",isbn:"978-1-83881-111-2",printIsbn:"978-1-83880-992-8",pdfIsbn:"978-1-83881-112-9",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,isSalesforceBook:!1,hash:"acb2875b3bfc189c9881a9b44b6a5184",bookSignature:"Dr. Abdo Abou Jaoudé",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/11865.jpg",keywords:"Linear Operators, Normal Operators, Spectral Theorem, Applications, Differential Operators, Integral Operators, Functional Calculus, Complex Variables, Complex Analysis, Theory, Recent Advances, Latest Trends",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"April 13th 2022",dateEndSecondStepPublish:"May 11th 2022",dateEndThirdStepPublish:"July 10th 2022",dateEndFourthStepPublish:"September 28th 2022",dateEndFifthStepPublish:"November 27th 2022",remainingDaysToSecondStep:"11 days",secondStepPassed:!0,currentStepOfPublishingProcess:3,editedByType:null,kuFlag:!1,biosketch:"Abdo Abou Jaoudé is a pioneering Associate Professor of Mathematics and Statistics at Notre Dame University-Louaizé. He holds two PhDs in Mathematics and Prognostics from the Lebanese University and Aix-Marseille University. His research interests are in the field of mathematics.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"248271",title:"Dr.",name:"Abdo",middleName:null,surname:"Abou Jaoudé",slug:"abdo-abou-jaoude",fullName:"Abdo Abou Jaoudé",profilePictureURL:"https://mts.intechopen.com/storage/users/248271/images/system/248271.jpg",biography:"Abdo Abou Jaoudé has been teaching for many years and has a passion for researching and teaching mathematics. He is currently an Associate Professor of Mathematics and Statistics at Notre Dame University-Louaizé (NDU), Lebanon. He holds a BSc and an MSc in Computer Science from NDU, and three PhDs in Applied Mathematics, Computer Science, and Applied Statistics and Probability, all from Bircham International University through a distance learning program. He also holds two PhDs in Mathematics and Prognostics from the Lebanese University, Lebanon, and Aix-Marseille University, France. Dr. Abou Jaoudé's broad research interests are in the field of applied mathematics. 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1. Introduction
Tumor microenvironment is a dynamic concept that includes, beside tumor cells, everything is not tumor cells. It consists of cells, soluble factors, signaling molecules, extracellular matrix (ECM), and mechanical cues that can promote neoplastic transformation, support tumor growth and invasion, protect the tumor from host immunity and foster therapeutic resistance [1]. It is organ-specific and in the brain it is not yet fully understood. In addition to cancer cells, it contains different stromal cells mainly represented by endothelial cells, microglia/macrophages, and reactive astrocytes [2], but other cell types should be considered such as fibroblasts, pericytes, immune cells, etc. (Figure 1). These cells are heterogeneously distributed in the tumor, according to its different phenotypes and relevant biological significances.
Figure 1.
Scheme of the relationship between vessels/endothelium and microenvironment cells.
2. Microenvironment cell components
2.1. Microglia/macrophages
Malignant gliomas are rich in microglia/macrophages that are classified as ramified or resident microglia, ameboid or activated microglia, macrophages and perivascular microglia [3]. They are called tumor-associated macrophages (TAM) and lack apparent phagocytic activity [4].They are considered as both intrinsic to the central nervous system (CNS) and blood-borne arrived, subjected to the local production of chemoattractant factors [5]; they share surface markers [6], but it has been demonstrated that microglia are chemokine (C-X3-C motif) receptor 1 (CX3CR1)+/chemokine (C-C motif) receptor 2 (CCR2)– and monocytes are CCR2+/CX3CR1– [7]. In acute conditions microglia is blood-derived, from adult haematopoietic stem cells (HSCs), even though macrophages in adult renew independently from HSCs. Their majority derives from Tie2+ pathway generating eritro-myeloid progenitors, distinct from HSCs, from the yolk sac they migrate in the various organs [8].
It is still debated whether they are included in or they are distinct from pro-inflammatory cells. They increase both in the center and at the periphery of the tumors [9] and it has been calculated that up to one third of the cells in glioma biopsies are represented by macrophages [9,10] (Figure 2A,B). In the tissue, microglia/macrophages are found as small or large clusters around vessels or necroses, whereas at the periphery or around the tumor they are more regularly distributed. Undoubtedly, they proliferate in response to tumor growth and they have a cytotoxic defense function [11], as well as the capacity for antigen presentation [12], but they can also promote tumor infiltration and proliferation [13,14]. An inverse correlation between TAM infiltration and glioblastoma multiforme (GBM) prognosis [15] and promotion of tumor progression have been found [16].
Together with fibroblasts, pericytes, neutrophils, mast cells, lymphocytes, dendritic and endothelial cells, macrophages belong to the category of stromal cells that interact with the tumor, as discussed before, via cell-cell or by cytokine or chemokine-mediated signaling. Tumor cells may influence stromal cells to produce growth factors such as vascular endothelial growth factor (VEGF), tumor necrosis factor alpha (TNF-α), transforming growth factor beta (TGF-β), interleukin 1 (IL-1) or CXC ligand 2 (CXCL2), CXCL8, CXCL12 that promote angiogenesis and tumor growth. Conversely, tumor cells are stimulated to produce chemokines that influence angiogenesis [16] and growth. There is both an autocrine and a paracrine tumor growth stimulation [17]. The enrichment in stromal cells, especially microglia/macrophages, in the brain adjacent to tumor (BAT) strongly influences immunoregulation and tumor growth on the one side, and it represents a defense from the tumor on the other side.
The existence of a positive relationship between microglia/macrophages and tumor-initiating cells (TICs) in the two opposite directions is relevant to the problem [18]. The vessels can be associated or not with macrophages (Figure 2C,D) even with only one (Figure 2E). They occur obviously in circumscribed necroses (Figure 2F). Basically, any glioma-associated monocytic cell with macrophage characteristics has been called “tumor associated microglia”. It shows a functional phenotype different from the inflammatory one and promotes glioma cell migration and tumor growth [19]. Migration promotion is accomplished through matrix metalloproteinases (MMPs) released by microglia [20,21] and CX3CL1 with its receptor (CX3CR1) [22]. The demonstration that microglia/macrophages promote glioma progression means that their inhibition can be a useful therapeutic tool [23]. Macrophages have long been recognized as critical components of immunity against tumors, because, when appropriately stimulated, they can attack tumor cells by contact interaction or by secreting cytotoxic and cytostatic factors [24]. However, they can also contribute to tumor development, by secretion of growth factors such as angiogenic factors, proteinases, which degrade the matrix, and immunosuppressor factors [25]. Their dual function is mainly exerted through TNF that demonstrates both an anticancer [26] and a tumorigenic activity [27]. However, it has also been shown that TNF can reduce glioma growth and prolong patient survival [28].
One specific question is the role of immune cells in the tumor microenvironment. These cells through cytokines, growth factors, chemokines and cerebrospinal fluid (CSF) interfere with tumor initiation, angiogenesis, proliferation and invasion [29]. IL-1β is the primary factor of microglia that enhances TGF-β, that, in turn, inhibits lymphocyte proliferation by suppressing antiglioma responses [30]. IL-1β also stimulates VEGF, epidermal growth factor receptor (EGFR) and MMP9 for angiogenesis, proliferation and invasion [31].
Macrophages can be subdivided into M1 and M2 subtypes, according their polarization status, supporting tumor suppression or progression, respectively [32]. As shown by the marker MHCII [33], they are strongly M2 in GBM [34]. In summary, it can be stated that macrophages support tumor progression and that tumor recruit macrophages [35]. There is an interrelationship between glioma stem cells (GSCs) and TAMs in GBM and it was shown that the former express Periostin, a member of the Fasciclin family (POSTN) [36] that has a supportive role in various tumors. TAM density correlates with POSTN in GBM and disrupting it TAM density is reduced so that GSCs secrete POSTN to recruit M2 that support tumor growth [37]. It was then showed that POSTN is highly expressed in high grade in comparison with low grade tumors [38]. How POSTN acts in potentiating tumor progression in niches has been widely discussed [39].
2.2. Reactive astrocytes
Reactive astrocytes can be sometimes confused with tumor cells, mainly because their phenotype changes over time until their complete maturation. There are analogies between glial reaction and physiological maturation of astrocytes during embryogenesis. In the initial phases, the fine processes originate directly from the cell soma and then from the thick and long processes [40]. Nestin and Vimentin would be the main markers of immature astrocytes whereas glial fibrillary acidic protein (GFAP) is the main marker of mature astrocytes [41,42].
Figure 2.
Glioblastoma. Macrophages/microglia. A – Cluster of macrophages in a proliferating area, not in relation with vessels; x200. B – Regular distribution of macrophages/microglia in a proliferating area not in relation with vessels; x200. C – Cluster of macrophages around a middle size vessel; x400. D – One vessel is surrounded by a crowd of macrophages, the other has none; x200. E – Capillaries with a macrophage adherent to the wall; x200. F – Macrophages in a perinecrotic palisade; x400. All double staining CD68-CD34, Alkaline Phosphatase Red and DAB, respectively.
It is still a debated question whether tumor infiltration can be recognized by magnetic resonance imaging (MRI), not only when adjacent to tumor, but also at distance. It has been observed, for example, that low grade gliomas, which preferentially locate in the insula and in the supplementary motor area, spread along distinct subcortical fasciculi [43]. By analyzing different peritumor areas with different MRI methods, it has been shown that fractional anisotropy and not apparent diffusion coefficient can be used to evaluate glioma cell invasion. An attempt to classify different peritumoral tissues by a voxel-wise analytical solution using serial diffusion MRI has been made [44].
Figure 3.
Glioblastoma. Reactive astrocytes. A – Regular distribution of reactive astrocytes in a cortex with mild infiltration. Some adhere to small vessels; GFAP, x200, DAB. B – Proliferating area with reactive astrocytes entrapped; almost only the large cytoplasm is visible; GFAP, x200, DAB. C – Glomeruli: multi-channel formations; double staining CD68-CD34, x100, DAB and Alkaline Phosphatase Red, respectively; D – Microvascular proliferations; x200, H&E. E – Pericytes; α-SMA, x200, DAB. F – Id. x400.
Peritumoral reactive gliosis (Figure 3A) has a particular importance because of three main characteristics: reactive astrocytes divide by mitosis as tumor cells do, they progressively lose Nestin and increase GFAP expression, as during development, and they may regionally exert a series of metabolic and molecular influences [45]. The most important point is that reactive astrocytes may be included in the advancing tumor (Figure 3B), in which they progressively become no more recognizable from tumor cells. The question is whether they disappear suffocated by the high tumor cell density, or if they remain, unrecognizable from tumor cells, to contribute to the pleomorphic aspect of gliomas, or if they even can be transformed into tumor cells [46]. There are evidences that reactive astrocytes support tumor progression [2].
3. The glioma origin and the stem cell theory
The existence of a similarity between cancer cells and embryonic stem cells is known since Virchow [47]. Glioma cells may derive through tumor transformation from immature glia cells [48,49], or primitive neuroepithelial cells or neural stem cells (NSCs) and many experimental demonstrations are available on this matter [50,51]. Glioma-initiating cells (GICs) and GSCs [52,53] share with NSCs some properties, i.e. proliferation and self-renewal, and GSCs share with malignant gliomas similar genetic alterations. In contrast to the hypothesis of the transformation of NSCs or neural progenitor cells (NPCs) into GSCs [54], either occurring in situ during embryogenesis or during migration and their relationship with GICs, the origin of GSCs has also been referred to dedifferentiation.
Dedifferentiation may refer to two distinct biological processes. The first one is represented by a multi-step process accompanied by genetic alterations that lead to the progressive transformation of normal cells into highly malignant cells. They require self-sufficiency growth signal, insensitivity to anti-growth signals, escape from apoptosis, proliferation potential, angiogenesis and invasion [55]. By combining activation of specific oncogenes and loss of tumor suppressor genes, it is possible to induce GBM from cortical astrocytes [56]. Examples are the combination of p16(INK4a)-p19(ARF) loss with K-Ras and Akt activation [57], p16(INK4a) and p19(ARF) loss with EGFR activation [58] and p53 loss with myr-Akt and c-Myc overexpression in mature astrocytes [59]. Basically, the capacity of transformation inversely correlates with differentiation. It is easier to get transformation from Nestin+ progenitors than from mature astrocytes by Ras and Akt activation [60].
