Department of Endocrinology, Max Planck Institute of Psychiatry, München, Germany



IGF‐I insulin‐like growth factor I IP3 inositol 1,4,5‐triphosphate JNK c‐Jun NH(2)‐terminal kinase MAPK mitogen‐activated protein kinase mTOR mammalian target of rapamycin NOS nitric oxide synthase

PI3K phosphatidyl inositol 3‐kinase PIP2 phosphatidylinositol 4,5‐bisphosphate PKC protein kinase C

PLA phospholipase A PLC phospholipase C

PTP protein tyrosine phosphatase Raf rapidly accelerated fibrosarcoma Rb retinoblastoma

SH2 src homology 2

SHP SH2‐containing phosphatase Sos son of sevenless

Src Rous sarcoma oncogene cellular homolog SSTR somatostatin receptors

TNFR1 tumor necrosis factor receptor 1 TSC2 tumor sclerosis complex 2 TSP‐1 thrombospondin‐1


Somatostatin mediates its action upon binding to somatostatin receptors (SSTR) which belong to the seven‐transmembrane domain, G‐protein‐coupled receptors (GPCRs) superfamily and are mainly coupled to the Gi protein and therefore inhibit adenylate cyclase and cAMP accumulation [1]. There are five somatostatin receptors SSTR1‐5.

The genes encoding human SSTR1‐5 are located in chromosome 14q13, 17q24, 22q13.1, 20p11.2 and 16p13.3. The gene encoding for SSTR2 has an intron and the transcribed mRNA can be spliced to encode SSTR2A and B isoforms [2]. SSTR5 also exists as truncated isoforms with four or five transmembrane domains (sst5TDM4 and sst5TDM5; [3]) generated by cryptic splice sites in the coding sequence and the 3′ untranslated region of the SSTR5 gene. All SSTR are Gi coupled and inhibit adenylate cyclase. However, as it will be described more extensively later, they also trigger several signaling cascades that may be pertussis toxin (i.e., Gi) dependent or independent.


Somatostatin was initially identified as a hypothalamic peptide able to inhibit growth hor­

mone (GH) secretion from the pituitary [4]. Two biological forms of somatostatin exist, somatostatin‐14 and ‐28, which are derived from a 92 aminoacid pro‐somatostatin

precursor [5, 6]. Somatostatin is a neurotransmitter and can be regarded as a secretory pan‐inhibitor; it suppresses GH, prolactin, thyroid‐stimulating hormone [7, 8] and adrenocorticotropic hormone (ACTH) [9] secretion from the anterior pituitary; cholecys­

tokinin, gastrin, secretin, vasoactive intestinal peptide, motilin, gastric inhibitory poly­

peptide from the gastrointestinal track (GI); glucagon, insulin, and pancreatic polypeptide from the endocrine pancreas [10]; triiodothyronine, thyroxin, and calcitonin from the thyroid; and renin and aldosterone from the kidney and the adrenals [11]. In addition to its endocrine action, it also suppresses exocrine secretion (e.g., gastric acid from intestinal mucosa, bicarbonate, and digestive enzymes from exocrine pancreas). In the GI, it also inhibits bile flow from the gallbladder, bowel motility and gastric emptying, smooth muscle contraction and nutrient absorption from the intestine. Somatostatin also inhibits cytokine and growth factors production from immune and various tumor cells.

Somatostatin suppresses GH and TSH through SSTR2 and SSTR5, and pro­

lactin predominantly through SSTR5 [12, 13]. GH secretion is also inhibited by SSTR1 [14]. Sstr2 knockout mice have elevated ACTH levels, indicating a regulatory role for SSTR2 [15]. Both SSTR2 and SSTR5 decrease ACTH syn­

thesis [16], with SSTR5 displaying a more potent suppressive action on ACTH release [17]. Insulin secretion is primarily inhibited by SSTR5, while glucagon secretion is primarily inhibited by SSTR2 [18]. Gastric acid and pancreatic amy­

lase release is inhibited by SSTR2 and SSTR4, while other GI hormones are inhibited by SSTR1, 2, and 5 [19, 20].

