COD levels of the effluent from wastewater treatment facilities in South Africa.
\r\n\tgas sensors.
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D in Physics in 2012 from Indian Institute of Technology Guwahati, India. Presently, he is associated with the Faculty of Science, Sri Sri University, India as an Assistant Professor in Physics. Prior to joining the current\naffiliation, he was a postdoctoral fellow at different renowned institutions, Kobe University Japan, S. N. Bose National Centre for Basic Sciences, India and Cardiff University, United Kingdom. He was awarded prestigious JSPS postdoctoral fellowship based on his research contribution on semiconducting nanowires. He has published more than 32 research articles including 1 review article in high profile international journals and 3 book chapters to his credit. His research trust areas of interests are semiconductor nanostructures, optoelectronics, solid state lighting and light sensors, spectroscopy of nanomaterials, thin-film transistors (TFTs) etc.",institutionString:"Sri Sri University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"2",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"Sri Sri University",institutionURL:null,country:{name:"India"}}}],coeditorOne:{id:"442408",title:"Dr.",name:"Gorachand",middleName:null,surname:"Dutta",slug:"gorachand-dutta",fullName:"Gorachand Dutta",profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:"Dr. Gorachand Dutta, PhD is an Assistant Professor with the School of MedicalScience and Technology, Indian Institute of Technology Kharagpur. His research interests include the design and characterization of portable\r\nbiosensors, biodevices and sensor interfaces for miniaturized systems and biomedical applications for point-of-care testing. He received his Ph.D in Biosensor and Electrochemistry from Pusan National University, South Korea,\r\nwhere he developed different class of electrochemical sensors and studied the electrochemical properties of gold, platinum, and palladium based metal electrodes. He completed his Post-doctoral fellowships in the Department of\r\nMechanical Engineering, Michigan State University, USA and Department of Electronic and Electrical Engineering at University of Bath, UK. 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These sources of water also serve as best sinks for the discharge of domestic and industrial wastes [2, 3]. The biggest threat to sustainable water supply in South Africa is the contamination of available water resources through pollution [4]. Many communities in South Africa still rely on untreated or insufficiently treated water from surface resources such as rivers and lakes for their daily supply. They have no or limited access to adequate sanitation facilities and are a high risk to waterborne diseases [5]. Since 2000, there has been a dramatic increase in the episodes of waterborne diseases in South Africa [6, 7].
\nSurface water has been exploited for several purposes by humans. It serves as a source of potable water after treatment and as a source of domestic water without treatment particularly in rural areas in developing countries. It has been used for irrigation purposes by farmers, and fishermen get their occupation from harvesting fish in so many freshwater sources. It is used for swimming and also serves as centers for tourist attraction. Surface water, therefore, should be protected from pollution. Major point sources of freshwater pollution are raw and partially treated wastewater. The release of domestic and industrial wastewater has led to the increase in freshwater pollution and depletion of clean water resources [8]. Most quantities of wastewater generated in developing countries do not undergo any form of treatment. In few urban centers, various forms of wastewater treatment facilities (WWTFs) exist but most of them are producing ill‐treated effluents, which are disposed of onto freshwater courses.
\nIn some developed countries of the world, adequate supply of potable water and improved sanitation facilities have been achieved. Strict environmental laws and monitoring for compliance prevent undue pollution to freshwater sources. Good waste management technologies and increased environmental protection awareness have contributed immensely to the success story. This has resulted in fewer cases of waterborne diseases reported compared to developing countries.
\nMany people in developing countries of the world still rely on untreated surface water as their basic source of domestic water supply. This is so because either there is an incessant supply of potable water or inadequate water supply systems. This problem is exacerbated in rural areas. Surface water is increasingly under undue stress due to population growth and increased industrialization. The ease of the accessibility of surface water makes them the best choice for wastewater discharge. Wastewater which comprises of several microorganisms, heavy metals, nutrients, radionuclides, pharmaceutical, and personal care products all find their way to surface water resources causing irreversible damage to the aquatic ecosystem and to humans as the aesthetic value of such water is compromised. These pollutants decrease the supply of useable water, increase the cost of purifying it, contaminate aquatic resources, and affect food supplies [9]. Pollution combined with the human demand for water affects biodiversity, ecosystem functioning, and the natural services of aquatic systems upon which society depends on.
\nUrban areas in most developing countries do have several wastewater management systems some of which are very effective and meet international standards, but many others are plagued with poor designs, maintenance problems, and expansion including poor investment in wastewater management systems. Most rural and poor communities often do not have any form of wastewater management systems. Effluents from large‐ and small‐scale industries are usually channeled to surface water courses, which often result in pollution, loss of biodiversity in the aquatic ecosystem, and possibly health risk to humans.
\nEnvironmental quality and antipollution legislations are the most widely used interventions to control and reduce environmental pollution [10, 11]. In most countries, environmental laws have been enacted by the government and enforced through its administrative structures [12]. The use of criminal sanctions has also limited pollution but the enforcement of these environmental laws remains inadequate [12, 13]. Enforcement of environmental laws in South Africa like other developing countries suffers major setbacks due to inadequate technical experts, insufficient funds, corruption, and low deterrent effects of sanctions [12, 13].
Surface water is one of the most influenced ecosystems on earth, and its alterations have led to extensive ecological degradation such as a decline in water quality and availability, intense flooding, loss of species, and changes in the distribution and structure of the aquatic biota [14], thus, making surface water courses not sustainable in providing goods and services [14, 15]. For instance, the health of a river system is influenced by various factors, which include the geomorphology and geological formations, physicochemical and microbial quality of the water, the hydrological regimes, and the nature of instream and riparian habitats [15].