A second meaning of dedifferentiation refers to tumor cells that would acquire stemness properties instead of reflecting the nature of the primitive cells [50,61].
Today, the existence of cell subpopulations, called cancer stem cells (CSCs) or GSCs, with stem cell-like properties such as multipotency, ability to self-renewal or to form neurospheres in vitro, is generally accepted, also for gliomas [62].
The origin of gliomas from NSCs has been repeatedly demonstrated by the experimental induction of brain tumors by nitrosourea derivatives [63]. Moreover, NSCs have been accepted as the source of gliomas, also because the signaling that regulates their self-renewal, proliferation and differentiation occurs, altered, in gliomas. Several studies demonstrated that GBM may arise from the subventricular zone (SVZ) [64,65] that is the source of stem cells and progenitors in adults [66,67]. The latter are represented by neuroblasts (type A cells) and oligodendrocyte precursor cells (OPCs), by quiescent type B cells that give origin to highly proliferative cells, and by transit-amplifying progenitor cells (type C cells), that differentiate into two lineage-restricted progenitor cells [68,69]. These cells accumulate mutations up to give rise to gliomas [70], not excluding the intervention of human Cytomegalovirus (HCMV) [71].
GBM is a heterogeneous tumor and its heterogeneity might be explained by either the hierarchical model mechanism [72] or the stochastic mechanism of development [73]. Progenitor cells are at risk of malignant transformation since they show the activation of the adequate cell machinery, represented by telomerase activity, promitotic and antiapoptotic genes [54]. Abnormal developmental patterns are Sonic hedgehog (Shh) pathway, EGFR and phosphatase and tensin homologue (PTEN) signaling. Although their clonal origin is from a small fraction of transformed NSCs, gliomas are heterogeneous as a consequence of an anomalous tumor cell differentiation [74]. The diversity within gliomas is due to changes of the subclones, being all of them generated by multipotent tumor cells, but also through an arrest of the differentiation process.
Recently, other cells have been supposed to give origin to GBM.
4. Origin of GSCs and glioma heterogeneity
The hypothesis of GSCs is based on the concept that a rare subset of cells within GBM may have significant expansion capacity and the ability to generate new tumors [72]. The remainder of tumor cells, which predominantly resemble GBM, may represent partially differentiated cells with limited progenitor capacity or terminally differentiated non-tumorigenic cells. A possible origin of gliomas is also from mature astrocytes by acquiring stemness properties through a dedifferentiation process, as above mentioned [54,75] or from NG2 cells that fit better with tumors arising far from the ventricles or with secondary GBMs [76]. Also reactive astrocytes can be candidate for gliomas [77,78], since they can acquire a stem-like phenotype [79].
In spite of the great similarity between SVZ NSCs or progenitors and GICs, the relationship with GSCs remains unresolved. Are they equivalent, or the latter have nothing to share with the former, if not the stemness properties? An answer can be that over time GICs can acquire sufficient alterations to engender GSCs. GICs are the first genetically aberrant cells that can initiate tumor development and that are responsible for the bulk of tumor cells. OPCs, the major dividing cell population in the adult brain that gives origin to oligodendrocytes, distributed in the SVZ and in the gray and white matter, remain a further unresolved problem. The EGFR and prostaglandin-endoperoxide synthase 2 (PTGS2) inhibition prevents the tumorigenesis of transformed OPCs and GICs for anaplastic oligodendroglioma but not the tumorigenesis of transformed NSCs or GICs for GBM, suggesting that the latter can arise from OPCs or NSCs [80].
In mice models, by using the retrovirus replication-competent avian sarcoma-leukosis virus long terminal repeat with splice acceptor (RCAS) [81], OPCs expressing 2’, 3’-cyclic-nucleotide 3’-phosphodiesterase (CNP) could be targeted later in their development or in the adult. Low grade oligodendrogliomas were obtained by RCAS-platelet-derived growth factor subunit beta (PDGF-β) expressing OPC markers such as sex-determining region Y (SRY)-box2 (SOX2), oligodendrocyte transcription factor 2 (OLIG2), NG2 and PDGF receptor (PDGFR), interpreted as indicating a slight dedifferentiation of tumor cells [82]. OPCs could serve as cells of origin of gliomas [83]. According to the already mentioned experiments by mosaic analysis with double markers (MADM), aberrant growth of precancerous lesions could only be found in cells differentiated along the oligodendrocyte lineage to become OPCs but not in any other lineage or in NSCs [84]. These demonstrations, however, do not exclude that aberrant growth can occur in NSCs, responsible for a direct origin of malignant tumors.
Heterogeneity in gliomas is not due to the occurrence in the same tumor of different non-tumor cells of various species, but to the cellular complexity formed by tumor cells that differ among themselves for a series of phenotypic and molecular characteristics affecting cell proliferation, invasion, etc. [85,86]. Cells are at risk of transformation only when demanded to proliferate, such as progenitors, opposite, for example, to B cells of SVZ that are protected [87]. The passage from B cells to amplifying cells implies a chromatin rearrangement from a quiescent to a proliferating status where genetic lesions, if not repaired, pass to the following dividing cells. There are interactions among DNA repair, epigenetics and stem cells. In the niche a homeostatic regulation of stem cells occurs, with a balance between self-renewal and differentiation, and with proliferation starting in response to a stimulating signal. Uncontrolled proliferation would take place when stem cells become independent of growth signal, because of mutations, or they resist anti-growth signals [88]. The homeostatic balance would be regulated by the interaction between Wnt/β-catenin pathway, that promotes cell growth, and bone morphogenetic protein (BMP) signaling that inhibits it. This can be the starting point of heterogeneity, largely dependent on the microenvironment. Gliomas with different genetic signatures may as well originate from different cell subtypes [89].
The same molecular mechanisms of NSCs regulate gliomas [90] that can undergo epigenetic changes and genetic mutations favoring evolution toward malignancy. During their lifespan, they can be exposed to genotoxic stress, to which they respond through repair mechanisms [76]. GBM has many molecular signatures depending on its polyclonality, and the events themselves may have an effect on the clonality. The greater is the potency of stem cells, the more anaplastic is the tumor.
The molecular profile of malignant gliomas has led to the distinction of proneural, proliferative and mesenchymal types associated to NSC profiles [91] or to the distinction of proneural, classic and mesenchymal types, the former expressing genes associated to progenitors and the latter two to stem cells [92]. The stemness would reflect the cell of origin, but it could also be acquired in the niche in adult gliomas [93]. On this basis, the contrasting results obtained on GBM can be explained by the finding of different series of TICs characterized by different phenotypic and molecular profiles [86,94].
5. Migration of NSCs or NPCs toward tumors
NPCs can migrate from the SVZ toward a tumor and target it [95]. Today, this migration may represent a new goal for therapeutic purposes. NSCs exhibit tumor-homing capability. In mice experiments, immortalized murine NSCs, implanted into glioma-bearing rodents, distributed within and around tumors, even migrating to the contralateral hemisphere [96]. Genetically engineered NSCs show a tropism for gliomas, on which may have an adverse effect [97-100], especially if they are also transduced with herpes simplex virus-thymidine kinase (HSVtk) gene and followed by the administration of systemic Ganciclovir [101-103]. Human NSCs implanted in rat brains containing a C6 glioma, migrated in the direction of the expanding tumor [104]. The same properties are shown by mesenchymal stem cells (MSCs) injected either into carotid arteries or intracerebrally [105,106] and by hematopoietic progenitor cells [107]. Endogeneous progenitor cells have been observed to migrate from the SVZ toward a murine experimental GBM [108]. The migrated Nestin+ cells were also actively cycling, as shown by Ki-67/MIB.1 positivity, and 35% of them expressed Musashi-1 [109]. In transgenic mice, virally labeled proliferating cells of the SVZ demonstrated that NPCs accumulate around gliomas, diverted from their physiological migratory pathway to the olfactory bulb [110].
Chemokines, angiogenic cytokines and glioma-produced ECM can play a role in the NSC tropism [111]. It is possible to take advantage of the natural capacity of chemokines to initiate migratory responses and to use this ability to enhance the tumor inhibitory capacity by NPCs to target an intracranially growing glioma [112]. The therapeutic possibilities offered by NSCs are continuously increasing. For example, they can be engineered as sources of secreted therapeutics, exploiting their mobility toward CNS lesions. They could function as minipumps [113].
Rat embryonic progenitor cells, transplanted at distance from a glioma grown in the striatum, migrate and co-localize with it. They modify their phenotype, express Vimentin and reduce the tumor volume, demonstrating that a cross-talk exists between them and the tumor [114]. It has been shown that hypoxia is a key factor in determining NSC tropism to glioma by stromal-derived factor 1 (SDF-1) and its receptor (CXCR4), urokinase-type plasminogen activator (uPA) and its receptor (uPAR) and VEGF and its receptor (VEGFR) [115]. It could be interesting to try to enhance motility of adult NSCs toward CNS injury or disease and to take into account that EGFR could play a role, because of its participation to malignant transformation [116]. It has also been recognized that a limitation exists to the possibility of migration of neural precursors from SVZ to an induced cortical GBM in mice. The limitation is caused by the age and the proliferation potential of the SVZ. Adult mice supply fewer cells than younger mice, depending on the expression of D-type Cyclins, because with aging Cyclin D1 is lost and only Cyclin D2 is expressed [110]. Recently, novel treatment strategies using NSCs have been proposed, for example the suicide gene therapy using converting enzymes [117]. New strategies will emerge from further NSC and brain tumor stem cell (BTSC) studies [118]. Is it possible that tumors grow from transplanted NSCs [119]?
6. Perivascular niches (PVN). Relationship between NPCs/GSCs and endothelial cells
GBM is composed of three concentric zones: a central necrotic area, surrounded by an intermediate zone containing large vessels with thrombosis or altered walls; a surrounding proliferation zone that abruptly or progressively flows into the normal tissue and invades it [63]. Neo-angiogenesis takes place in the proliferating zone or in normal surrounding tissue after tumor cell invasion. In the latter, new capillaries are formed from the pre-existing venules. Basically, new capillary formation is due to the endothelial proliferation that mimics angiogenesis in normal embryonic conditions, with buds and new tubule formation. In comparison with normal angiogenesis, tumor angiogenesis is often dysregulated until the formation of glomeruli (Figure 3C). In the invasion zone, tumor cells wrap around vessels (co-option). In invaded cortex, the vascular tree coming down from the meningeal vessels is assailed by advancing and invading tumor cells and it progressively deforms through endothelial cell hypertrophy and hyperplasia. It becomes less adequate to perfuse the increased mass of tumor cells coming up from the white matter, because transformed into a lumpy tree with irregular lumina. The generated microvascular proliferations (MVPs) (Figure 3D) are mainly found at the transition from central necrosis to the proliferation zone, where circumscribed necroses with pseudopalisading develop [120]. As a consequence, areas very rich in capillaries and small vessels, produced by an intense angiogenesis, coexist in tumors beside areas poorly vascularized where necroses develop.
Vasculogenesis is a mechanism of tumor neovascularization that has been also attributed to circulating bone marrow (BM)-derived cells known as endothelial progenitor cells (EPCs). Its importance is debated [121,122], but it was shown that mesenchymal progenitors from bone marrow can differentiate into proliferating endothelial cells [123,124]. Also BM-derived TAMs, including TIE-2 expressing monocytes/macrophages (TEMs), circulate in the blood, home at sites of pathological neovascularization and differentiate into endothelial cells or macrophages [125,126].
