors, maintain PSG neuron sur- pathetic neuron survival, but likely via the ligand
vival and proliferation [48]. At later stages of artemin instead of NRTN. SGs also produce high
branching morphogenesis, the neurotrophic fac- amounts of NGF and genetic ablation of NGF or
tor neurturin (NRTN), which is mainly secreted its TrkA receptor leads to defective sympathetic
by endbud progenitors, not only promotes neuro- innervation, indicating its crucial role in sympa-
nal survival via GFRα2/RET but also maintains thetic neuron survival [22, 27]. Depletion of non-
axon outgrowth along ducts toward the endbuds canonical WNT5a in WNT1-derived neural crest
[49]. In the developing lung, there also appears to cells further leads to incomplete sympathetic
be a link between nerves and blood vessels. innervation and branching in prenatal SGs. While
Denervation, in this case via physical cell abla- the authors suggest this is due to an autocrine
tion, resulted in reduced endothelial prolifera- WNT5a/retinoid-related orphan receptor (ROR)
tion, leading to hypo-vascularized lungs [9]. It is pathway in sympathetic neurons, it doesn’t rule
unclear whether this is a direct or indirect out that epithelial WNT5a-producing cells might
neuronal-endothelial effect and whether similari- be stimulating sympathetic neurons as well [89].
ties exist within the developing SG. Similarly, endothelial-released endothelin 3
Detailed anatomical descriptions of nerves in (EDN3) is also suggested to be a cue for a sub-
adult SGs are outlined in a recent review [40]. It set of EDN receptor A+ sympathetic neurons to
is assumed that similar communication between innervate the prenatal SG along the nascent exter-
nerves and epithelium persists into adulthood as nal carotid arteries [63]. The specific role of other
denervation of SGs, via ductal ligation or neurec- neurotransmitters from the GDNF and NPY fam-
tomy, reduces epithelial content that regenerates ily as well as other neurotrophic factors are still
after ligation removal if the nerve is intact or being explored. While semaphorins are involved
reconnected [46, 55, 65]. A morphological differ- in axon pruning and neuronal migration in the
ence of early development with later stages and central nervous system, they also appear to have a
adulthood is that smaller ganglia are found dis- role in developing SGs. Semaphorin (SEMA) 3A
persed within adult tissue [40], presumably to and 3C bind co-receptors neuropilin and plexin.
reach their target cells more easily as distances Neuropilin is expressed by epithelial endbuds
are much larger compared to embryonic and by activation with SEMA3A and 3C cleft
development. formation is induced without changing prolifera-
Even though tyrosine hydroxylase (TH)- tion and, most likely, by affecting cell movement
expressing sympathetic ganglia are presumed [15]. However, additional FGF7/10 growth-pro-
not to be present at SG ontogenesis, some moting signals from surrounding mesenchyme
mRNA expression levels of its unique recep- were required to mediate this cleft formation.
tor neuropeptide Y receptor 2 (NPY2R) were Whether additional participation of SEMAs on
detected early during development at low levels receptive nerves is required for cleft formation or
that increase before birth [23]. Since NPY2R is SG development still remains unclear.
also present on endothelial cells, some, if not At adulthood, it remains to be determined how
all, of the mRNA expression could be related to sensitive sympathetic nerves are to injuries such
blood vessel formation within the SG. However, as radiation. In rodents, sympathetic nerve func-
TH-expressing neuronal cells were detectable tion was retained after radiation [52], and
by E16.5, which might indicate there is a pre- increased levels of TH as well as NGF/NGFR and
natal presence of sympathetic ganglia [89]. adrenergic receptor 2 (ADRA2B) were detected
Nevertheless, postnatal sympathetic denervation in radiated human SMGs [49]. Whether a
1 Implications of Salivary Gland Developmental Mechanisms for the Regeneration of Adult Damaged Tissues 11
D positively influences lung growth by inducing laminins. These components in turn served as
maturation in vitamin D receptor-expressing epi- scaffolds for increased axon outgrowth.