\nWater quality is described by chemical, physical, and biological characteristics of water that determine its fitness for a variety of uses and for the protection of the health and integrity of aquatic ecosystems [16]. Each aquatic ecosystem has the natural tendency to adapt and compensate for changes in water quality parameters through dilution and biodegradation of some organic compounds [17]. But when this natural buffering capacity of the aquatic ecosystem is exceeded due to the introduction of various classes of contaminants from point and nonpoint sources on a continuous basis, water pollution sets in.
\nIn South Africa like most other developing countries in the world, surface water is usually used for domestic, recreational, and agricultural purposes mostly in the rural areas [9, 18]. Water quality is affected by both natural processes and anthropogenic activities. Generally, natural water quality varies from place to place, depending on seasonal changes, climatic changes, and with the types of soils, rocks, and surfaces through which it moves [5, 19]. A variety of human activities such as agricultural activities, urban and industrial development, mining, and recreation significantly alter the quality of natural waters and change the water use potential [16, 19].
\nDecrease in water quality can lead to increased treatment costs of potable and industrial process water [19]. The use of water with poor quality for agricultural activities can affect crop yield and cause food insecurity [4]. The presence, transport, and fate of heavy metals and organic compounds (which are toxic and persistent) in water bodies are a cause for serious concern globally [4]. Groundwater can be polluted through the release of chemicals contained in wastewater. Riverbeds and wetlands are threatened with increased sediment impoundments and the presence of toxic and persistent chemicals. Such pollution can persist long after their original sources have ceased.
\nThe health of the aquatic ecosystem can be negatively affected by the presence of toxic substances. This is further exacerbated with high population of pathogens in the water. The use of microbiologically contaminated water for domestic and other purposes is detrimental to human health and the society at large [20]. These conditions may also affect wildlife, which uses surface water for drinking or as a habitat. Generally, for measuring water quality, the physical (turbidity, electrical conductivity, temperature, total dissolved solids, color, and taste), chemical (pH, COD, BOD, nonmetals, metals, and persistent organic pollutants, POPs), and biological (fecal coliform, total coliform, and
Wastewater comprises of all used water in homes and industries including storm water and runoffs from lands, which must be treated before it is released into the environment in order to prevent any harm or risk it may have on the environment and human health. The major types of wastewater are shown in Figure 1.
Types of wastewater.
The major aim of wastewater treatment is to protect human health and prevent environmental degradation by the safe disposal of domestic and industrial wastewater generated during the use of water. One of the objectives of wastewater treatment is to recycle wastewater for reuse in irrigation, thereby preserving water resources, which is scarce in arid and semiarid regions of the world [21, 22]. In ancient times, there was no specific treatment given to wastewater. Instead, wastewater was channeled from buildings into waterways through gutters and canals, which eventually ended up in rivers, streams, lakes, and oceans, which were used by people [23]. This natural treatment process based on dilution was adequate presumably due to a smaller population and low population density as well as human activities, resulting in lower pollution load as compared to the present times [23].
\nIncrease in population and industrial growth led to the generation of a high quantity of untreated wastewater channeled to water bodies as raw water [24]. Eutrophication, fish kill, and cholera outbreaks have commonly been reported in communities that use contaminated water for domestic and other purposes [24]. This necessitates the consideration of a more advanced technology in treating wastewater. Wastewater treatment facilities were initially designed to remove/decrease conventional pollution parameters (BOD5, COD, total suspended solids, and nutrients) from the wastewater stream so that the final effluents do not constitute new sources of pollution [25]. However, it has been discovered that the wastewater organic load contains high levels of a variety of hazardous organic pollutants, and thus, additional treatment steps and control measures become very necessary [21, 25].
\nThe quality of wastewater varies according to the types of influents the WWTFs receive such as domestic wastewater, dry and wet atmospheric deposition, urban runoff containing traffic‐related pollution, or agricultural runoff [25]. The range of contaminants becomes broader when industrial wastewater is included into the raw water stream that enters a WWTF [25–27]. Recently, it has been shown that WW effluents contain emerging organic contaminants such as persistent organic pollutants (POPs), brominated flame retardants, per‐fluorinated compounds, and pharmaceuticals, which are not removed during the treatment process [25, 28]. Wastewater treatment technology is fast changing so as to meet the current day challenge.
\nIn many countries, urbanization is growing at an unprecedented rate, and such development is often unbalanced with much of the disposable municipal expenditure devoted to high‐profile infrastructure with waste disposal and management coming well down in the list of priorities in terms of allocation of funds [29]. A study conducted by Saving Water South Africa [30] showed that less than half of the South African wastewater treatment plants (WWTPs) treat wastewater they receive to a safe and acceptable level [31]. The health risk from wastewater usually comes from microbial pathogens, nutrient loads, heavy metals, and some organic chemicals [31, 32]. Bacteria are the most common pathogens usually found in treated wastewater and cause several infections and diseases particularly to young, pregnant, immune‐compromised and aged people [31, 33].
\nMost wastewater treatment facilities in South Africa dispose their effluents directly to nearby rivers or streams, which are used by the surrounding villages for their various water needs. Ogola et al. [34] demonstrated from their study on wastewater treatment facilities in Limpopo Province of South Africa that wastewater is rarely treated to acceptable standards, and this was further confirmed by Edokpayi [35] and Pindihama et al. [36]. Their findings suggest that inadequate investment in wastewater treatment infrastructure, shortage of skilled manpower, poor planning or corruption [31] could have resulted in the poor performances of wastewater treatment facilities in that region.