Another type of vascularization is represented by the “vascular mimicry” due to the capacity of tumor cells to form a functional net of channels coated by themeselves. Two types of vascular mimicry have been described. The patterned matrix type is composed of a basement membrane, lined by tumor cells, forming channels with flowing blood [127]. Vasculogenic mimicry of the tubular type may be morphologically confused with endothelial cell-lined blood vessels. In both types, cells express endothelium-associated genes, as in embryonic vasculogenesis [128,129]. These properties are associated with CSCs [130]. By fluorescent in situ hybridization (FISH) and immunophenotyping, these non-endothelial cell-lined vessels have been demonstrated to be primary tumor cells. In vitro CD133+ GSCs are vasculogenetic even with vascular smooth muscle-like cell differentiation. The cells do not express CD34 and show EGFR gene amplification [131]. It must be remarked, however, that usually cells of tumor vessels and MVPs never show either isocitrate dehydrogenase 1 and 2 (IDH1/2) mutations or EGFR gene amplification, never exceeding 1 or 2 copies [132]. They do not share with tumor cells genetic alterations and this is in line with the lack of TP53 mutations in MVPs [133].
In tumors transplanted into mice and irradiated, recruitment through hypoxia of BM-derived cells occurs, able to restore circulation through SDF1 and CXCR4 [134]; among these cells, EPCs prevail [121,135-137]. Vasculogenesis can be blocked by pharmacological inhibition or antibodies toward SDF1 and CXCR4 [134].
Interestingly, also a GBM-endothelial cell transdifferentiation is considered to contribute to tumor vascularization, favored by hypoxia [138], independently of VEGF [139]. It has been observed that a quota of GBM CD31+ endothelial cells shares with tumors cells chromosomal aberrations [140] and that a quota of GBM CD105+ endothelial cells harbours the same somatic mutations identified within tumor cells, such as amplification of EGFR and chromosome 7 [141]. In a GBM model, it was demonstrated that the tumor-derived endothelial cells originated from TICs [138]. This finding is of paramount importance because of the possibility to use an anti-VEGF antibody (Bevacizumab) for therapy [142]. Unfortunately, the effects of the drug are only transient [143] and the reason of the failure is the activation of other pro-angiogenic pathways, the recruitment of BM-derived cells and the increase of pericyte protection and tumor invasion [144,145]. The possibility that the tumor becomes more aggressive after therapy has been contemplated [146].
The problem of transdifferentiation and the role that CSCs play in this process are still under discussion [139]. All the observations have been made in animals or from animal models, and in vivo experiments of transdifferentiation have been challenged [85]. In human pathology, the contribution of tumor cells to the GBM vasculature has never been demonstrated and vessel cells with typical genetic changes of tumor cells, such as those of EGFR, PDGFR, PTEN, TP53, IDH1/2 have never been found in GBM [132].
By intussusception, pre-existing brain capillaries can be multiplied by transluminal endothelial bridges and by lumen partitioning; it is an early phenomenon [147].
As NPCs or NSCs reside in the normal SVZ niche at close contact with endothelial cells, in GBM, GSCs and/or NPCs are located in PVN. In the latter, a strict similarity exists with what happens in the normal SVZ niche, where the intimate association between normal NSCs and endothelial cells regulates self-renewal and differentiation of the former. In PVN, angiogenesis is activated by VEGF produced by NSCs/GSCs [88,148], whereas their stemness is maintained by Notch produced by endothelial cells through nitric oxide [19,149,150]. Notch is constitutively active in high grade gliomas and conditions their progression [104]. PVNs are strictly correlated with tumor progression. There would be a bidirectional communication between endothelial cells and TICs or GSCs [151].
The PVN composition has been carefully described in GBM, with the inclusion, beside cells of the environment, of ECM, integrins, cell adhesion signaling, cadherin family, etc. [152]. In GBMs, strong evidence for the existence of an endothelial mesenchymal transition (EMT) process is still lacking, but this process is increasingly reported as instrumental to tumor growth and diffusion [153,154]. It is defined by the possibility that differentiated epithelial cells establish stable contacts with neighbor cells, assume a mesenchymal cell phenotype with loss of cell-cell interactions, reduce cellular adhesion, active production of ECM proteases, increase cytoskeletal dynamics and changes in transcription factor expression, and acquire a stem cell program, all of them leading to increased migration and invasion ability [155]. The three major groups of transcription factors, the SNAI, Twist-related protein 1 (TWIST1) and Zinc-finger enhancer binding (ZEB) family members, have been reported to be altered in GBM. Their over-expression follows the activation of Wnt/β-catenin pathway and results in vitro in an increased cell migration and invasion [156,157]. It is likely that the high expression of mesenchymal genes in the mesenchymal subset of human GBMs [91] can be considered to be reminiscent of the EMT program [92] or that the aberrant activation of EMT factors during gliomagenesis can trigger the mesenchymal shift in GBM [158].
The influence that GSCs can exert on BM-derived endothelial cells has been summarized as follows [159]: to elicit angiogenesis, to home at the tumor the BM-derived EPCs and to promote their differentiation into blood vessels that incorporate into the existing vasculature. Transdifferentiation into endothelial-like cells contributes to the formation of blood vessels [140,160].
The PVN concept was substantiated by the demonstration of Nestin+ and CD133+ cells on capillaries, forming a microvasculature in which the microenvironment that maintains CSCs and their renewal is given by endothelial cells that, in turn, are stimulated by CSCs [149]. A positive correlation was found between the CD133+ niches and CD133+ blood vessels, similar to the correlation between the Nestin+ niches and Nestin+ blood vessels [161]. A good PVN demonstration has been given [2] and beautiful and useful schemes have been provided [159, 162]. It can be added that angiogenesis and self-renewal would represent a resistance to chemo- and radio-therapy.
The location of GSCs in PVN was confirmed by several studies using either CD133 positivity [163] or side population signature genes, such as aspartate beta-hydroxylase domain-containing protein 2 (ASPHD2) or nuclear factor erythroid 2-related factor 2 (NFE2L2) or hypoxia-inducible factor 2 (HIF-2) [164]; they increase with malignancy [161]. By comparing xenografts of C6 glioma with a high or low fraction of GSCs, it was observed that the former exhibit an increased microvessel density and an increased recruitment of BM-derived endothelial progenitors [123]. The relevance of the hypoxia will be discussed later.
6.1. Pericytes
Pericytes, the last PVN component, are perivascular cells that support blood vessels [165], control blood vessel stability, function through paracrine factors and direct cell-cell contacts, and promote vascular maturation (Figure 3E,F). They express different markers including PDGFR-β, α-smooth muscle Actin (α-SMA), Desmin, and NG2. They originate from mesoderm-derived MSCs or from neuroectoderm-derived neural crest cells, depending on their location within the brain. Pericytes are an essential element of the neurovascular unit and contribute to the function of blood-brain-barrier (BBB) [166]. Gliomas can induce the differentiation of MSCs into pericytes [167]. MSCs injected into brain tumors in mouse models have been shown to closely associate with the tumor vasculature and also with up-regulation of the expression of pericyte markers [168].
Pathology observations show that pericytes increase in number in GBM and wrap around vessels with endothelial hyperplasia.
7. PVN neuropathology
The description of the niches must be obviously a survey of the different vascular structures in GBM with their surrounding cell components. The first question to give an answer is: does each vascular structure represent a niche, or are they distributed in the tumor and how? The second question is: is the cell composition of the niches a constant one or does it vary from one another? In the literature, GSCs have been demonstrated in perivascular position [149], as well in perinecrotic niches [164,169] as discussed later. Good schemes of PVN are provided including all the cells that can be encountered in such position [62,159,162]. Such schemes, obviously, are not encounted as real occurrences in the histological examination of GBMs.
By examining the vascular structures in the different tumor zones, in infiltration areas capillaries, arterioles, venules or penetrating vessels from the meninges occur. Around them, there are tumor stem cells/progenitors, often forming cuffings (co-option), or Nestin+ cells adherent to the walls, or reactive GFAP+ astrocytes (Figure 4A–D). Scattered in the tissue, microglia/macrophages occur rather regularly, occasionally distributed in perivascular position (Figure 2). Reactive astrocytes continue to be present also in more intense infiltration, recognizable for their GFAP positivity and for what remains of their long and thick processes; however, they are regularly distributed in the tumor tissue and occasionally they can be found in perivascular position.
In areas of intense tumor cell proliferation, many small vessels can be found either with or without endothelial hyperplasia, sometimes forming a dense net. Around them, tumor cells, mostly Nestin+ and SOX2+, crowded, that can easily be considered as undifferentiated and containing sometimes cells with stemness properties, associated with occasional CD68+ cells. In proliferating areas, larger vessels can be found, with walls thicker than in capillaries, surrounded by a dense cuffing of cells that are Nestin+ in the inner part and GFAP+ outside (Figure 4E,F). In most vessels, pericytes appear wrapping the channel outside the endothelial cell layer; they are well evident in MVPs or in glomeruli that, on the other hand, do not appear to be surrounded by other cell types, if not tumor cells.
In intermediate areas or near the central necrosis, many vessels of different size and nature are associated with edema or tissue dissociation and they do not show to be surrounded by any special cell kind. Scattered in the tumor, myeloid cells can be found in variable quantity, associated or not with other types of cells among which macrophages seem to be the most frequent. Microglia/macrophages are distributed in small or large clusters around necroses or around vessels where they can be associated or not with some of the other cell types. The association with myeloid cells is the most striking.
The neuropathological study provides the information that PVN represents a theoretical picture where the different cell types can be represented and where cross-talks occur among the different signalings that support some tumor activities such as invasion, growth, etc. Of course, the most important dialogue in these structures occurs between GSCs and endothelial cells, and this is feasible around capillaries and small vessels, even though the thickness of the vessel walls could not in absolute be an insuperable obstacle.
8. Hypoxia and necroses – Perinecrotic niches
In GBM, there are two main types of necrosis: large necroses, usually at the tumor center, of thrombotic origin, and circumscribed necroses, occurring in the proliferative areas and representing a hallmark of the tumor. Hypoxia is, therefore, a tumor characteristic [170], mediated by HIF-1/2 composed of two subunits, an oxygen insensitive HIF-β subunit and an oxygen regulated HIF-α subunit [171]. Under normoxic conditions, HIF-α is rapidly degraded following hydroxylation by the oxygen-dependent prolyl-hydroxylase domain proteins (PHDs), that mark it for ubiquitination and proteasomal degradation [172]. Hypoxia stabilizes HIF-1α by preventing its hydroxylation and degradation; together with HIF-2α, it is critically involved in the regulation of GSCs [164]. Hypoxia directly promotes the GSCs expansion. In human GBM biopsies, GSCs are enriched in perinecrotic regions, where the oxygen tension is reduced and HIF-1α and HIF-2α are activated [164,173]. HIF-2α remains elevated under chronic hypoxia, while HIF-1α is only transiently upregulated [174].
Hypoxia through HIF-1α promotes the expansion of GSCs through the phosphatidylinositol 3-kinase (PI3K)/Akt and ERK1/2 pathways, the inhibition of which reduces the fraction of CD133+ GSCs [175]. In perinecrotic regions hypoxia regulates many properties [159]. In GSCs under hypoxic conditions, it activates Notch by inducing its ligands and the activation of target genes Hes1 and Hey2 [164,176]. Blockade of Notch signaling with γ-secretase inhibitors depletes the GSC population, reduces the expression of GSC markers such as CD133, Nestin, Bmi1 and OLIG2 and inhibits the growth of tumor neurospheres and xenografts [177].
GSCs can be demonstrated to lie around circumscribed necroses or scattered in the tissue by CD133 positivity [169] or other specific antigens [164].
Hypoxia is generally realized when tumor growth exceeds neovascularization, and it would not only regulate tumor cell proliferation, metabolism, differentiation, but also induce key stem cell genes such as Nanog, Oct4 and c-Myc [178].