Somatostatin exerts its antisecretory action mainly by inhibiting exocytosis. This is mediated by its inhibitory action on adenylate cyclase and subsequent decrease in cyclic adenosine monophosphate (cAMP) production [21–24]. The effect is pertussis toxin‐dependent indicating the involvement of the Gi protein [25]. In addition to cAMP suppression, somatostatin activates potassium (K+) channels (delayed recti­

fying, inward rectifying and ATP sensitive) and induces membrane hyperpolarization that inhibits depolarization‐induced Ca2+ influx via voltage‐sensitive Ca2+ channels.

This reduces intracellular Ca2+ and inhibits exocytosis [26–30]. The inhibitory action of somatostatin on Ca2+ is mediated through the Gi and Go protein subtypes [31, 32].

In addition, an alternative pathway involving a cGMP‐dependent protein kinase was identified behind the inhibitory action of somatostatin on neuronal calcium channels [33]. All SSTRs, except SSTR3, couple to voltage‐gated K+ channels, but SSTR2 and 4 are more potent in increasing K+ currents [34]. SSTR1, 2, 4 and 5 couple to N‐ and L‐type voltage‐sensitive Ca2+ channels indicating a direct effect [35–38]. In addition, somatostatin has a distal to secondary messengers effect on exocytosis by activating the Ca2+‐dependent phosphatase calcineurin [39, 40].

Regarding the effect of somatostatin on hormone transcription, initial studies did not find changes in GH mRNA levels after somatostatin administration, supporting the hypothesis that somatostatin suppresses GH secretion by blocking exocytosis rather than transcription [41–43]. However, studies in vitro and in tumors from patients with acromegaly who were preoperatively treated with somatostatin analogs revealed reduced GH transcript levels after somatostatin treatment [44–47]. Somatostatin sup­

pressed GH‐releasing hormone‐induced GH promoter activity in a pertussis toxin‐

sensitive manner [48]. SSTR2 overexpression in human somatotropinomas and


prolactinomas in primary cell cultures suppressed GH and PRL transcripts, indicating a role for this receptor in somatostatin’s suppressive action on GH [49]. Interestingly, somatostatin was shown to stimulate GH secretion at low doses (below 10−13 M), an effect that was mediated by SSTR5 [50, 51]. By contrast, SSTR5 agonists suppress PRL secretion, but not transcription in vitro [52]. Somatostatin analogs suppress POMC promoter activity, an effect that is abolished by SSTR2 knockdown [53].

AntiProliferAtive signAling

Somatostatin limits cell growth through cytostatic or apoptotic mechanisms depend­

ing on the SSTR [54, 55]. One of the first described mechanisms behind the antipro­

liferative action of SSTR was the inhibitory action on growth factor receptor signaling [56–58]. Protein tyrosine phosphatases (PTPs) were shown to play a central role in this process by de‐phosphorylating the growth factor bound tyrosine kinase receptors [59]. PTP activity was found to be increased after somatostatin treatment in many cell systems [60–63] and in human tumors in primary cell culture [64, 65]. PTP were shown to be activated by Gαi [59] and Gαi/o [66]. SSTR associate with the cytosolic src homology 2 (SH2) domain containing PTP, SHP‐1 (PTP1C) and SHP‐2 (PTP1D), and the membrane anchored PTPη (DEP1) [67–74]. Through PTPs, somatostatin blocks cell cycle progression by arresting cells at the G1/S (SSTR1, 2, 4 and 5) or the G2/M (SSTR3) boundary [75, 76]. In addition, SSTR2 and SSTR3 were shown to induce apoptosis [77–79]. SSTRs also induce acidification, which results in apoptosis via a SHP‐1‐dependent mechanism [80], while SSTR1, 3 and 4 inhibit the Na+/H+ exchanger NHE1, leading to increased intracellular acidification [81, 82]. Finally, SSTR1, 2, 3 and 5 block nitric oxide synthase (NOS), revealing an additional regula­

tion point in the antiproliferative action of somatostatin [83, 84].