\nWastewater needs to be adequately treated prior to its disposal or reuse in order to protect receiving water bodies from contamination [31]. The discharge of poorly treated wastewater usually affects water users downstream and contaminates groundwater [31]. Waste stabilization ponds (WSPs) are usually used to provide an effective and low‐cost means of handling domestic wastewater for smaller towns and communities [34]. The use of WSPs is advantageous over the conventional WWTPs because they are very simple to design, operate, and maintain and do not necessarily need skilled manpower [37]. However, Jagals et al. [38] conducted a study on WSPs in the Free State Province of South Africa; their results revealed that most of the municipal waste stabilization ponds were performing less than the required standard. They recommended the implementation of a frequent monitoring program. Wastewater has also been implicated as a possible source of heavy metals, polycyclic aromatic hydrocarbons (PAHs), and microbial contamination to soils, surface water, sediment and groundwater [39–41]. The inadequate storage facility in most WWTPs often gives room to untreated wastewater loss into the surrounding lands and rivers, especially during heavy rains and flooding.
\nWeber et al. [21] showed from their studies the presence of a wide range of contaminants of emerging concerns in wastewater even after the conventional treatment process. Such contaminants include pesticides, polycyclic aromatic hydrocarbons, and pharmaceutical and personal care products. Bundschuh et al. [22] reported on the impacts of wastewater, that concerns have been largely associated the presence of microorganisms, while other toxic and persistent components like heavy metals and POPs have not been given appropriate consideration. Treated wastewater often contains some pollutants such as POPs and heavy metals which are not removed in the treatment processes. The use of such water for irrigation may lead to the accumulation of those contaminants in soils which can be bioavailable for uptake to plants and animals. Thus, providing a pathway through the food chain to man. They also have biological effects on soil fauna and flora after long‐term application [39, 42, 43].
\nThe cultivation of vegetables in soils irrigated with wastewater containing high concentrations of toxic metals usually take up such metals and accumulate them in edible and nonedible parts of the vegetables in quantities large enough to cause potential health risks both to animals and humans consuming these metal‐rich plants [44–48]. Heavy metals have special features that make them toxic even at very low concentrations. They are nonbiodegradable and persistent in various environmental media and can accumulate in plants and animals [45]. The oral route has been identified as the major pathway through which heavy metals enter into the human body. Consumption of food crops from farmlands irrigated with wastewater and ill‐treated wastewater effluents could make people who feed on them at risk to several diseases, some of which only become evident after many years of exposure [49, 50].
\nWang et al. [43] reported the accumulation of polycyclic aromatic hydrocarbons (PAHs) in soils irrigated with wastewater such that the concentration of PAHs was found to be higher in soils very close to the main entrance of the wastewater and decreased gradually with distance away from the plant. Once these pollutants are released into the environment, they are capable of persisting for a long period of time. PAHs can affect humans and animals both externally and internally. On the skin, they cause several inflammations which are often associated with itching and irritation. They can also cause cancer and are endocrine disruptors [51]. Most studies on the impact of wastewater on the receiving watershed in South Africa are often limited to the microbiological quality of the discharged effluent [38, 39].
\nThe release of raw and ill‐treated wastewater onto water courses has both short‐ and long‐term effect on the environment and human health. Freshwater sources have been negatively impacted by wastewater. Such impacts are dependent on the composition and concentration of the wastewater contaminants as well as the volume and frequency of wastewater effluents entering surface water source [52]. Eutrophication of water sources may also create environmental conditions that favor the growth of toxin producing cyanobacteria, and exposure to such toxins is hazardous to human beings.
\nPoorly treated wastewater can have a profound influence on the receiving watershed. The toxic impacts may be acute or cumulative. Acute impacts from wastewater effluents are generally due to high levels of ammonia and chlorine, high loads of oxygen‐demanding materials, or toxic concentrations of heavy metals and organic contaminants. Cumulative impacts are due to the gradual buildup of pollutants in receiving surface water, which only become apparent when a certain threshold is exceeded [18, 21, 34, 39]. All aquatic organisms have a temperature range for their optimum function and survival [51]. When there are sudden changes within those ranges, their reproductive cycle, growth, and life can be reduced or threatened. Owing to the organic load of wastewater, discharged effluents from wastewater treatment facilities usually contribute to oxygen demand level of the receiving water. There is increased depletion of dissolved oxygen (DO) in surface water that receives ill‐treated wastewater. From previous studies, the levels of DO in the effluent of various wastewater treatment facilities in South Africa are usually lower than the required standard of 8–10 mg/L [53, 54]. DO level below 5 mg/L would adversely affect aquatic ecosystem. DFID [55], Momba et al. [39], and Morrison et al. [56] stated that the effect of ill‐treated wastewater on surface water is largely determined by the oxygen balance of the aquatic ecosystem, and its presence is essential in maintaining biological life within the system.