Necroses are the place where hypoxia occurs, but it must be taken into account that usually its occurrence is histologically deduced from its pathologic effects, i.e., necrosis in the tissue. Hypoxia at its very beginning could not yet be visible as necrosis, but already efficient for other signs. It is possible that tissue features in an area not suspected to be hypoxic, are indeed due to hypoxia. An example is given by apoptosis. Apoptotic nuclei are found in proliferating tumor areas due to an intrinsic or transcriptional pathway via mitochondria and focused on TP53 [179], or in hypoxic areas through an extrinsic pathway or TNF [180].
It is, however, possible that isolated apoptotic nuclei in a proliferating area are not due to the first type of apoptosis, i.e. the intrinsic one, but to the extrinsic type, consequence of a not yet morphologically evident hypoxia [181]. As a matter of fact, HIF-1α expression can be mainly demonstrated around circumscribed necroses, but also in scattered cells in proliferating areas (Figure 5A,B) [45].
Figure 4.
Glioblastoma. D – Nestin+ tumor cells adhere to small vessels; Nestin, x200, DAB. B – GFAP+ cells scattered in the tissue or in relation with vessels directly or by vascular feet: tumor cells or reactive astrocytes; double staining GFAP-CD34, x200, DAB and Alkaline Phosphatase Red, respectively. C – Id. with a cuffing of GAFP+ cells in the outer layer; GFAP, x200, DAB. D – Cuffing of Nestin+ cells on a medium size vessel; Nestin, DAB, x200. E – Infiltrative area with Nestin+ cells on small vessels; Nestin, x200, DAB. F – Id. Some GFAP+ tumor cells adhere to vessels; GFAP, x200, DAB.
Circumscribed necroses in GBM are the hallmark of the tumor, but their origin and development are still discussed. They have been carefully described and codified [139,182,183] as due to an ischemic process following a vascular occlusion or to a pathology of the endothelium. The consequent hypoxia would stimulate angiogenesis, through HIF-1 and VEGF. Another interpretation can be given: necroses develop in hyperproliferating areas, with a high Ki-67/MIB.1 labeling index (LI) and a high Nestin expression in comparison with GFAP, due to the focal insufficiency of angiogenesis to feed a very large number of tumor cells, because of the imbalance between the high tumor cell proliferation capacity and the low one of endothelial cells (Figure 6A–F and Figure 7) [184-186].
Figure 5.
Glioblastoma. A – HIF-1+ cells in perinecrotic position; HIF-1, x200, DAB. B – HIF-1+ cells scattered in a proliferative area; HIF-1, x200, DAB. C – A large avascular area; CD34, x25, DAB. D – High vessel density; CD34, x100, DAB. E – Perinecrotic palisade with high density of SOX2+ cells; SOX2, x200, DAB. F – Cuffing of SOX2+ cells around vessels; SOX2, x200, DAB.
This observation does not exclude that inside necroses regressive pathological vessels occur [183]. In GBMs, beside areas with a high vessel density due to an active neoangiogenesis, large avascular areas occur where necroses develop (Figure 5C,D).
Figure 6.
Glioblastoma. A – High Ki-67/MIB.1 labeling index (LI) in a hyperproliferating area; Ki-67/MIB.1, x200, DAB. B – High Ki67/MIB.1 LI in the perinecrotic palisade; Ki-67/MIB.1, x200, DAB. C – Perinecrotic palisade with high density of Nestin+ cells; Nestin, x400, DAB. D – Id. with only rare GFAP+ cells; GFAP, x400, DAB. E – A circumscribed necrosis in hyperproliferating Nestin+ area; Nestin, x200, DAB. F – Id. only rare GFAP+ tumor cells; GFAP, x200, DAB.
The palisades would be the remnants of the hyperproliferating area after necrosis development. Both are composed of a high number of cells positive for stemness markers such as CD133, Nestin, SOX2, and RE-1-silencing transcription factor (REST), and have a high proliferation index (Figure 5E,F) [163,187,188]. GSCs can be conceived as deriving from dedifferentiated tumor cells that acquired stemness properties [189]; they would be concentrated in the above mentioned malignant tumor areas where circumscribed necroses develop because of the vascular insufficiency. It is likely that GSCs around necroses represent the quota of GSCs that populated the hyperproliferating areas and remained unaffected by necrosis development. The palisadings themselves would be the remnants of hyperproliferating areas, spared by necrosis [45,189].
Figure 7.
Progression from hyperproliferating areas with GSCs/progenitors → development of avascular area → appearance of necrosis → necrosis surrounded by GSCs/progenitors.
9. Functions of the niches in the tumor and their interdependence
The GSC maintenance is provided by the signalings that occur in the niches; they can expand and form new ones that, in turn, drive the tumor growth [190]. Signalings involved in the GSC regulation are Oct4, c-Myc, Notch, TGF-β, Wnt/β-catenin pathways. Genes associated with shorter patient survival, as already observed [91], are overexpressed in the side population found by Seidel et al [164] and, viceversa, downregulated in those associated with longer survival. The overexpression concerns more primary than secondary glioblastomas that show a reduced CSC component [191] that, however, may still support tumor growth.
Perivascular and perinecrotic niches are not separated entities, first of all for temporal reasons. Hypoxia is the main cause of angiogenesis, but this is realized through factors, such as VEGF, Angiopoietin 1 and 2, SDF1 produced by GSCs and, at the same time, the imbalance between the high proliferation rate of tumor cells and the low one of endothelial cells makes angiogenesis insufficient and causes necrosis development. Moreover, besides tumor areas rich in small neo-formed vessels and capillaries, MVPs due to a dysregulated angiogenesis do not show sufficient exchanges with tumor cells and are responsible for hypoxia [63]. Another important question, widely discussed [172], is how hypoxia and the vasculature regulate macrophages and immune cells through HIFs and nuclear factor kappa-light-chain-enhancer of activated B cells (NF-kB) [192,193] and CXCR4 [194].
It cannot be established whether GSCs of perivascular and perinecrotic niches belong to the same population, because, although showing the same stemness antigens, they still represent progenitors that can be in different state of differentiation. The significance conferred to GSCs in perinecrotic position as dedifferentiated tumor cells which reached stemness beyond a certain point of dedifferentiation, cannot be recognized to GSCs in perivascular niches [45,189]. Letting aside the transdifferentiation of tumor cells into endothelial cells, which did not received sufficient support, another point of link between the two microenvironments is represented by cell migration through EMT that is promoted by hypoxia and bound to GSCs [155]. GSCs can migrate along newly formed vessels and favor tumor diffusion.
The most important question in this topic is the occurrence of circumscribed necroses in the tumor areas with the highest malignant phenotype including both avascular districts and districts with a high vessel density, so that perinecrotic niches appear to be associated with perivascular niches to characterize these malignant areas [45,189,195].
10. Conclusions
The origin of gliomas has been outlined as traceable back to the transformation of primitive neuroepithelial cells or NSCs, capable of self-renewal and proliferation, i.e. endowed with stemness properties, or to the dedifferentiation of adult glia to reach stemness properties. The CSC responsibility for tumor proliferation, recurrence and resistance to therapies falls today into the most credited hypothesis. Many experiments have shown that GSCs derive by transformation of NSCs or they represent a simple functional stemness status. Some aspects of the problem remain unresolved, for example, the relationship between TICs and CSCs or the CSCs location in the tumor, as well as the existence in the tumor of NSCs that continuously renew the CSCs quota.
Recently, a new concept arose to indicate everything in the tumor, outside cancer cells, that regulates tumor proliferation, invasion, differentiation, resistance to therapies as the microenvironment, with its innumerable molecular pathways and numberless signalings and cross-talks. Major expressions of the microenvironment are in GBM the perivascular and the perinecrotic niches. The former are important for the endothelial cell/CSC relationship that, on one side, maintains the stemness status of CSCs and, on the other side, gives origin to angiogenesis. The latter are important for the occurrence of hypoxia through HIF-1/2 that can induce CSC formation.
The neuropathological study of GBMs with the final goal to find a concrete expression to the perinecrotic niche concept, provides an alternative interpretation to that considering perinecrotic CSCs as induced by hypoxia. They can be the remnants of CSCs that crowded the hyperproliferating and malignant areas of the tumor in which necrosis developed for insufficient vascularization. Perivascular niches are usually very well depicted as schemes that contemplate all the cells that can be in contact with vessels/endothelial cells. This event, however, is not observed to be realized with all the identified cells in all the vessels, going from capillaries or small vessels to larger vessels, MVPs or glomeruli in the different tumor areas. The cells described in the schemes never occur concurrently in one or all the vessels, so that the schemes themselves remain as a theoretical indication of possible relationships that can be established between tumor cells and vessels as a consequence of a general molecular regulation that is realized in the microenvironment.
Acknowledgments
This work was supported by Grant n. 4011 SD/cv 2011-0438 from Compagnia di San Paolo, Turin, Italy.
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Introduction",level:"1"},{id:"sec_2",title:"2. Microenvironment cell components",level:"1"},{id:"sec_2_2",title:"2.1. Microglia/macrophages",level:"2"},{id:"sec_3_2",title:"2.2. Reactive astrocytes",level:"2"},{id:"sec_5",title:"3. The glioma origin and the stem cell theory",level:"1"},{id:"sec_6",title:"4. Origin of GSCs and glioma heterogeneity",level:"1"},{id:"sec_7",title:"5. Migration of NSCs or NPCs toward tumors",level:"1"},{id:"sec_8",title:"6. Perivascular niches (PVN). Relationship between NPCs/GSCs and endothelial cells",level:"1"},{id:"sec_8_2",title:"6.1. Pericytes",level:"2"},{id:"sec_10",title:"7. PVN neuropathology",level:"1"},{id:"sec_11",title:"8. Hypoxia and necroses – Perinecrotic niches",level:"1"},{id:"sec_12",title:"9. Functions of the niches in the tumor and their interdependence",level:"1"},{id:"sec_13",title:"10. 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Prolyl hydroxylase-1 negatively regulates IkappaB kinase-beta, giving insight into hypoxia-induced NFkappaB activity. Proc Natl Acad Sci U S A. 2006; 103(48): 18154–18159.'},{id:"B193",body:'Taylor CT, Cummins EP. The role of NF-kappaB in hypoxia-induced gene expression. Ann N Y Acad Sci. 2009; 1177: 178–184.'},{id:"B194",body:'Tafani M, Di Vito M, Frati A, Pellegrini L, De Santis E, et al. Pro-inflammatory gene expression in solid glioblastoma microenvironment and in hypoxic stem cells from human glioblastoma. J Neuroinflammation. 2011; 8: 32.'},{id:"B195",body:'Bar EE. Glioblastoma, cancer stem cells and hypoxia. Brain Pathol. 2011; 21(2): 119–129.'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Davide Schiffer",address:"davide.schiffer@unito.it",affiliation:'
Neuro-Bio-Oncology Research Center / Policlinico di Monza Foundation, Consorzio di Neuroscienze, University of Pavia, Vercelli, Italy
Dpt. Medical Sciences, University of Turin, Turin, Italy
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1. Introduction
Over the last year, COVID-19 has been the most widely spoken and researched disease worldwide and, inevitably, other existing pathologies were moved to the background. Amongst these, cardiovascular diseases (CVDs) should be highlighted because they still are by far the major contributor to global mortality [1]. CVDs are mainly caused by a blockage that prevents blood from flowing properly, known as atherosclerosis [2, 3]. This is a complex disease that affects medium and large size arteries and consists of a build-up of fatty deposits on the inner walls of the blood vessels, hampering the blood flow through the body [4]. The effect of atherosclerosis can be exacerbated by other diseases that affect blood circulation. Particularly, it has been shown that patients with COVID-19 are prone to develop blood clots on both arteries and veins [5], and thus atherosclerosis may be an even more important factor to global mortality.
Given the prevalence of this disease, atherosclerosis has been intensely studied through both cardiovascular modeling and experimental procedures, as reviewed elsewhere [6, 7, 8, 9]. Nevertheless, with the growing trend of greater computer power, computational approaches have become a valuable, cheaper, and efficient alternative for numerous researchers to predict blood flow behavior [10, 11, 12, 13].