SSTR have common and individual signaling aspects, which are covered in more detail further (Fig. 2.1).


SSTR1 couples to Gαi3 and Gαi1/2 [85–87] and inhibits adenylate cyclase when overexpressed in Chinese hamster ovarian (CHO) cells [88]. SSTR1 also increases PTP activity [60, 69, 89]. In fact, it uses SHP‐2 to activate the serine/threonine mitogen‐activated protein kinase (MAPK) concomitantly with its antiproliferative action in these cells [64]. The MAPK pathway usually mediates the mitogenic action of growth factors, cytokines and hormones. However, depending on the cell system and extracellular milieu, the MAPK pathway can also halt cell growth in order to promote cell differentiation. Typically, the pathway starts with activation of the tyro­

sine kinase domain of the growth factor receptors and the association through special adaptors to Sos which enhances the GTP‐binding activity of the GTP‐ase Ras. GTP‐

bound activated Ras associate with, brings to the membrane and activates the Raf family of kinases (A‐Raf, B‐Raf, and c‐Raf/Raf‐1). Raf kinases (MAPK kinase

kinases) phosphorylate and activate the MAPK kinases MEK1/2 which then phos­

phorylate and activate the p44 and p42 MAPK. Raf‐1 can also be activated by the src family of tyrosine kinases. SSTR1 activated SHP‐2 dephosphorylates c‐src at an inhibitory site (Tyr529) which enables its phosphorylation at the stimulatory Tyr418.

This enables c‐src to phosphorylate and activate Raf‐1, which in turn phosphorylates and activates MEK/MAPK leading to upregulation of the cell cycle inhibitor p21/

Cip1. This pathway is inhibited by the Gi inhibitor pertussis toxin and is mediated by the βγ subunits of the Gi protein. It also involves an active phosphatidyl inositol 3 kinase (PI3K) although the exact mechanism is not clear [64].

Somatostatin treatment induces a long‐lasting PTP activity that cannot be explained by the rapidly activated SHP‐2. This PTP is the membrane anchored PTPη, which was described as a tumor suppressor in several tumor types [90, 91]. The importance of PTPη in mediating the antiproliferative action of SSTR1 was demon­

strated in the PC CI3 clonal thyroid cells, which loose their ability to respond to somatostatin after oncogene‐induced cellular transformation that suppresses PTPη;

re‐introducing PTPη restores their response to the antiproliferative action of somato­

statin [73]. SSTR1 inhibits MAPK through PTPη in glioma and neuroblastoma cells


figure 2.1 Schematic presentation of the main signaling cascades of the five SSTRs. All SSTRs are coupled to Gi, inhibit adenylate cyclase and lower cAMP. SSTR1, 2, and 3 trans­

duce their antiproliferative action by stimulating one or more PTP which in turn affects the mitogenic MAPK and the survival PI3K pathways. By contrast, SSTR5 mediates its antipro­

liferative action through PTP‐independent pathways. Open arrowheads: stimulatory effect;

blunt arrowheads: inhibitory effect; interrupted lines: indirect effect.

SSTR2 11

[92]. SSTR1 activates Jak2, in a pertussis toxin‐sensitive manner, which then phosphorylates and activates SHP‐2 leading to c‐src dephosphorylation and activation, and eventually to PTPη phosphorylation [93].


SSTR2 is the best‐studied mediator of somatostatin’s antiproliferative action. In fact, SSTR2 is considered as a tumor suppressor in pancreatic cancer since its expression is lost in these tumors [94, 95].

SSTR2A and B inhibit adenylate cyclase, and this effect was found to depend on the G protein subunits available in each cell type [86, 96, 97]. In pituitary tumor GH4C1 cells, the ability of SSTR2A to inhibit adenylate cyclase and sub­

sequently cAMP production resulted in decreased protein kinase A (PKA) activity [98]. The antiproliferative action of SSTR2 also begins with PTP activation. The PTP associated with SSTR2 is the cytosolic SH2 domain con­