\nOsuolale and Okoh [57] reported that DO concentration in two WWTPs in Eastern Cape province of South Africa was in the range of 3.9–9.6 mg/L and 6.9–9.4 mg/L, respectively, from September 2012 to August 2013. For most of the study period, the levels of DO measured in one of the WWTPs were lower than the concentrations of 8–10 mg/L, which is characteristic of unpolluted water except in December 2012 (9.6 mg/L). Momba et al. [39] recorded DO levels in the range of 3.26–4.57 mg/L in their investigation of the impact of inadequately treated effluents of four wastewater treatment facilities in Buffalo City and Nkonkobe Municipality of Eastern Cape Province of South Africa. Concentrations below 5 mg/L can have a negative effect on aquatic organisms in the water resource [39]. Igbinosa and Okoh [58] reported a DO concentration in the range of 4.15–6.26 mg/L in autumn, 4.99–5.38 mg/L in summer, 4.85–11.22 mg/L in winter, and 4.96–6.69 mg/L in spring. This shows that seasonal variations have significant influence on the levels of DO in surface water. The presence of degradable organics in wastewater is responsible for the low levels of DO determined when compared to surface water sources. Low DO values can lead to the malfunctioning of some fish species and can eventually lead to the death of fish [58].
\nBOD and COD usually give an estimate of organic pollution in water and wastewater. They are important wastewater quality parameters as they are used to measure the efficiency of most wastewater treatment facilities. Surface water is expected to have low BOD/COD values to sustain aquatic life. High levels of BOD and COD can cause harm to aquatic life, especially fish. Low levels of BOD and COD in river systems indicate good water quality, while high levels indicate polluted water. There is an inverse relationship between the BOD/COD levels and DO concentrations. When large biodegradable organics are present in water as it is the case with most wastewater, DO is consumed by bacteria. When this happens, the DO level drops below a threshold point, with negative impact on life as they are unable to continue their normal life sustaining processes such as growth and reproduction. Such decrease affects fish and other aquatic life. The levels of COD reported for the effluent of several WWTFs in South Africa is presented in Table 1.
WWTF\'s location | COD (mg/L) | References |
---|---|---|
Eastern Cape Province I | 4.6–211 | [56] |
Eastern Cape Province II | 10.33–88.33 | [56] |
Alice WWTP, Eastern Cape Province III | 7.5–248.5 | [57] |
Thohoyandou WWTP, Limpopo Province | 50–105 | [31] |
Siloam WSPs, Limpopo Province | 82–200 | [58] |
COD levels of the effluent from wastewater treatment facilities in South Africa.
The South African guideline value for COD in wastewater is 75 mg/L but this level was exceeded for most of the sampling months in the WWTFs. From Table 1, wastewater effluent is a major contributor to organic pollution in surface water of South Africa.
\nThe influx of nutrients such as nitrites, nitrates, and phosphorus into water bodies can induce eutrophication. Generally, nitrogen‐containing compounds are abundant in many wastewater streams, and the inadequate treatment of them can lead to their introduction on the receiving watershed with their attendant consequences. Eutrophication can result when nutrient‐rich wastewater effluents are discharged onto water courses. This can lead to algae blooms and growth of plants in the aquatic ecosystem. When this happens, turbidity of the water increases, plant and animals’ biomass increases, sedimentation rate increases, species diversity decreases, and anoxic conditions may develop, and this could give rise to change in dominant species of the aquatic biota [35]. Nitrate nitrogen and phosphorus levels capable of inducing eutrophication have been reported by several authors for wastewater effluents in South Africa [31, 53, 58].
Contamination of surface water with pathogenic organisms in wastewater could result in the transmission of waterborne diseases for people who use the water resource for domestic and other purposes downstream [59, 60]. About 25% of all deaths worldwide are the result of infectious diseases caused by pathogenic microorganisms [61]. Scientists have identified about 1400 species of microorganisms that can cause ill health, including bacteria, protozoa, protozoan parasites, parasitic worms, fungi, and viruses [4]. The major concern of wastewater discharge onto freshwater courses is the impact they have on public health. Wastewater consists of various classes of pathogens which are capable of causing diseases of various magnitude to man. Unlike some of the environmental impacts that can take a long time before they manifest, pathogens cause immediate negative health impact on people that use contaminated surface water resource for domestic, agricultural, and recreational purposes. Some common pathogens found in untreated and ill‐treated wastewater are presented in Table 2.
Agent | Species | Disease |
---|---|---|
Bacteria | Gastroenteritis (possibly long‐term sequelae e.g., arthritis) | |
Gastroenteritis | ||
Bloody diarrhea, hemolytic uremic syndrome | ||
Abdominal pain, peptic ulcers, gastric cancer | ||
Salmonellosis, gastroenteritis, diarrhea (possibly long‐term sequelae e.g., arthritis) | ||
Typhoid fever | ||
Dysentery (possibly long‐term sequelae e.g., arthritis) | ||
Cholera | ||
Helminths | Ascariasis | |
Ancylostoma duodenal and | ||
Clonorchiasis | ||
Fascioliasis | ||
Fascioloidiasis | ||
Opisthorchiasis | ||
Schistosomiasis (Bilharzia) | ||
Trichuriasis | ||
Taeniasis | ||
Protozoa | Balantidiasis (dysentery) | |
Cryptosporidiosis | ||
Persistent diarrhea | ||
Amoebiasis (amoebic dysentery) | ||
Giardiasis | ||
Viruses | Adenovirus | Respiratory disease, eye infections |
Astrovirus | Gastroenteritis | |
Calicivirus | Gastroenteritis | |
Coronavirus | Gastroenteritis | |
Enteroviruses | Gastroenteritis | |
Echovirus | Fever, rash, respiratory and heart disease, aseptic meningitis | |
Poliovirus | Paralysis, aseptic meningitis | |
Hepatitis A and E | Infectious hepatitis | |
Parvovirus | Gastroenteritis | |
Norovirus | Gastroenteritis | |
Rotavirus | Gastroenteritis | |
Coxsackie viruses | Herpangina, aseptic meningitis, respiratory illness, fever, paralysis, respiratory, heart and kidney disease |
Pathogens found in untreated wastewater (adapted with permission from WHO [60]).