There are two main approaches for simulating blood flow, computational fluid dynamics (CFD) and fluid-structure interaction (FSI). In the first one, the arterial wall is assumed as rigid, while in the second one, arteries are considered elastic and the interaction between the blood and the arterial walls are included in the simulation [14]. Although CFD has been widely applied in the study of blood flow under pathological conditions in virtue of lower computational cost [15, 16, 17, 18, 19, 20], since FSI provides a more realistic simulation of the human vasculature behavior, it has received increasing interest [21, 22]. Nonetheless, this approach requires significantly more computational effort, and the foremost difficulty is stability and convergence [23, 24].
In order to evaluate if the differences between CFD and FSI results are significant, some researchers have investigated and compared both. A commonly mentioned work was developed by Torii et al. [25]. The authors studied the effects of wall compliance on a stenotic patient-specific coronary artery and found noticeable differences in the instantaneous wall shear stress (WSS) produced by the FSI and rigid wall models. However, the effects of wall compliance on time-averaged WSS (TAWSS) and oscillatory shear index (OSI) were negligible. Malvè et al. [26] performed a similar study in the left coronary artery bifurcation and the conclusions regarding the WSS agreed with the previous study, but they observed significant differences in the TAWSS, especially on its spatial distribution. More recently, another similar study was performed on carotid bifurcation [10]. The authors found that the rigid model overestimates the flow velocity and WSS, but its influence on the TAWSS is minimal.
The differences between the CFD and FSI simulations have thus been the subject of several studies, however, as demonstrated, there is still a debate as to whether it is really necessary to use the most realistic approach, namely in computing WSS dependent variables, and sometimes the findings are contradictory. In this regard, this work presents the comparison of the results of both CFD and FSI simulations in an idealized stenotic coronary artery, with a degree of stenosis of 50%.
2. Methods
The first step necessary to study blood flow consisted in obtaining the three-dimensional geometry of the lumen of an idealized coronary artery as depicted in Figure 1. This geometry was previously adopted in other works by these authors [27, 28].
Figure 1.
Geometry and mesh of the coronary artery for both solid and fluid domain with 50% of stenosis.
In the construction of the solid domain, a thickness of 0.8 mm was considered, according to an in vivo study [29].
Moreover, the fluid domain and the solid domain were discretized in 428,800 and 15,480 hexahedral elements, respectively, making a total of 444,280 elements for the FSI simulations. To ensure the quality of the mesh, the skewness and orthogonal quality were evaluated. The average skewness and orthogonal quality were approximately 8.3 e−2 and 0.98, respectively. These parameters prove that the mesh is reliable for the study presented [30] and it is worth mentioning that a previous mesh study was carried out for CFD simulations [16], which was then adapted for this study.
2.1 Mathematical formulation
Blood flow is governed by the incompressible Navier-Stokes and the continuity equations as described in Eqs. (1) and (2),
∇·u=0E1
ρ∂u∂t+u·∇=−∇p+μ∇2uE2
where u is the velocity, p is the static pressure, ρ is the fluid density, and μ the dynamic viscosity [30, 31].
In the present study, blood was modeled as incompressible, laminar, and non-Newtonian fluid, having a density of 1060 kg/m3 [32]. Although it is commonly assumed as a Newtonian fluid, the ability of red blood cells to deform and aggregate makes blood a non-Newtonian fluid [33]. The well-known Carreau model was used to simulate the shear-thinning blood behavior, and it is defined by Eq. (3) [30, 31]:
μ=μ∞+μ0−μ∞1+λγ̇2n−12E3
where μ is the viscosity, μ∞=0.00345Pa∙s is the infinite shear viscosity, μ0=0.0560Pa·s is the blood viscosity at zero shear rate, γ̇ is the instantaneous shear rate, λ=3.313s is the time constant and n=0.3568 is the power-law index, as previously applied by [27].
The governing equation for the solid domain is the equilibrium equation (Eq. (4)) [30, 31]:
ρs∂2u∂t2−∇σ==ρsb→E4
where ρs is the solid density, u represents the solid displacements, b→, the body forces applied on the structure, and σ= is the Cauchy stress tensor. For an isotropic linear elastic solid, the stress tensor is represented by Eq. (5) [30, 31]:
σ==2μLε=+λLtrε=IE5
where λL and μL are the first and second Lamé parameters, respectively, ε=, the strain tensor, tr, the trace function, and I, the identity matrix. For compressible materials, Lamé parameters can be written as a function of Young’s modulus, E, and Poisson’s coefficient, v, as follows.
λL=vE1+v2v−1E6
μL=E21+vE7
The arterial wall was modeled as a linear elastic, incompressible, isotropic, and homogeneous material with Young’s modulus of 3.77MPa [34], a density of 1120kg/m3 [35], and a Poisson’s ratio of 0.49[21].
The FSI simulations were performed using the Arbitrary-Lagrangian-Eulerian (ALE) methodology for the fluid flow. Taking into account that the interface between the lumen and the wall deforms, the equations governing fluid flow have to be expressed in terms of the fluid variables relative to the mesh movement. The ALE-modified Navier-Stokes momentum equation for a viscous incompressible flow is described as follows in Eq. (8) [30, 31]:
ρf∂u∂t+u−ug·∇u=−∇p+μ∇2uE8
where ρf, p, u, and ug are the fluid density, the pressure, the fluid velocity, and the moving coordinate velocity, respectively. The term u−ug, in the ALE formulation, is added to the conventional Navier-Stokes equations to account for the movement of the mesh.
The displacement and equilibrium forces at the interface are represented by Eqs.(9) and (10) [30, 31]:
uf,Γ=us,ΓE9
tf,Γ→=ts,Γ→E10
where uf,Γ is the displacement of the fluid at the interface, us,Γ, the displacement of the solid at the interface, tf,Γ→, the forces of the fluid on the interface and ts,Γ→, the forces of the solid on the interface.
2.2 Boundary conditions
Regarding the boundary conditions used in this study, at the inlet, a physiologically accurate pulsatile velocity profile was set, which is depicted in Figure 2. At the outlet, a pressure of 80 mmHg was assumed [17, 36].
Figure 2.
Velocity profile implemented in CFD and FSI simulations.
The solid and fluid wall-boundaries were defined as a fluid-structure interface, and the inlet/outlet adjacent solid boundaries were fixed in all directions.
2.3 Numerical solution
For the CFD simulations, the Ansys Fluent software was used which applies the finite-volume discretization method. In this method, the fluid domain is divided into a finite number of control volumes, the conservation equations are applied to each control volume. Then, a system of algebraic equations for the variables is obtained. For the velocity-pressure coupling, the semi-implicit method for the pressure-linked equations (SIMPLE) scheme was used [37].
In FSI simulations, the same finite-volume method is applied in the fluid domain, and the computed forces in Fluent are transferred to the solid domain, through the interface. The finite element method (FEM) is used to solve the governing equations of the solid domain. Then, the computed displacements are transferred back to the fluid domain. This two-way coupling process was repeated until the difference of the displacements and forces for the last two iterations is below 1%. A time step of 0.01 s was used for every simulation.
2.4 Hemodynamic parameters
The formation of atherosclerotic lesions has been widely associated with hemodynamic parameters, such as the wall shear stress (WSS) and its indices, time-averaged wall shear stress (TAWSS), and oscillatory shear index (OSI) [38, 39]. These have been very useful to predict and estimate disturbed flow conditions and the development of local atherosclerotic plaques [27, 40].
The spatial WSS, τw, is calculated by Eq. (11), being γ., the deformation rate, and μ the dynamic viscosity.
τw=μ∂u∂y=μγ.E11
The TAWSS index allows obtaining an average temporal evaluation of the WSS exerted during a cardiac cycle (T) [40]. This is calculated by Eq. (12):
TAWSS=1T∫0TWSSdtE12
The OSI index is the temporal fluctuation of low and high average shear stress during a cardiac cycle (T) and it is calculated by applying Eq. (13):
OSI=121−∫0TWSSdt∫0TWSSdtE13
The formulation developed in this section describes the models that couple the fluid dynamics and the mechanical interaction with the arteries’ wall which is treated as a deformable material. This methodology enables the computation of critical parameters for understanding the hemodynamics in the presence of a stenosis, such as the WSS. The advantages of this method are made evident by comparing it with a simple CFD analysis as detailed in the following section.
3. Results and discussion
3.1 Velocity profiles along the cardiac cycle
Figure 3 illustrates the velocity profiles measured along the center of the artery for both CFD and FSI simulations, in two different phases of the cardiac cycle: systole (0.4 s) and diastole (0.58 s).
Figure 3.
Axial flow velocity profiles at the center line drawn across the artery at (a) systole and (b) diastole.
Looking at the results in Figure 3, it can be observed that the estimated velocity profiles are similar for both CFD and FSI modeling. Moreover, as expected, during diastole (Figure 3b) the velocities measured are higher than during systole (Figure 3a). This happens because, during systole, the coronary arteries are compressed by the contraction of the myocardium, and so, most of the coronary flow occurs during diastole, where the flow increases. In addition, the maximum velocities in both cases are measured in the stenosis throat (x = 0 mm) as observed by other investigations [15, 27].
It is also noted that the velocity is overestimated in the CFD model, particularly at and upstream of the stenosis throat. This is expected because the deformation of the elastic model provides a larger volume for the blood flow through and, as the inflow rate is equal for both models, naturally, the velocities will be higher when a rigid wall is considered. Downstream of the stenosis, at an x coordinate of approximately 10 mm, the velocity is higher for the FSI case, which indicates that the pressure drop at the stenosis creates zones of low pressure, which contracts the artery, and forces the flow to accelerate. In this case, it is thus observed the effect of artery compliance, which allows a steadier supply of flow despite the variable nature of the cardiac cycle.
3.2 Velocity streamlines along the cardiac cycle
After evaluating the velocity profiles, velocity streamlines were created to better visualize and understand how blood flow behaves, as shown in Figure 4.
Figure 4.
Velocity streamlines obtained during systole and diastole for both CFD and FSI simulations.
The results indicate the existence of fluid recirculation downstream of the stenosis for both CFD and FSI models, but the recirculation zones are longer in FSI simulations, and this is due to the considerable vessel expansion driven by the pulsatile blood flow.
3.3 WSS and its indices
The magnitude of the WSS predicted by FSI and rigid model along the artery wall for both systole and diastole are compared in Figure 5. In this case, it is observed that the differences between compliant and rigid-wall models are remarkable. In CFD simulations, WSS values estimated in the stenosis throat are approximately twice of those obtained with FSI simulations. This indicates that the WSS distributions were substantially affected by arterial wall compliance, which is in agreement with previous research [25, 26, 41].
Figure 5.
Wall shear stress profiles obtained along artery wall at (a) systole and (b) diastole.
Taking into account that WSS-related hemodynamic parameters, such as OSI and TAWSS, play an important role in atherogenesis, these were also evaluated. Figure 6 depicts the TWASS profiles obtained in both CFD and FSI simulations.
Figure 6.
Time-averaged wall shear stress profiles obtained in CFD and FSI simulations.
The results evidence high values of TAWSS at the stenosis throat, due to flow acceleration and high-velocity gradient near the wall, and, as expected the TAWSS is overestimated by the CFD model as previously explained for WSS distributions. In spite of these observations, the overall TAWSS distributions for the FSI and rigid-wall cases are identical.
Regarding the OSI profiles depicted in Figure 7, it can be observed that for both CFD and FSI simulations, the maximum values (≈0.5) are obtained downstream of the stenosis, which indicates the presence of unsteady and oscillatory flow, commonly associated with higher susceptibility to atherosclerotic plaque development [27, 40]. Nonetheless, although the OSI profiles for the two cases look similar and unaffected by wall distensibility, in the distal region, OSI values for the FSI case are slightly higher than for the rigid wall [25]. These differences may be due to the occurrence of longer recirculation areas with the elastic model.
Figure 7.
Oscillatory shear index obtained in CFD and FSI simulations.
In general, it was found that for both rigid and compliant models the post-stenotic region presents lower TAWSS and higher OSI values, which constitute risk factors for the incidence and abnormal plaque formation [16, 27].