thelial cells (VDR) [64]. As VDR is also present In addition to blood vessels, we must not for-
on endothelial cells, this enhanced growth might get the circulating cells within them. White blood
be due to direct effects of vitamin D on endothe- cell monocyte-derived macrophages and den-
lial cells and/or indirect effects from epithelia to dritic cells arise from the bone marrow and colo-
endothelia. Nevertheless, it is clear that epithe- nize tissues via blood vessels to phagocytose
lial-endothelial communication requires a tight cellular debris and help in the innate non-specific
balance as any hyper-vascularization inhibits epi- and specific adaptive immune defense. While
thelial growth [14]. macrophages normally develop in the bone mar-
Apart from endothelial-epithelial cross- row via granulocyte-macrophage colony-
communication, there is also endothelial- stimulating factor (GM-CSF), mesenchymal
mesenchymal communication, as recently cells in tissues can also release GM-CSF to
reviewed [94]. The early endothelial cells pro- induce a similar differentiation effect on circulat-
mote survival of pancreatic mesenchymal cells, ing monocytes. While it is clear that both macro-
which in turn have a pivotal role in organ devel- phages and dendritic cells may be involved in
opment. A similar complex paracrine signaling organ morphogenesis, their exact functions are
network was also found in the lung. Retinoic not always fully understood. Also in adult tissues,
acid (RA), which is produced by endothelial for example, in the lung, there is conflicting data
cells, induces VEGF-A expression in lung epi- on their specific role: antigen-sensing dendritic
thelia. Evidently, endothelial cells are recruited cells might induce different immune responses
via VEGF-A, and thus angiogenesis is stimu- depending on their physical location in the tissue
lated via this endothelial-epithelial communica- while surrounding different epithelial cell types
tion loop. Furthermore, endothelial-released RA [54]. Similarly, various macrophages invade the
also stimulated mesenchymal cells to produce mesenchyme where they can interact with den-
more FGF18 and ECM component elastin, thus dritic cells, lymphocytes, and epithelia to regu-
increasing epithelial alveolar formation [108]. late immunity. Macrophages suppress immune
Other organ-specific angiocrine factors that may responses by inhibiting both dendritic-mediated
follow this paracrine loop include HGF, WNT, T-cell activation and inactive TGFβ production.
NOTCH, and BMP ligands. Mesenchymal cells Subsequent activation of this inactive TGFβ into
also signal back to endothelial cells to stimulate bioactive TGFβ by lung epithelia is essential in
survival, proliferation, migration, and autoph- order to prevent spontaneous inflammation after
agy via production of ECM components, such acute injury. Lung alveolar cells in turn secrete
as the perlecan/heparan sulfate proteoglycan various ligands to receptive macrophages to
(HSPG2) fragment endorepellin, decorin, and ensure this prevention of inflammatory responses.
endostatin [18, 75]. Whether a similar action or disruption in this
While blood vessels and nerves can indepen- communication is occurring in adult SGs after
dently respond to their own set of signaling fac- radiation remains to be determined.
tors, there also seems to be a paracrine connection Apart from immune regulators, macrophages
via epithelial-released VEGF. Even though further shape the branching patterning of organs
VEGFR is absent on nerves and not required for by remodeling the ECM around the ducts to
innervation, VEGF overexpression in pancreas allow outgrowth as well as survival of endbud
not only led to hyper-vascularization but also to stem/progenitor cells [11, 102]. They also regu-
hyper-innervation [85]. Interestingly, endothelial late angiogenesis by instructing endothelial cells
cells did not produce any known neurotrophic to undergo apoptosis via WNT signaling, coun-
factors, but the effect appeared to be related to terbalancing a pro-survival factor produced by
their upregulated expression of basement mem- pericytes, which wrap around endothelial cells to
brane components, such as collagens and influence functions such as blood flow [2].
1 Implications of Salivary Gland Developmental Mechanisms for the Regeneration of Adult Damaged Tissues 13
In sum, blood vessels play important roles 29, 99]. This indicated that SG mesenchyme has
during development in other branching tissues strong and unique multicomponent instructional
not only for oxygen supply but also to maintain properties. One of them is the high production of
essential communication signaling pathways FGF10, which is also essential for lung, lacrimal,
with epithelia and surrounding mesenchyme. The and mammary gland initiation. Notably, non-SG
bone marrow-derived cells circulating in the epithelia only adapted SG-like branching patterns
blood vessels also aid in tissue branching mor- when they were placed in close vicinity to high
phogenesis and evoke or suppress immune FGF10-expressing mesenchymal tissue, confirm-
responses after injury. Whether similar mecha- ing the importance of FGF10’s spatiotemporal
nisms exist in the developing and adult SGs dosage [99]. With this in mind, it is important to
remains to be determined. understand that the SG mesenchymal component
in these experimental conditions contains mesen-
chymal cells as well as ganglia and blood vessels
1.3.3 Supporting Mesenchymal albeit disconnected from the rest of the body. It
Cells can therefore not be excluded that SG-specific
neuronal cells and/or blood vessels may have addi-
Embryonic SG mesenchymal cells are WNT1+ tional contributions to this specific SG patterning.