Several episodes of disease outbreaks such as diarrhea and cholera have been reported in various provinces of South Africa with wastewater effluents as the major contributor. In 2004, Mail and Guardian [62] reported a cholera outbreak in Delmas region of Mpumalanga Province of South Africa where 380 cases of diarrhea and 30 cases of typhoid fever were recorded. Similarly, sickness and death were recorded in KwaZulu‐Natal and Eastern Cape Provinces of South Africa where sewage spills occurred on surface water sources [53, 63]. South Africa suffered a cholera outbreak in 2003 when 3901 cases were reported in Mpumalanga Province, the Eastern Cape Province, and Kwazulu‐Natal Province, and 45 deaths were confirmed. In 2004, 1773 cases of cholera were reported in Mpumalanga\'s Nkomazi region, which borders Mozambique, and 29 people died. Also in the same year, 738 people were diagnosed with cholera in the Eastern Cape Province, of which 4 died [63]. And 260 more cases were reported in the North West Province of which two people died. In early 2014, a diarrhea outbreak was reported in Limpopo province [64]. Forty‐five people were admitted to hospital for treatment after contracting diarrhea. In almost all the cases stated above, the use of contaminated water as a source of domestic water was implicated to be the major cause of the epidemics. Several studies have shown that wastewater effluents still contain high amount of fecal coliforms which do not conform, to the 1000 cfu/100 mL in the DWA guideline for wastewater discharge [6, 31, 38, 39, 58, 59, 65].
Surface water will remain as an alternative source of water to meet domestic water demand mostly in rural areas of the world if potable water is not supplied on a regular basis. Wastewater effluents should be treated efficiently so as not to pose a health risk to the users of surface water resources. The major cause for the failing state of wastewater treatment facilities in South Africa as well as other developing countries includes inadequate coverage of wastewater treatment facilities in both urban and rural areas, poor operational state of wastewater infrastructure, design weaknesses, expertise, corruption, insufficient funds allocated for wastewater treatment, overloaded capacities of existing facilities, and inefficient monitoring for compliance with recommended guidelines. Enforcement of water and environmental laws must be in place to protect the environment and the health of numerous people that still depend on surface water as their major source of water supply.
WWTP | Wastewater treatment plant |
WWTF | Wastewater treatment facilities |
DO | Dissolved oxygen |
COD | Chemical oxygen demand |
BOD | Biochemical oxygen demand |
WHO | World Health Organization |
DWAF | Department of Water Affairs |
Colon cancer is a frequent neoplastic disease which is ranked second in female after breast cancer and third in men after prostate and lung and cancer [1]. Despite constant research in the field of colon cancer, its incidence continues to be high worldwide. Moreover, the number of people age 50 or younger diagnosed with colon cancer is dramatically increasing in last years. This finding upholds the idea that colon cancer is not a disease considered to be under control at this time, and efforts should be made in order to better understand its pathogenic mechanism.
\nFive-year overall survival in colon cancer ranges from 90% in early stages to less than 10% in advanced, metastatic cases [2]. It is thus important to try to diagnose the disease in early stage, so an appropriate treatment can be applied. Achieving this condition can be difficult, considering the fact that a large number of colon cancer patients present with late stage, often inoperable tumors.
\nEven if important progress has been made in terms of imaging diagnosis of colon cancer, early detection is still difficult to achieve. An important role in detecting early colon cancer cases is assigned to screening programs that have to be applied nationally, and population should be well informed of their importance. More than detecting incipient cases, early detection of advanced cases is also of crucial importance, and efforts should continue in this direction by further research groups.
\nColon cancer stem cells (CCSCs) are multipotent neoplastic cells that have the ability to differentiate and initiate the carcinogenesis process [3]. Due to their increased viability, CCSCs are responsible for both tumor growth and tumor recurrence [4, 5]. According to a recent study, the presence of CCSCs is also responsible for resistance to chemotherapeutic treatments, which is observed in some cases [5]. A new treatment concept linked to CCSCs is based on their early detection, before the onset of the tumor, which would allow them to target with apoptotic substances.
\nDetection of cancer stem cells (CSCs) in various digestive and extra-digestive cancers has been a topic of great interest in the literature of recent years and was frequently done using cluster of differentiation (CD) markers. In colon cancer, various biomarkers have been identified at the surface of CSCs, and their role in colon cancer is currently being tested: EpCAM, CD133, CD29, CD24, CD44, CD166, ALDH1A1, and ALDH1B1 [3, 4].
\nThe aim of this paper is to review the most important biomarkers which have been identified in colon cancer, to expose current information regarding their role in colon cancer development and progression and to identify possible predictive biomarkers for advanced stages of the disease.