3.4 Displacement
Figure 8 represents the arterial wall displacement contours of the FSI simulations during systole and diastole.
Figure 8.
Displacement profile at the arterial wall obtained in CFD and FSI simulations.
In the first place, it is noted that the displacements are similar for both cycle phases. This is a consequence of the assumption of the constant outlet pressure, which is a limitation of this work. In this case, the deformations are slightly bigger in the region upstream of the stenosis, and as there is a pressure drop in the throat, the displacements are somewhat lower in the downstream region.
It is also noteworthy that the displacements of the arterial wall are approximately 1.5–2% of the vessel thickness, which is in agreement with the hypothesis that arteries become stiffer with the development of atherosclerosis. Despite this order of magnitude of the displacement values, these still bring considerable differences in the calculations of the velocity and WSS-related variables.
4. Conclusions
The study of blood flow in stenotic arteries has been made mainly assuming the artery’s wall as rigid, however, in reality, they are naturally elastic. Given that there are some inconsistencies in the literature regarding the comparison between CFD and FSI simulations, in the present work, a comparative study between FSI and CFD modeling was performed in order to investigate the influence of artery compliance on stenotic coronary artery hemodynamics and wall shear stress distribution. The main conclusions obtained from this work are:
Comparing the rigid and compliant models, the velocities predicted differ slightly.
The difference between WSS profiles was remarkable. The CFD simulations overestimate the WSS values, which consequently indicates that when a more realistic WSS estimation is needed, is essential to consider the effect of the atrial wall on blood flow.
Insignificant differences were verified in the TAWSS and OSI measurements.
Acknowledgments
This work has been supported by FCT—Fundação para a Ciência Tecnologia within the R&D Units Project Scope: UIDB/00319/2020, UIDB/04077/2020, UIDB/04436/2020, and NORTE-01-0145-FEDER-030171 (PTDC/EMD-EMD/30171/2017) and EXPL/EME-EME/0732/2021, NORTE-01-0145-FEDER-029394 funded by COMPETE2020, NORTE 2020, PORTUGAL 2020. Violeta Carvalho, Diogo Lopes and João Silva would like to express their gratitude for the support given by FCT through the PhD Grants SFRH/UI/BD/151028/2021, SFRH/BD/144431/2019, and SFRH/BD/130588/2017, respectively.
Conflict of interest
The authors declare no conflict of interest.
\n',keywords:"atherosclerosis, blood flow, coronary arteries, fluid-structure interaction, computational fluid dynamics",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/80150.pdf",chapterXML:"https://mts.intechopen.com/source/xml/80150.xml",downloadPdfUrl:"/chapter/pdf-download/80150",previewPdfUrl:"/chapter/pdf-preview/80150",totalDownloads:94,totalViews:0,totalCrossrefCites:0,dateSubmitted:"April 26th 2021",dateReviewed:"December 20th 2021",datePrePublished:"January 24th 2022",datePublished:null,dateFinished:"January 20th 2022",readingETA:"0",abstract:"Cardiovascular diseases are amongst the main causes of death worldwide, and the main underlying pathological process is atherosclerosis. Over the years, fatty materials are accumulated in the arterial which consequently hinders the blood flow. Due to the great mortality rate of this disease, hemodynamic studies within stenotic arteries have been of great clinical interest, and computational methods have played an important role. Commonly, computational fluid dynamics methods, where only the blood flow behavior is considered, however, the study of both blood and artery walls’ interaction is of foremost importance. In this regard, in the present study, both computational fluid dynamics and fluid-structure interaction modeling analysis were performed in order to evaluate if the arterial wall compliance affects considerably the hemodynamic results obtained in idealized stenotic coronary models. From the overall results, it was observed that the influence of wall compliance was noteworthy on wall shear stress distribution, but its effect on the time-averaged wall shear stress and on the oscillatory shear index was minor.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/80150",risUrl:"/chapter/ris/80150",signatures:"Violeta Carvalho, Diogo Lopes, João Silva, Hélder Puga, Rui A. Lima, José Carlos Teixeira and Senhorinha Teixeira",book:{id:"10695",type:"book",title:"Computational Fluid Dynamics",subtitle:null,fullTitle:"Computational Fluid Dynamics",slug:null,publishedDate:null,bookSignature:"Dr. Suvanjan Bhattacharyya",coverURL:"https://cdn.intechopen.com/books/images_new/10695.jpg",licenceType:"CC BY 3.0",editedByType:null,isbn:"978-1-83968-248-3",printIsbn:"978-1-83968-247-6",pdfIsbn:"978-1-83968-321-3",isAvailableForWebshopOrdering:!0,editors:[{id:"233630",title:"Dr.",name:"Suvanjan",middleName:null,surname:"Bhattacharyya",slug:"suvanjan-bhattacharyya",fullName:"Suvanjan Bhattacharyya"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:null,sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. 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Relationship between endothelial wall shear stress and high-risk atherosclerotic plaque characteristics for identification of coronary lesions that cause ischemia: A direct comparison with fractional flow reserve. Journal of the American Heart Association. 2016;5(12):1-10. DOI: 10.1161/JAHA.116.004186'},{id:"B39",body:'Ku D. Blood flow in arteries. Annual Review of Fluid Mechanics. 1997;29:399-434. DOI: 10.1146/annurev.fluid.29.1.399'},{id:"B40",body:'Pinto SIS, Campos JBLM. Numerical study of wall shear stress-based descriptors in the human left coronary artery. Computer Methods in Biomechanics and Biomedical Engineering. 2016;19(13):1443-1455. DOI: 10.1080/10255842.2016.1149575'},{id:"B41",body:'Dong J, Sun Z, Inthavong K, Tu J. Fluid–structure interaction analysis of the left coronary artery with variable angulation. Computer Methods in Biomechanics and Biomedical Engineering. 2015;18(14):1500-1508. DOI: 10.1080/10255842.2014.921682'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Violeta Carvalho",address:"violeta.carvalho@dem.uminho.pt",affiliation:'
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Dr. Camarillo ́s research is directed to the identification of microRNAs, lncRNAs and proteins deregulated in breast, lung, ovarian and colorectal cancers using omics approaches. We are interested in the identification of novel therapeutic targets, and the elucidation of molecular mechanisms of tumorigenesis. We are also working on Nutrigenomics evaluating the chemopreventive role and impact in methylome/microRNOme of dietary polyphenols in cancer cells. Also we are working in miRNAs host response to E. histolytica. Dr. Camarillo is the recipient of Lola e Iggo Flisser-OUIS-UNAM award, XIX National Biomedical Research Prize, Capital City Heberto Castillo Award, and Breast Cancer Research Bristol Award. 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This is not only worrying for critical tasks such as those performed by surgical, or military robots but also for household robots such as vacuum cleaners or for teleconference robots compromise privacy and safety of their owners. What will happen if these robots are hacked? This study presents a survey on the cybersecurity attacks associated with service robots, and as a result, a taxonomy that classifies the risks faced by users when using service robots, distinguishing between security and safety threads, is presented. We also present the robot software development phase as one the most relevant ones for the security of robots.",book:{id:"6003",slug:"robotics-legal-ethical-and-socioeconomic-impacts",title:"Robotics",fullTitle:"Robotics - Legal, Ethical and Socioeconomic Impacts"},signatures:"Francisco J. Rodríguez Lera, Camino Fernández Llamas, Ángel\nManuel Guerrero and Vicente Matellán Olivera",authors:[{id:"124522",title:"Dr.",name:"Vicente",middleName:null,surname:"Matellan",slug:"vicente-matellan",fullName:"Vicente Matellan"},{id:"211294",title:"Prof.",name:"Camino",middleName:null,surname:"Fernández-Llamas",slug:"camino-fernandez-llamas",fullName:"Camino Fernández-Llamas"},{id:"211295",title:"MSc.",name:"Ángel Manuel",middleName:null,surname:"Guerrero-Higueras",slug:"angel-manuel-guerrero-higueras",fullName:"Ángel Manuel Guerrero-Higueras"},{id:"211296",title:"Dr.",name:"Francisco Javier",middleName:null,surname:"Rodríguez-Lera",slug:"francisco-javier-rodriguez-lera",fullName:"Francisco Javier Rodríguez-Lera"}]},{id:"53439",doi:"10.5772/65765",title:"Rethinking Autonomy and Consent in Healthcare Ethics",slug:"rethinking-autonomy-and-consent-in-healthcare-ethics",totalDownloads:2503,totalCrossrefCites:5,totalDimensionsCites:5,abstract:"In healthcare ethics, autonomy has arguably become the ‘principal principle’. As a principle that can be readily turned into a process, the giving of ‘informed consent’ by a patient has become the surrogate measure of whether medical interventions are ethically acceptable. While ‘informed consent’ processes in medical care are presumed to be robust, research confirms that most patients do not adequately understand the medical purpose, limitations or potential ethical implications of the many medical procedures to which they consent. In this chapter, we argue that the founding tenets of autonomy and informed consent which presume people to be detached autonomous individuals who act rationally from self‐interest does not authentically capture the essence of human ‘being’. Furthermore, such assumptions do not acknowledge the deeply relational and embedded reality of the human condition which inevitably shape decision making. We contend that within healthcare organisations, the current processes of operationalising informed consent predominantly serve legal and administrative needs, while unwittingly disempowering patients, and silencing key aspects of their experience of illness. Rather than rational self‐interest, we argue that vulnerability, interdependence and trust lie at the core of ethical decision making in healthcare. Re‐framing autonomy in a way that deliberately considers the unique moral frameworks, relationships, and cultures of individuals can provide a more ethically sensitive and respectful basis for decision making in healthcare. As interdependence is an integral consideration in decision making, it must be deliberately acknowledged and incorporated into healthcare practices. Embracing a narrative approach within a shared decision making framework allows the vulnerabilities, fears and aspirations of stakeholders to be heard, creating a more effective and authentic way to meet the ethical goal of respecting those who seek care.",book:{id:"5418",slug:"bioethics-medical-ethical-and-legal-perspectives",title:"Bioethics",fullTitle:"Bioethics - Medical, Ethical and Legal Perspectives"},signatures:"Eleanor Milligan and Jennifer Jones",authors:[{id:"187831",title:"Prof.",name:"Eleanor",middleName:null,surname:"Milligan",slug:"eleanor-milligan",fullName:"Eleanor Milligan"}]},{id:"52563",doi:"10.5772/65089",title:"Medical Ethics and Bedside Rationing in Low‐Income Countries: Challenges and Opportunities",slug:"medical-ethics-and-bedside-rationing-in-low-income-countries-challenges-and-opportunities",totalDownloads:2102,totalCrossrefCites:0,totalDimensionsCites:3,abstract:"There’s evidence that implementing the four medical ethics principles may be challenging especially in low income country contexts with extreme resource scarcity and limited capacity to facilitate deliberations on the different ethical dilemmas. These challenges can partly be explained by the social, economic, and political contexts in which the decisions are made, as well as the limited time, training and guidance to facilitate ethical decision making. Based on current literature, and using the example of bedside rationing; this chapter synthesizes the challenges clinicians face when operationalizing the four principle; identifying the opportunities to address them. We suggest that clinicians’ ability to implement the four principles are constrained by meso‐ and macro‐level decision making as well as their lack of training, explicit guidelines, and peer support. To ameliorate this situation, current efforts to strengthen the clinicians’ capacity to make ethical decisions should be complimented with developing of context relevant guidelines for ethical clinical decision making. The renewed global commitment to the sustainable development goals and universal healthcare coverage should be recognized as an opportunity to leverage resources and champion the integration of equity and justice as a core value in resource allocation at the bedside, meso-, macro- and global levels.",book:{id:"5418",slug:"bioethics-medical-ethical-and-legal-perspectives",title:"Bioethics",fullTitle:"Bioethics - Medical, Ethical and Legal Perspectives"},signatures:"Lydia