taining SHP‐1, which associates with the receptor constitutively through Gαi3 [70–89]. Somatostatin treatment leads to SHP‐1 dissociation from the receptor and activation resulting in the dephosphorylation of tyrosine kinase receptors (e.g., insulin receptor) and its substrates (e.g., insulin receptor substrate‐1, IRS‐1) [99]. Another mechanism leading to SHP‐1 activation is through SHP‐2, which also associates with SSTR2 [100]. upon receptor activation, the βγ subunits of the Gi proteins activate src, probably by binding src to β‐arrestin, which then phosphorylates SHP‐2 and subsequently activates SHP‐1 [101]. Finally, SSTR2 activates SHP‐1 through the α subunit of the Gi protein and the receptor‐bound tyrosine kinase JAK2 and inhibits fibroblast growth factor (FGF)‐2 isoform of 210 amino acids (HMW FGF‐2)‐induced pancreatic tumor cell growth [102].

This was a novel finding since JAK2 is traditionally considered to associate with the cytokine receptor family.

SSTR2 was shown to inhibit growth factor induced MAPK phosphorylation and activation [103, 104], but also to activate MAPK, which together with the activated p38‐MAPK leads to decreased cell proliferation [105]. In this setting, the SSTR2‐

induced MAPK activation was mediated by Ras and B‐Raf, but also by Rap1 that is another member of the Ras subfamily of small GTP‐ases [106]. SSTR2 also activates the survival PI3K signaling, in a mechanism involving Gβγ and SHP‐2 [106, 107].

By contrast, activation of overexpressed or endogenous SSTR2 inhibits the PI3K pathway in tumor cell systems [108, 109]. SSTR2 binds directly p85 and this is a unique feature of SSTR2 not shared by another member of the SSTR family. SSTR2 activation disrupts its association with p85 by associating filamin A, resulting in PI3K inhibition [110]. In pituitary tumor cells, p85 physically associates with SHP‐1 and SSTR2 activation with octreotide leads to decreased p85 tyrosine phosphoryla­

tion, which was SHP‐1 dependent. Although the effect of octreotide was pertussis toxin sensitive, indicating involvement of the Gi, it was not depending on Gβγ show­

ing that Gi‐linked GPCR could interact with and inhibit PI3K through the Gi α‐sub­

unit. This way SSTR2 inhibits the serine/threonine kinase Akt that mediates the

antiapoptotic and cell survival effects of several growth factors. This is done in part by phosphorylating and subsequently inhibiting glycogen synthase kinase‐3 (GSK3β) which halts cell cycle progression. Cell cycle progression starts with the activation of D‐type cyclins and their associated cyclin‐dependent kinases Cdk4 and 6 [111]. The G1 to S transition is primarily governed by cyclin E and its associated kinase Cdk2, which hyperphosphorylates retinoblastoma (Rb) [112]. Phosphorylated Rb dissoci­

ates from E2F transcription factors resulting in the transcription of genes that will bring the cell to the S phase of the cell cycle [113]. Cyclin/CDK complexes are inhibited by cyclin kinase inhibitors such as p21/Cip1 and p27/Kip1. p27/Kip1 is the primary regulator of cyclin E/CDK2 complex, since by sequestering Cdk2 it prevents the complex formation. GSK3β phosphorylates and marks for proteolytic degrada­

tion the cyclins E and D1 and activates p27/Kip1. SSTR2 upregulates p21/Cip1 after stimulating both ERK1/2 and p38‐MAPK [105] and p27/Kip1 in a mechanism involving SHP‐1 [72, 83].

Although p27/Kip1 is an important downstream target of somatostatin’s antip­

roliferative signaling, cells like the rat pituitary tumor GH3 that do not express p27/Kip1 also respond to SSTR2 activation by decreasing cell proliferation [114].