\nCD133 was first described in 1997 by Yin et al. on the cellular surface of hematopoietic cells [6]. Also called prominin-1, CD133 is a 5-transmembranaire glycoprotein of 120 kDa which can be found in two isoforms: CD133-1 and CD133-2 [5, 6, 7]. CD133 is found on the short arm of chromosome 4 [5]. Its cellular function is unclear [5, 6, 7], but its involvement in cell-cell and cell-matrix interactions was described [5]. According to some recent studies, CD133 expression is an important tool in cancer stem cells (CSCs) identification and characterization [7]. CD133 was found to be expressed in various digestive (pancreatic, liver, colorectal) and non-digestive tumors (brain, kidney, prostate, ovary cancer) [7, 8, 9]. CD133 expression promotes cancer cell proliferation through activation of Wnt/beta-catenin pathway [10, 11]. Moreover, in highly expression CD133 cancer stem cells, the development of solid tumor mass is assured by the anti-apoptotic factors BCL-2, BCL-XL, and MCL-1 that are stimulated through PI3K pathway, with subsequent activation of Akt [11]. Even if various studies focused on targeting CSCs and especially CD133 due to its overexpression, most of the results arise from in vitro research and not from clinical experience. Targeted therapy was tested using Anti-CD133 scFv immunotoxins by Waldron et al. that found an interruption of the protein synthesis secondary to this process [12].
\nCD133 expression in colon cancer was confirmed 10 years after its initial description in 2007 [13, 14], when Obrien et al. proved that neoplastic cells expressing CD133 have the ability to form solid colon cancer masses in immunodeficient mice. From that point, many studies focused on CD133 expression in colon cancer carcinogenesis. Various studies analyzed CD133 expression in relation to clinical and pathological characteristics of the neoplastic patients, but result were inconsistent. CD133 expression correlates with the degree of tumor wall involvement (T) [15], with distant metastasis formation (M) [5, 16], with venous (V) and lymphatic (L) invasion [15]. A relation between CD133 expression and tumor recurrence was also noticed in one study [5], while other research groups found a significant association between CD133 expression and tumor size [7]. CD133 expression was correlated in some studies with a poor degree of tumor differentiation (G) [7], but the result was not confirmed by other studies where CD133 expression was found more frequent in moderate (G2) and well differentiated (G1) colon tumor tissues [17].
\nChemoresistance was also found to be influenced by CD133 expression in colon cancer especially due to upregulation of FLICE-like inhibitory protein (FLIP), a ligand that inhibits tumor necrosis factors (TNF)-mediated apoptosis [11]. According to some studies, tumors expressing CD133 are more likely to be resistant to chemotherapy [5, 7, 18]. Moreover, tumors expressing high CD133 and CD44 biomarkers on the cellular surface are expected to be unresponsive to chemotherapy when compared to tumors where the expression of the two molecules is low or absent [16].
\nResults are contradictory in terms of CD133 expression in liver metastases secondary to colon cancer. While CD133 expression in liver metastases was thought to predict a better overall survival (OS) in colon cancer patients [19], Spelt et al. found, in a recent study, different results [4]. According to them, CD133 expression in liver metastases is associated with worse overall survival (OS). Results in favor of a worse prognostic impact of CD133 expression in liver metastases are suggested also by Narita et al. which demonstrated an increased CD133 expression in cases of early recurrence of liver metastases compared with a low CD133 expression in late recurrent liver metastases [20].
\nIn terms of survival, overexpression of CD133 was associated with worse overall survival in some studies [16, 21, 22, 23] and also with low disease-free survival interval [23], but the relation was not found by others [4, 5, 17, 24, 25]. According to two recent meta-analyses, CD133 expression represents a negative prognostic factor in colon cancer patients [23, 26].
\nHeterogeneous results exist in literature considering CD133 role in colon cancer. Its involvement in tumor progression and metastasis formation is suggested, but its precise role remains unclear. CD133 represents a useful tool for CSCs identification and characterization in colon cancer samples. Various studies analyzed the correlation between CD133 expression and clinical and pathological characteristic of the patient, but a direct association between its degree of expression and advanced tumor stages was not confirmed. Moreover, its prognostic role regarding overall survival in colon cancer is still debated, and further studies are needed for a better characterization of the molecule in relation to colon cancer patients.
\nCD44 is a type 1, 85–200 kDa transmembrane glycoprotein expressed in both normal and tumor tissues [16, 27, 28]. Discovered initially as a receptor for hyaluronic acid, the molecule has retained its affinity for it and for other components like collagens, osteopontin, or type I metalloproteinase [3, 27]. Supplementary, an adhesion function was highlighted for CD44 that was found to intervene in both cell-cell and cell-matrix interactions [4, 16]. From a structural point of view, CD44 has three main domains: an extracellular one, a transmembrane, and, respectively, an intracellular domain [27]. CD44 has the capacity to present in various isoform, depending on the exons that attach to the extracellular part (CD44v) [27]. Its encoded gene is located on the short arm of chromosome 13 [29].
\nCD44 is expressed ubiquitary in normal tissue and participates, through lymphocytes activation, in various inflammatory processes [3, 27]; its involvement in wound healing processes was also described by some authors [3]. In neoplastic lesions, CD44 is expressed, in different isoforms, in pancreatic (CD44v8–10) and colon cancer (CD44v6) [27], in prostatic tumors (CD44s—standard isoform), in breast cancer [27], and also in epithelial ovarian cancers [30]. Through its adhesiveness properties, CD44 was found to intervene in tumor growth [16, 17]. Additionally, tumor cells expressing CD44 present with invasiveness properties and are also characterized by the capacity to initiate the metastatic process [28, 31] intervening thus in cell differentiation, proliferation, and migration [32]. The mechanisms by which the molecule intervenes in these processes remain, however, unknown, and further studies have to be performed.