Kapiriri",authors:[{id:"189068",title:"Associate Prof.",name:"Lydia",middleName:null,surname:"Kapiriri",slug:"lydia-kapiriri",fullName:"Lydia Kapiriri"}]},{id:"56170",doi:"10.5772/intechopen.69768",title:"Ethic Reflections about Service Robotics, from Human Protection to Enhancement: Case Study on Cultural Heritage",slug:"ethic-reflections-about-service-robotics-from-human-protection-to-enhancement-case-study-on-cultural",totalDownloads:1601,totalCrossrefCites:0,totalDimensionsCites:2,abstract:"In a vision of future implications of human‐robot interactions, it is vital to investigate how computer ethics and specifically roboethics could help to enhance human’s life. In this chapter, the role of design expertise will be emphasized by setting multiple disciplines into a constructive dialogue. The reflections will take into consideration different themes, such as acceptability and aesthetics, but above all the ability to generate value and meaning in different contexts. These contexts could find a description in the concept of human enhancement, connected through each other with the skills of the design research. The methodology of the design research will find applicability in the case study of Virgil, where a roboethic approach is contextualized into a cultural heritage field. In this field, it is shown how the ethical approach will bring a benefit to local communities, but at large to any social and cultural strategies involved in the stakeholders’ network.",book:{id:"6003",slug:"robotics-legal-ethical-and-socioeconomic-impacts",title:"Robotics",fullTitle:"Robotics - Legal, Ethical and Socioeconomic Impacts"},signatures:"Luca Giuliano, Maria Luce Lupetti, Sara Khan and Claudio Germak",authors:[{id:"203858",title:"Dr.",name:"Claudio",middleName:null,surname:"Germak",slug:"claudio-germak",fullName:"Claudio Germak"},{id:"203861",title:"Dr.",name:"Luca",middleName:null,surname:"Giuliano",slug:"luca-giuliano",fullName:"Luca Giuliano"},{id:"203862",title:"Dr.",name:"Maria Luce",middleName:null,surname:"Lupetti",slug:"maria-luce-lupetti",fullName:"Maria Luce Lupetti"},{id:"211018",title:"Dr.",name:"Sara",middleName:null,surname:"Khan",slug:"sara-khan",fullName:"Sara Khan"}]},{id:"52100",doi:"10.5772/64947",title:"Ethical Publications in Medical Research",slug:"ethical-publications-in-medical-research",totalDownloads:1868,totalCrossrefCites:2,totalDimensionsCites:2,abstract:"Ethics in medical sciences research may not always translate into ethical publications. Unfortunately due to lack of regulatory bodies, publication misconduct is now a global menace for the scientific community. Publication misconducts are not only restricted to research fraud or data manipulations alone but also seriously include plagiarism, duplicate publications especially on figures and tables, authorship disputes and conflict of interests. As global scientific research is expanding particularly in the field of health sciences hence possibilities of more rise of unethical practices from research to publications are very high, authors suggest a strong peer-reviewing system, use latest technological support, strong publication ethics policies, active monitoring, protection of whistle blowers and more liaisons between journals and research institutions or universities possibly to prevent publication misconduct effectively. This chapter discusses how medical publications might have abused various ethical norms not only while conducting research but also during the publication process. The review also discusses the possible preventive measures against unethical practices of research publications.",book:{id:"5418",slug:"bioethics-medical-ethical-and-legal-perspectives",title:"Bioethics",fullTitle:"Bioethics - Medical, Ethical and Legal Perspectives"},signatures:"Kusal K. Das and Mallanagoud S. Biradar",authors:[{id:"187859",title:"Prof.",name:"Kusal",middleName:"K.",surname:"Das",slug:"kusal-das",fullName:"Kusal Das"},{id:"188854",title:"Prof.",name:"M.S.",middleName:null,surname:"Biradar",slug:"m.s.-biradar",fullName:"M.S. Biradar"}]}],mostDownloadedChaptersLast30Days:[{id:"52101",title:"Ethical Issues in Organ Procurement and Transplantation",slug:"ethical-issues-in-organ-procurement-and-transplantation",totalDownloads:4749,totalCrossrefCites:1,totalDimensionsCites:1,abstract:"The Ciba Foundation held the first international, interdisciplinary conference on ethical and legal issues in transplantation in March 1966. Many of the ethical issues discussed at that conference remain with us today. Organ procurement and transplantation have forced the medical community and society at large to ask such fundamental questions as when are we dead, how can death be declared so that any life‐support measures can be discontinued? Is it ethical to remove an organ or part of an organ from a living person? Since there is such a shortage of organ and people on transplant waiting lists die for lack of an organ, what types of incentives, if any, can be used to increase the organ supply? Transplant centers face additional ethical issues. How can a limited supply of organs be fairly allocated to a large number of patients on the waiting list? Are the methods of putting patients on the waiting list appropriate? Transplant centers are regulated by a variety of governmental organizations. These organizations may have performance criteria. Do these performance criteria lead transplant centers to modify which organs they will accept or which patients they will list? As long as a shortage of organs remains, these ethical issues are likely to persist.",book:{id:"5418",slug:"bioethics-medical-ethical-and-legal-perspectives",title:"Bioethics",fullTitle:"Bioethics - Medical, Ethical and Legal Perspectives"},signatures:"Richard J. Howard and Danielle L. Cornell",authors:[{id:"188201",title:"M.D.",name:"Richard",middleName:null,surname:"Howard",slug:"richard-howard",fullName:"Richard Howard"},{id:"194143",title:"Ms.",name:"Danielle",middleName:null,surname:"Cornell",slug:"danielle-cornell",fullName:"Danielle Cornell"}]},{id:"56170",title:"Ethic Reflections about Service Robotics, from Human Protection to Enhancement: Case Study on Cultural Heritage",slug:"ethic-reflections-about-service-robotics-from-human-protection-to-enhancement-case-study-on-cultural",totalDownloads:1603,totalCrossrefCites:0,totalDimensionsCites:2,abstract:"In a vision of future implications of human‐robot interactions, it is vital to investigate how computer ethics and specifically roboethics could help to enhance human’s life. In this chapter, the role of design expertise will be emphasized by setting multiple disciplines into a constructive dialogue. The reflections will take into consideration different themes, such as acceptability and aesthetics, but above all the ability to generate value and meaning in different contexts. These contexts could find a description in the concept of human enhancement, connected through each other with the skills of the design research. The methodology of the design research will find applicability in the case study of Virgil, where a roboethic approach is contextualized into a cultural heritage field. In this field, it is shown how the ethical approach will bring a benefit to local communities, but at large to any social and cultural strategies involved in the stakeholders’ network.",book:{id:"6003",slug:"robotics-legal-ethical-and-socioeconomic-impacts",title:"Robotics",fullTitle:"Robotics - Legal, Ethical and Socioeconomic Impacts"},signatures:"Luca Giuliano, Maria Luce Lupetti, Sara Khan and Claudio Germak",authors:[{id:"203858",title:"Dr.",name:"Claudio",middleName:null,surname:"Germak",slug:"claudio-germak",fullName:"Claudio Germak"},{id:"203861",title:"Dr.",name:"Luca",middleName:null,surname:"Giuliano",slug:"luca-giuliano",fullName:"Luca Giuliano"},{id:"203862",title:"Dr.",name:"Maria Luce",middleName:null,surname:"Lupetti",slug:"maria-luce-lupetti",fullName:"Maria Luce Lupetti"},{id:"211018",title:"Dr.",name:"Sara",middleName:null,surname:"Khan",slug:"sara-khan",fullName:"Sara Khan"}]},{id:"52100",title:"Ethical Publications in Medical Research",slug:"ethical-publications-in-medical-research",totalDownloads:1871,totalCrossrefCites:2,totalDimensionsCites:2,abstract:"Ethics in medical sciences research may not always translate into ethical publications. Unfortunately due to lack of regulatory bodies, publication misconduct is now a global menace for the scientific community. Publication misconducts are not only restricted to research fraud or data manipulations alone but also seriously include plagiarism, duplicate publications especially on figures and tables, authorship disputes and conflict of interests. As global scientific research is expanding particularly in the field of health sciences hence possibilities of more rise of unethical practices from research to publications are very high, authors suggest a strong peer-reviewing system, use latest technological support, strong publication ethics policies, active monitoring, protection of whistle blowers and more liaisons between journals and research institutions or universities possibly to prevent publication misconduct effectively. This chapter discusses how medical publications might have abused various ethical norms not only while conducting research but also during the publication process. The review also discusses the possible preventive measures against unethical practices of research publications.",book:{id:"5418",slug:"bioethics-medical-ethical-and-legal-perspectives",title:"Bioethics",fullTitle:"Bioethics - Medical, Ethical and Legal Perspectives"},signatures:"Kusal K. Das and Mallanagoud S. Biradar",authors:[{id:"187859",title:"Prof.",name:"Kusal",middleName:"K.",surname:"Das",slug:"kusal-das",fullName:"Kusal Das"},{id:"188854",title:"Prof.",name:"M.S.",middleName:null,surname:"Biradar",slug:"m.s.-biradar",fullName:"M.S. Biradar"}]},{id:"52301",title:"Pharmacy Ethics and the Spirit of Capitalism: A Review of the Literature",slug:"pharmacy-ethics-and-the-spirit-of-capitalism-a-review-of-the-literature",totalDownloads:2260,totalCrossrefCites:0,totalDimensionsCites:2,abstract:"This chapter explores the issue of the conflict (real or potential) between the ethical imperatives that should guide the pharmacist in the typical practicing of the profession (i.e. within a pharmacy) and the economic constraints derived from the business dimension of the pharmacy. Marrying service and business in a single profession, pharmacy is supposed to balance harmoniously its two sides, if not to subject business demands to the higher societal, ethical requirements. However, such a balancing exercise is rather like dancing on a rope, and ethics may be trumped by economics, a phenomenon deplored sometimes by pharmacy academics or hospital pharmacists, and by a part of community pharmacists as well. Economics may prevail over ethics in rough forms such as selling health risk products (as it was in the past for tobacco or alcohol) or in more elusive ones, such as longer work hours and shorter counselling times, promoting or dispensing needless or ineffective products (food supplements, cosmetics, etc.), silently refusing to provide or recommend lower cost generics, etc. Ethical research in the field of pharmacy has generally been scarce, and numerous knowledge gaps remain to be filled by future investigations.",book:{id:"5418",slug:"bioethics-medical-ethical-and-legal-perspectives",title:"Bioethics",fullTitle:"Bioethics - Medical, Ethical and Legal Perspectives"},signatures:"Robert Ancuceanu and Ioana-Laura Bogdan",authors:[{id:"189717",title:"Associate Prof.",name:"Robert",middleName:null,surname:"Ancuceanu",slug:"robert-ancuceanu",fullName:"Robert Ancuceanu"}]},{id:"53299",title:"‘Assisted Dying’: A View of the Legal, Social, Ethical and Clinical Perspectives",slug:"-assisted-dying-a-view-of-the-legal-social-ethical-and-clinical-perspectives",totalDownloads:1672,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"Discussion of legislation of physician-assisted suicide and euthanasia, often euphemistically called ‘assisted dying’, frequently focuses on individual cases promoted by campaigners as the reason that the law to licence doctors to supply lethal drugs to patients requesting them should change under certain conditions. But such legislation has wider consequences that simply for a handful of cases, as the relentlessly increasing numbers of such deaths have shown.",book:{id:"5418",slug:"bioethics-medical-ethical-and-legal-perspectives",title:"Bioethics",fullTitle:"Bioethics - Medical, Ethical and Legal Perspectives"},signatures:"Ilora Gillian Finlay of Llandaff",authors:[{id:"191502",title:"Prof.",name:"Ilora Gillian",middleName:null,surname:"Finlay of Llandaff",slug:"ilora-gillian-finlay-of-llandaff",fullName:"Ilora Gillian Finlay of Llandaff"}]}],onlineFirstChaptersFilter:{topicId:"267",limit:6,offset:0},onlineFirstChaptersCollection:[],onlineFirstChaptersTotal:0},preDownload:{success:null,errors:{}},subscriptionForm:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[],offset:8,limit:8,total:0},allSeries:{pteSeriesList:[{id:"14",title:"Artificial