neural crest-derived cells [44, 105] and provide Interestingly, early-stage E11.5–12.5 SG epithe-
supportive cues such as growth factors, proteases, lia, but not later stages, are able to instruct E10.5
and ECM proteins to guide and activate epithelial, mesenchyme from different sources to produce
neuronal, and endothelial cells (Fig. 1.5). In vitro FGF10. However, not every mesenchyme is as
recombination experiments show that the SG mes- competent to receive this signal as only SG and pha-
enchyme induces an SG-like branching pattern in ryngeal second arch mesenchyme responded and
various epithelia such as a pancreatic, mammary, limb mesenchyme, for example, did not. This indi-
and pituitary gland [96]. This property, however, is cates that this initial signal is exclusively located
not found in mesenchyme from non-SG tissues, as within specific regions of the embryo, likely to
E11.5–13 SG epithelium does not properly branch restrict specific organ outgrowth to the correct loca-
unless it is recombined with SG mesenchyme [28, tion in the body. What this initial epithelial signal is
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mieheni — olet sanonut rakastavasi minua, ja minä olen vastannut
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paremmin kuin itse voimme?»
Kuningas Thandar
Hän oli sairas, eikä häntä hoivaamassa ollut ketään, mutta hän ei
valittanut. Sellainen oli hänen kansansa tapa. Kun ihminen tuli liian
vanhaksi kyetäkseen hyödyttämään yhdyskuntaa, oli hänen paras
kuolla, eikä välttämätöntä lopputulosta senvuoksi pyritty millään
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taakaksi, oli tapana jouduttaa loppua — tarkasti tähdätty, raskaalla
kivellä sivallettu isku oli omiaan nopeasti huojentamaan
yhdyskunnan taakkaa ja toimintakyvyttömän yksilön kärsimyksiä.
»En tiedä, kuka olet; sen vain tiedän, ettet ole edes meidän
kansaamme. Kerron teille kaikki tietoni nyt ennen kuolemaani.
Tulkaa likelleni, sillä ääneni heikkenee nopeammin kuin ruumiini!»
Thandar tunsi, että loppu oli käsissä. Hän näki, kuinka ankarasti
vanhus ponnisteli koettaessaan torjua luotaan heltymätöntä
niittomiestä voidakseen vielä puhua. Kuolevan silmissä oli kysyvä ja
vetoava ilme. Thandar ei voinut ymmärtää sitä väärin.
Nadara itki hiljaa. Vanhahko nainen, jonka suussa oli yksi ainoa
hammas, huomasi hänet ja alkoi valittaa myötätunnosta. Valittelun
houkuttelemina liittyi heidän seuraansa pian muita naisia, joihin
tarttui naissukupuolen perinnöllinen, kummallinen hysteria, niin että
he alkoivat säestää hampaattoman voivotuksia.
Vastausta ei kuulunut.
»Mutta miten hän kaiken sen tekee», kysyi eräs nuori mies, »jollei
hän ole koko heimon paras taistelija?»
Suuri N a g o o la
Olisiko se onnistunut vai eikö, sitä emme saa koskaan tietää, sillä
viimeisellä hetkellä astui väliin kohtalo, pyyhkäisten yhdellä vedolla
pois hänen kaikki suunnitelmansa ja pyrkimyksensä.
Niinpä Thandar laati uudet lait, joiden oli siitä alkaen oltava hänen
kansansa ohjenuorana. Miesten oli valmistettava kaikki tarve-esineet
ja aseet, sillä hän oli jo opettanut heidät käyttämään jousta ja nuolia
sekä keihästä. Naisten oli pidettävä kaikki teräaseet terävinä.
Miesten oli kaadettava tukit ja rakennettava talot — naisten
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pidettävä talot järjestyksessä.
Thandar naurahti.
»No niin, sitten meillä ei ole hätääkään», huudahti hän, »sillä kun
sen päällä on kaksi vuorta yhdessä röykkiössä, ei se pääse
karkaamaan».
»Kenpä tietää?» tuumi Nadara. »Se on iso, yhtä iso kuin pieni
vuori. Jonakin päivänä väitetään sen reutoutuvan irti, ja sitten ei
mikään pysty vaimentamaan sen vimmaa, ennenkuin se on tuhonnut
kaikki elävät olennot maan päältä.»