\nAssessment of the prognostic value of CD44 was analyzed in recent papers that highlighted an association between CD44 expression and both advanced tumor stages and liver metastasis formation [27, 31]. Overexpression of CD44 in colon cancer samples was found to negatively influence overall survival of colon cancer patients [33, 34]; one study group found a negative association between CD44 expression and poor overall survival only for a specific variant of CD44 and, respectively, Cd44v2 [35]. The association between upregulation of CD44 in colon cancer and worse overall survival was not confirmed by other study groups [24, 36], but the analysis was completed based on standard isoform of CD44 (CD44s). CD44 usage as an independent prognostic factor in colon cancer patients is not currently recommended [17], but further studies need to concentrate on specific isoforms, like the one abovementioned, in order to correctly identify its value as a prognostic marker.
\nCD44 targeting is currently being tested in various digestive (stomach, colon cancer) [31, 37] and non-digestive cancer (lung, breast cancer) [38]. The results in terms of cancer stem cell apoptosis for in vitro and preclinical animal models are promising. In pancreatic cancer the anti-CD44 antibody tested against CD44v6 isoforms with promising antitumor results was bivatuzumab [37], while the first humanized antibody directed toward solid tumors expressing CD44 approved for clinical research is RO5429083 (NCT01358903), and the publication of results is in progress.
\nCD24 is a glycoprotein located on the external surface of the cellular membrane [16]. It is formed of 27 amino acids, and it has a molecular weight of 24–70 kDa [5, 26]. Its expression was confirmed in normal nervous tissue [16] and in cancers of the colon [5], pancreas [24], breast, and prostate [26]. CD24 is involved in cellular signaling processes, in cellular differentiation, and in proliferation and is being considered a significant marker of cancer stem cells (CSCs) [4, 16, 39]. The mechanism by which CD24 participates in signaling processes seems to be related to mitogen-activated protein kinase (MAPK) and serine/threonine pathway [26].
\nIn colon cancer, CD24 was found to be expressed in a percentage of 50–68% [24, 40]. CD44 is involved in first steps of carcinogenesis and plays an important role in liver metastasis formation [4, 9, 41, 42, 43]. Yeo et al. found CD24 a useful diagnostic marker of early colon cancer [39], whereas its expression was higher in malignant polyps than CD24 expression in colon adenomatous lesions.
\nNo correlation was found between CD24 expression in colon cancer and tumor type or degree of differentiation (G) [5, 44]; other authors have highlighted, however, an inverse relation between CD24 expression and tumor size, poor differentiated cancers, and advanced TNM stages [39]. Regarding lymph node involvement and CD24 expression, as association between high CD24 expression and a larger number of lymph nodes involved was reported in some research papers [45] but not in others [5, 24]. In terms of overall survival, CD24 expression was in general associated with worse survival rates [16, 26]; results were not confirmed by other recent research papers [5, 24, 44]. Resistance to chemotherapeutic treatment was also objective by Nosrati et al. [5] probably due to their capacity to induce the epithelial-mesenchymal transition (EMT) mechanism [46]. Moreover, colon cancer stem cells expressing both CD133 and CD24 markers were found to be resistant to chemotherapeutic regiments based on 5-FU [47].
\nCD24 was highly studied in colon cancer samples, but consistent results have failed to establish its precise role in colon cancer, considering the heterogeneous results observed.
\nEpithelial cell adhesion molecule (EpCAM) is a Ca2+ independent, type I transmembrane glycoprotein with a molecular weight of 40 kDa [48] located on the basolateral surface of epithelial tissues [49]. EpCAM expression was not seen in mesenchymal or lymphoid tissues [50]. EpCAM presents with two main domains: EpICD, an intracellular domain, and EpEx, an extracellular domain of 26, respectively, and 242 amino acids [48, 51].
\nEpCAM was found to be overexpressed in various digestive (stomach, colon, pancreas, and esophagus) and non-digestive (prostate, ovary, breast) cancers [49]. EpCAM is principally involved in adhesion processes, but its role in cellular differentiation and progression was also confirmed [50].
\nA high percentage of colon cancer cases (79–99.7%) is characterized by overexpression of EpCAM molecule at tumor level [52, 53]. Moreover, EpCAM was found to be expressed also in liver metastases secondary to colon cancer, a situation that confirmed its involvement in cancer progression as well [50, 52]. Normal liver parenchyma does not express EpCAM [54].
\nOverexpression of EpCAM in colon cancer correlates in some studies with advanced stages of the disease [50, 55, 56], with a higher risk of metastases [55, 56], with poor differentiated (G3) patterns [54, 55, 56, 57], with the number of lymph nodes involved (N) [48, 54], and with perilymphatic (L) and perivenous (V) invasion [54, 57] but also with worse overall survival [55, 56]. The results were not, however, confirmed by other study groups, so the predictive value of EpCAM in colon cancer patients was difficult to establish [58].
\nEpCAM is also involved in epithelial-mesenchymal transition (EMT) process [56]. During EMT, neoplastic cell detaches from the primary tumor (due to loss of EpCAM expression and less intercellular adhesions) to enter the lymphatic and vascular system and initiate the carcinogenesis process [56]. Detached cells, also called circulating tumor cells (CTCs), can be identified from blood samples through “liquid biopsy” technique that is based also on EpCAM detection using specific anti-EpCAM antibodies [59, 60].