In these cells, SSTR2 was shown to induce the expression of the tumor suppressor Zac1, in a mechanism involving Gαi, SHP‐1, GSK3β, and the Zac1 activator p53 [109]. Zac1 (gene name Plagl1) is a zinc finger protein able to induce apoptosis and cell cycle arrest that is frequently downregulated/lost in several solid cancers [115]. RNA interference experiments in pituitary tumor cells revealed that Zac1 is essential for octreotide’s antiproliferative action. A retrospective immunohisto­

chemical analysis on archival paraffin embedded tumoral tissue from acromegalic patients treated with somatostatin analogs pre‐operatively revealed a strong positive correlation between treatment response and ZAC1 immunoreactivity, with strong ZAC1 immunoreactivity positively correlating with IGF‐I normalization and tumor shrinkage after treatment [116]. Interestingly, in GH3 cells ZAC1 gene expression was suppressed after knocking down the aryl hydrocarbon receptor interacting protein (AIP), which is triggered by octreotide treatment [117]. The gene encoding for AIP was found to have germline mutations in patients with familial and sporadic acromegaly and AIP mutations predict an unfavorable response to somatostatin analogs [118, 119].

In addition to its action on cell cycle proteins, GSK3β also activates the tumor suppressor tuberin (TSC2), which inhibits the mammalian target of rapamycin (mTOR) controlling cap‐dependent translation and subsequently cell growth in terms of cell size rather than cell proliferation. SSTR2 by inhibiting Akt decreased GSK3β phosphorylation and increased its activity leading to decreased phosphorylation of the mTOR effectors p70/S6K and 4E‐BP1 [120]. Suppression of the mTOR pathway may explain the observations reporting tumor shrinkage in acromegalic patients treated with SSTR2 agonists not due to apoptosis but rather due to decrease in cell volume [121, 122].

There is increasing evidence that SSTR2 is not only cytostatic but also able to induce apoptosis by upregulating the death receptor 4 (DR4) and tumor necrosis factor receptor 1 (TNFR1) and downregulating the antiapoptotic Bcl2 [123].

SSTR5 13


SSTR3 inhibits adenylate cyclase activity in a pertussis toxin sensitive pathway by coupling to Gαi1 [96]. Similar to SSTR1 and 2, SSTR3 is also able to activate a PTP;

overexpressed SSTR3 was found to activate SHP‐2 and subsequently inactivate Raf‐1 [63, 71]. Nevertheless, SSTR3 was initially described as the only SSTR able to induce apoptosis, since its activation in cells selectively expressing SSTR3 led to apoptosis but not to cell cycle arrest [77, 124]. This effect is mediated by upregulat­

ing p53 and the proapoptotic protein Bax. In addition, an involvement of SHP‐1 and activated caspase 8 was described in the somatostatin‐induced cell acidification and apoptosis in SSTR3‐expressing cells [80, 125]. SSTR3 is also characterized by a unique antiproliferative action in endothelial cells, constituting it as the primary apo­

ptotic and antiangiogenic SSTR [126, 127].


This receptor type is the less studied in the family. The original studies failed to dem­

onstrate a coupling of SSTR4 to Gi and adenylate cyclase; but eventually, it was shown to suppress cAMP production similar to the other members of the family [128]. Furthermore, SSTR4 was found to activate MAPK in a pertussis toxin sensitive manner by activating phospholipase A (PLA)‐2 and arachidonate production. In fact, this is the only SSTR that is reported to stimulate cell proliferation. SSTR4 is also coupled to K+ channels (delayed rectifier) leading to decreased Ca2+ influx. SSTR4 displays an unusually long lasting effect and is hypothesized to mediate the antiepi­

leptic properties of somatostatin [129, 130]. Interestingly, this receptor was also shown to mediate the anti‐inflammatory properties of somatostatin [131].


SSTR5, together with SSTR2, is the main SSTR inhibiting hormone release. SSTR5 (initially termed “SSTR4”) was cloned as an adenylate cyclase coupled SSTR with high affinity to somatostatin‐28 [132]. Similar to the other SSTRs it is able to inhibit adenylate cyclase in a pertussis toxin sensitive mechanism. SSTR5 induces K+ leading to cell hyperpolarization which subsequently closes the L‐type voltage‐

sensitive Ca2+ channels resulting in decreased Ca2+ influx [133]. SSTR5 also affects phospholipase C (PLC) in a mechanism only partially involving Gi and requiring the Gαq [134]. PLC cleaves phosphatidylinositol 4,5‐bisphosphate (PIP2) into diacyl glycerol (DAG) and inositol 1,4,5‐triphosphate (IP3), which gets released into the cytosol where it binds to Ca2+ channels and increases Ca2+ influx into the cytosol.