Intelligence",numberOfPublishedBooks:9,numberOfPublishedChapters:87,numberOfOpenTopics:6,numberOfUpcomingTopics:0,issn:"2633-1403",doi:"10.5772/intechopen.79920",isOpenForSubmission:!0},{id:"7",title:"Biomedical Engineering",numberOfPublishedBooks:12,numberOfPublishedChapters:98,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2631-5343",doi:"10.5772/intechopen.71985",isOpenForSubmission:!0}],lsSeriesList:[{id:"11",title:"Biochemistry",numberOfPublishedBooks:27,numberOfPublishedChapters:287,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2632-0983",doi:"10.5772/intechopen.72877",isOpenForSubmission:!0},{id:"25",title:"Environmental Sciences",numberOfPublishedBooks:1,numberOfPublishedChapters:9,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2754-6713",doi:"10.5772/intechopen.100362",isOpenForSubmission:!0},{id:"10",title:"Physiology",numberOfPublishedBooks:11,numberOfPublishedChapters:139,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-8261",doi:"10.5772/intechopen.72796",isOpenForSubmission:!0}],hsSeriesList:[{id:"3",title:"Dentistry",numberOfPublishedBooks:8,numberOfPublishedChapters:129,numberOfOpenTopics:0,numberOfUpcomingTopics:2,issn:"2631-6218",doi:"10.5772/intechopen.71199",isOpenForSubmission:!1},{id:"6",title:"Infectious Diseases",numberOfPublishedBooks:13,numberOfPublishedChapters:107,numberOfOpenTopics:3,numberOfUpcomingTopics:1,issn:"2631-6188",doi:"10.5772/intechopen.71852",isOpenForSubmission:!0},{id:"13",title:"Veterinary Medicine and Science",numberOfPublishedBooks:10,numberOfPublishedChapters:103,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2632-0517",doi:"10.5772/intechopen.73681",isOpenForSubmission:!0}],sshSeriesList:[{id:"22",title:"Business, Management and Economics",numberOfPublishedBooks:1,numberOfPublishedChapters:12,numberOfOpenTopics:2,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:0,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:null,doi:"10.5772/intechopen.100360",isOpenForSubmission:!1},{id:"24",title:"Sustainable Development",numberOfPublishedBooks:0,numberOfPublishedChapters:10,numberOfOpenTopics:4,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100361",isOpenForSubmission:!0}],testimonialsList:[{id:"6",text:"It is great to work with the IntechOpen to produce a worthwhile collection of research that also becomes a great educational resource and guide for future research endeavors.",author:{id:"259298",name:"Edward",surname:"Narayan",institutionString:null,profilePictureURL:"https://mts.intechopen.com/storage/users/259298/images/system/259298.jpeg",slug:"edward-narayan",institution:{id:"3",name:"University of Queensland",country:{id:null,name:"Australia"}}}},{id:"13",text:"The collaboration with and support of the technical staff of IntechOpen is fantastic. 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Dr. Blumenberg’s research is focused on the epidermis, expression of keratin genes, transcription profiling, keratinocyte differentiation, inflammatory diseases and cancers, and most recently the effects of the microbiome on the skin. He has published more than 100 peer-reviewed research articles and graduated numerous Ph.D. and postdoctoral students.",institutionString:null,institution:{name:"New York University Langone Medical Center",institutionURL:null,country:{name:"United States of America"}}},editorTwo:null,editorThree:null},subseries:{paginationCount:3,paginationItems:[{id:"7",title:"Bioinformatics and Medical Informatics",coverUrl:"https://cdn.intechopen.com/series_topics/covers/7.jpg",isOpenForSubmission:!0,editor:{id:"351533",title:"Dr.",name:"Slawomir",middleName:null,surname:"Wilczynski",slug:"slawomir-wilczynski",fullName:"Slawomir Wilczynski",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000035U1loQAC/Profile_Picture_1630074514792",biography:"Professor Sławomir Wilczyński, Head of the Chair of Department of Basic Biomedical Sciences, Faculty of Pharmaceutical Sciences, Medical University of Silesia in Katowice, Poland. His research interests are focused on modern imaging methods used in medicine and pharmacy, including in particular hyperspectral imaging, dynamic thermovision analysis, high-resolution ultrasound, as well as other techniques such as EPR, NMR and hemispheric directional reflectance. Author of over 100 scientific works, patents and industrial designs. Expert of the Polish National Center for Research and Development, Member of the Investment Committee in the Bridge Alfa NCBiR program, expert of the Polish Ministry of Funds and Regional Policy, Polish Medical Research Agency. Editor-in-chief of the journal in the field of aesthetic medicine and dermatology - Aesthetica.",institutionString:null,institution:{name:"Medical University of Silesia",institutionURL:null,country:{name:"Poland"}}},editorTwo:null,editorThree:null},{id:"8",title:"Bioinspired Technology and Biomechanics",coverUrl:"https://cdn.intechopen.com/series_topics/covers/8.jpg",isOpenForSubmission:!0,editor:{id:"144937",title:"Prof.",name:"Adriano",middleName:"De Oliveira",surname:"Andrade",slug:"adriano-andrade",fullName:"Adriano Andrade",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRC8QQAW/Profile_Picture_1625219101815",biography:"Dr. Adriano de Oliveira Andrade graduated in Electrical Engineering at the Federal University of Goiás (Brazil) in 1997. He received his MSc and PhD in Biomedical Engineering respectively from the Federal University of Uberlândia (UFU, Brazil) in 2000 and from the University of Reading (UK) in 2005. 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Science",numberOfPublishedBooks:10,numberOfPublishedChapters:103,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2632-0517",doi:"10.5772/intechopen.73681",isOpenForSubmission:!0}],sshSeriesList:[{id:"22",title:"Business, Management and Economics",numberOfPublishedBooks:1,numberOfPublishedChapters:12,numberOfOpenTopics:2,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:0,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:null,doi:"10.5772/intechopen.100360",isOpenForSubmission:!1},{id:"24",title:"Sustainable Development",numberOfPublishedBooks:0,numberOfPublishedChapters:10,numberOfOpenTopics:4,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100361",isOpenForSubmission:!0}],subseriesList:[{id:"4",title:"Fungal Infectious Diseases",scope:"Fungi are ubiquitous and there are almost no non-pathogenic fungi. Fungal infectious illness prevalence and prognosis are determined by the exposure between fungi and host, host immunological state, fungal virulence, and early and accurate diagnosis and treatment. \r\nPatients with both congenital and acquired immunodeficiency are more likely to be infected with opportunistic mycosis. Fungal infectious disease outbreaks are common during the post- disaster rebuilding era, which is characterised by high population density, migration, and poor health and medical conditions.\r\nSystemic or local fungal infection is mainly associated with the fungi directly inhaled or inoculated in the environment during the disaster. The most common fungal infection pathways are human to human (anthropophilic), animal to human (zoophilic), and environment to human (soilophile). Diseases are common as a result of widespread exposure to pathogenic fungus dispersed into the environment. \r\nFungi that are both common and emerging are intertwined. In Southeast Asia, for example, Talaromyces marneffei is an important pathogenic thermally dimorphic fungus that causes systemic mycosis. Widespread fungal infections with complicated and variable clinical manifestations, such as Candida auris infection resistant to several antifungal medicines, Covid-19 associated with Trichoderma, and terbinafine resistant dermatophytosis in India, are among the most serious disorders. \r\nInappropriate local or systemic use of glucocorticoids, as well as their immunosuppressive effects, may lead to changes in fungal infection spectrum and clinical characteristics. Hematogenous candidiasis is a worrisome issue that affects people all over the world, particularly ICU patients. CARD9 deficiency and fungal infection have been major issues in recent years. Invasive aspergillosis is associated with a significant death rate. Special attention should be given to endemic fungal infections, identification of important clinical fungal infections advanced in yeasts, filamentous fungal infections, skin mycobiome and fungal genomes, and immunity to fungal infections.\r\nIn addition, endemic fungal diseases or uncommon fungal infections caused by Mucor irregularis, dermatophytosis, Malassezia, cryptococcosis, chromoblastomycosis, coccidiosis, blastomycosis, histoplasmosis, sporotrichosis, and other fungi, should be monitored. \r\nThis topic includes the research progress on the etiology and pathogenesis of fungal infections, new methods of isolation and identification, rapid detection, drug sensitivity testing, new antifungal drugs, schemes and case series reports. It will provide significant opportunities and support for scientists, clinical doctors, mycologists, antifungal drug researchers, public health practitioners, and epidemiologists from all over the world to share new research, ideas and solutions to promote the development and progress of medical mycology.",coverUrl:"https://cdn.intechopen.com/series_topics/covers/4.jpg",keywords:"Emerging Fungal Pathogens, Invasive Infections, Epidemiology, Cell Membrane, Fungal Virulence, Diagnosis, Treatment"},{id:"5",title:"Parasitic Infectious Diseases",scope:"Parasitic diseases have evolved alongside their human hosts. In many cases, these diseases have adapted so well that they have developed efficient resilience methods in the human host and can live in the host for years. Others, particularly some blood parasites, can cause very acute diseases and are responsible for millions of deaths yearly. Many parasitic diseases are classified as neglected tropical diseases because they have received minimal funding over recent years and, in many cases, are under-reported despite the critical role they play in morbidity and mortality among human and animal hosts. The current topic, Parasitic Infectious Diseases, in the Infectious Diseases Series aims to publish studies on the systematics, epidemiology, molecular biology, genomics, pathogenesis, genetics, and clinical significance of parasitic diseases from blood borne to intestinal parasites as well as zoonotic parasites. We hope to cover all aspects of parasitic diseases to provide current and relevant research data on these very important diseases. In the current atmosphere of the Coronavirus pandemic, communities around the world, particularly those in different underdeveloped areas, are faced with the growing challenges of the high burden of parasitic diseases. At the same time, they are faced with the Covid-19 pandemic leading to what some authors have called potential syndemics that might worsen the outcome of such infections. Therefore, it is important to conduct studies that examine parasitic infections in the context of the coronavirus pandemic for the benefit of all communities to help foster more informed decisions for the betterment of human and animal health.",coverUrl:"https://cdn.intechopen.com/series_topics/covers/5.jpg",keywords:"Blood Borne Parasites, Intestinal Parasites, Protozoa, Helminths, Arthropods, Water Born Parasites, Epidemiology, Molecular Biology, Systematics, Genomics, Proteomics, Ecology"},{id:"6",title:"Viral Infectious Diseases",scope:"The Viral Infectious Diseases Book Series aims to provide a comprehensive overview of recent research trends and discoveries in various viral infectious diseases emerging around the globe. The emergence of any viral disease is hard to anticipate, which often contributes to death. A viral disease can be defined as an infectious disease that has recently appeared within a population or exists in nature with the rapid expansion of incident or geographic range. This series will focus on various crucial factors related to emerging viral infectious diseases, including epidemiology, pathogenesis, host immune response, clinical manifestations, diagnosis, treatment, and clinical recommendations for managing viral infectious diseases, highlighting the recent issues with future directions for effective therapeutic strategies.",coverUrl:"https://cdn.intechopen.com/series_topics/covers/6.jpg",keywords:"Novel Viruses, Virus Transmission, Virus Evolution, Molecular Virology, Control and Prevention, Virus-host Interaction"}],annualVolumeBook:{},thematicCollection:[],selectedSeries:{title:"Infectious Diseases",id:"6"},selectedSubseries:null},seriesLanding:{item:null},libraryRecommendation:{success:null,errors:{},institutions:[]},route:{name:"profile.detail",path:"/profiles/348547",hash:"",query:{},params:{id:"348547"},fullPath:"/profiles/348547",meta:{},from:{name:null,path:"/",hash:"",query:{},params:{},fullPath:"/",meta:{}}}},function(){var e;(e=document.currentScript||document.scripts[document.scripts.length-1]).parentNode.removeChild(e)}()