\nIn order to achieve distant metastasis formation, circulating tumor cells have to undergo a second, reversed process called mesenchymal-epithelial transition (MET) during which an upregulation of EpCAM expression at the cellular surface has been observed [59]. Secondary to it, cells acquire adhesion properties that allow them to form a solid metastatic mass [59].
\nDespite constant research in the field of cancer stem cell biomarkers in colon cancer, specific factors or local conditions that initiate and promote EMT or MET are insufficiently known, and further research have to be performed.
\nCD166, also called activated leukocyte cell adhesion molecule (ALCAM), is a 110 kDa, transmembrane type-1 glycoprotein used for colon cancer stem cell (CCSC) identification [3, 61, 62]. Providing the leukocyte receptor function, CD166 expression was identified in both normal and colonic tissue, in the latter cases the expression being superior [3, 63]. CD166 expression in colon cancer varies between 58.6 and 76% [64, 65] and is higher in colonic adenomas [66], suggesting its involvement in colon carcinogenesis. Due to its adhesive properties, CD166 is considered to be involved in colon cancer tumor growth [62]. CD166 expression was also confirmed in pancreatic, esophageal and gastric, prostate, melanoma, and breast cancers [63].
\nExpression of CD166 in colon cancer was studied in relation to tumor stage [61, 64, 65], lymph node involvement [61, 64], or degree of cellular differentiation (G) [61], but even if overexpression was confirmed, no statistic significant correlation was found. Regarding overall survival of colon cancer patients, overexpression of CD166 failed to predict its outcome. Some literature studies found a worse overall survival in colon cancer cases characterized by high CD166 expression [64]. Levin et al. found that even the survival was reduced by 15 months for patients who presented colon tumors characterized by high CD166 expression compared with tumors with low or absent CD166 expression [67]. Other studies could not establish the prognostic relation of CD166 in colon cancer patients [65].
\nLimited number of studies analyzed CD166 expression in colon cancer patients, and existing results are inconclusive. Therefore, the role of CD166 in colon cancer remains unclear.
\nThrough CD29 molecule, also known as integrin β1, cells adhere to extracellular compartment proteins and facilitate intracellular transmission of the cellular signal [68]. CD29 presents with 3 structural domains, the extracellular one being best represented [69].
\nExpression of CD29 was observed in normal and tumor colonic tissues, and a presumptive role in cellular differentiation was attributed to it, due to the activation of Erk signaling pathway [68, 69]. In normal colonic mucosa, CD29 is expressed in the lower part of the intestinal crypt [69] and is considered to be involved in intestinal proliferation [68]. However, its precise role in colon cancer is unknown [68].
\nAt present, CD29 expression in colon cancer is only used as diagnostic marker for CSCs. Further studies are needed to evaluate its involvement in cancer progression and metastasis.
\nLeucine-rich repeat-containing G-protein coupled receptor 5 or Gpr49 is a receptor formed by eight main domains [69]. Lgr5 was identified on the cellular surface of intestinal and colonic stem cells and is being considered thus a biomarker of them [70]. Lgr5 overexpression was also confirmed in esophageal and colon cancer, in hepatocellular carcinoma, and in ovarian cancer [70].
\nLgr5 is expressed in both normal and tumor colonic tissues [69]. In normal colon tissue, Lgr5 is expressed in a small area of the intestinal crypts. Its expression area increases with cell transformation in adenoma and is most elevated in colon adenocarcinoma [69]. The percentage of colon cancer patients expressing Lgr5 is, according to literature studies, around 80% [70, 71].
\nOverexpression of Lgr5 in colon cancer correlates with advanced stages of the disease [70, 71], with lymph node involvement (L) [70, 71] and perineural invasion [71] and distant metastases (M) [70]. Lgr5 involvement in cellular proliferation is also suggested due to the correlation found between Lgr5 expression and Ki-67 expression [70].
\nLgr5 is thus considered to have a role in colon cancer development and progression and possibly in liver metastases formation as well [69]. Moreover, Lgr5 is considered to have a clinical role in predicting advanced pathological stages of colon cancer tumors [72].
\nAldehyde dehydrogenase 1 is a detoxifying enzyme involved in colon cancer proliferation [73]. Expressed in low percentage in normal colonic mucosa, ALDH1 was found to be overexpressed in colon adenocarcinoma [73, 74]. A number of 75.5–76.5% of colon cancer cases express ALDH1 at tumoral level [73, 74].
\nALDH1 expression is associated with colon cancer location [73], with advanced stages of the disease [75], with number of lymph nodes involved (N) [73, 75, 76], and with perivenous invasion (V) [73] but also with local tumor recurrence [75]. The association between ALDH1 expression and lymph node involvement was not seen by Zhou et al. [74].
\nRecently, ALDH1 expression was found to be involved in epithelial-mesenchymal transition (EMT) and could play, thus, a role in cancer progression and distant metastases formation [75, 76, 77].
\nMoreover, ALDH1 associates with resistance to chemotherapy [75] and poor overall survival [75, 76, 78].
\nIn conclusion, ALDH1 could represent a promising prognostic marker in colon cancer patients that associate with advanced colon cancer stages and worse overall prognosis.
\nColon cancer stem cells (CCSCs) could be responsible for tumor metastases, resistance to chemotherapy, and recurrence, and their identification is thus of major importance. However, the amount of biomarkers identified at the cellular surface of CCSC failed to become valuable prognostic markers, and further studies are necessary to evaluate their role in cancer progression and distant metastases formation.
\nThe author declares that she has no conflict of interest.
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