DAG is membrane bound and together with Ca2+ functions in recruiting and acti­

vating protein kinase C (PKC). Overexpressed SSTR5 was reported to increase IP3 and subsequent Ca2+ increase [135]. By contrast, it was found to inhibit cholecysto­

kinin (CCK)‐induced Ca2+ influx by inhibiting PLC and IP3 generation [89]. Contrary

to what is the case for the other SSTRs, no PTP is required for SSTR5 antiproliferative effect [89]. Instead, SSTR5 acts by inhibiting CCK‐induced cyclic GMP (cGMP), which can activate specific kinases (G kinases) able to upregulate c‐fos and subse­

quently cell proliferation [136]. In this model, SSTR5 by decreasing cGMP inhibits MAPK. In addition, SSTR5 activation in human pancreatic carcinoid cells increases the receptor association with the src‐like tyrosine kinase p60src, which phosphory­

lates and inactivates neuronal nitric oxide synthase (nNOS), and therefore suppresses tumor cell proliferation [137]. These data show that SSTR5 employs completely dif­

ferent cascades to induce its antiproliferative effect compared to the other SSTR.

indirect AntiProliferAtive Action of sstrs

SSTR do not abolish the mitogenic action of growth factors only by inhibiting their signaling cascades, but also by downregulating the synthesis of the growth factors themselves. The founding example of somatostatin‐induced growth factor downreg­

ulation is IGF‐I, which is primarily regulated by GH. Somatostatin analogs used in the treatment of acromegaly decrease circulating IGF‐I levels by inhibiting GH syn­

thesis. In addition a direct action on hepatocyte IGF‐I production was shown with the activation of hepatic SSTR2 and 3 inhibiting GH‐induced IGF‐I by dephosphorylat­

ing STAT5b, an important transcription factor for IGF‐I promoter activation, in a pertussis toxin sensitive mechanism involving a PTP [138].

The ability of SSTRs to suppress growth factor synthesis is also responsible for their antiangiogenic action. Angiogenesis is regulated by the vascular endothelial growth factor (VEGF), which drives the development of new vessels under the trigger of hypoxia in the growing tumor. Somatostatin treatment in an in vivo model of Kaposi sarcoma inhibited tumor growth despite the complete lack of SSTR in these cells, an effect that was attributed to the antiangiogenic action of somatostatin [127].

SSTR1 is highly expressed in vessels where it inhibits endothelial proliferation, migration and neovascularization [139, 140]. Endothelial SSTR3 downregulates VEGF and endothelial NOS (eNOS) transcription [126]. The ability of SSTR3 to decrease eNOS activity is also shared by SSTR1 and SSTR2 [84, 126]. More recently, SSTR2 activation was found to block angiogenesis by upregulating the secretion of antiangiogenic factor thrombospondin‐1 (TSP‐1) from pancreatic cancer cells bring­

ing another twist in the antiangiogenic action of somatostatin [141].

orgAn sPecific distribution

All SSTR are expressed in the brain: SSTR1 in the cortex, hippocampus, hypo­

thalamus, midbrain, and cerebellum; SSTR2 in the cortex, basal ganglia, and hypo thalamus; SSTR3 in the cortex, hypothalamus (arcuate and ventromedial nuclei), and basal ganglia; SSTR5 (and SSTR4 in less extent) in the hypothalamus

thalamus, midbrain, and cerebellum; SSTR2 in the cortex, basal ganglia, and hypo thalamus; SSTR3 in the cortex, hypothalamus (arcuate and ventromedial nuclei), and basal ganglia; SSTR5 (and SSTR4 in less extent) in the hypothalamus

In document University of Groningen Somatostatin Receptor Scintigraphy in Medullary Thyroid Cancer van der Horst-Schrivers, Anouk N. A.; Brouwers, Adrienne; Links, Thera (Page 21-36)