The C-C motif chemokine ligand 22 (CCL22) chemokine is produced by M2-like tumor-associated macrophages (TAMs) in the tumor microenvironment. Chemokine C-C motif receptor 4 (CCR4), the CCL22 receptor, on T helper2 (Th2) cells leads to a Th2 cytokine-dominant environment. In our previous study, lymph node metastasis was the main predictor of tongue squamous cell carcinoma (SCC) via CCL22. Therefore, the present study aimed to investigate the effects of CCL22 and a Th2 cytokine-predominant tumor microenvironment on vascular endothelial growth factor (VEGF)-C expression and lymphangiogenesis. The post-operative courses of 110 patients with early-stage tongue SCC with a histopathological diagnosis based on the 8th TNM classification were followed up (mean/median follow-up time, 47.1/42.0 months) from surgery until death or the last follow-up visit, and subsequent lymph node relapse was assessed. Lymphangiogenesis and the immunohistochemical expression of several markers (CCL22, CCR4 and VEGF-C) were evaluated. The Kaplan-Meier method was used to plot lymph node relapse-free survival and overall survival curves, which were compared using the log-rank test. In vitro, the association between CCL22 and VEGF-C by interleukin (IL)-4/signal transducer and activator of transcription 6 (STAT6) stimulation was examined. Lymphangiogenesis was significantly associated with lymph node relapse (P<0.001) and a CCL22⁺ macrophage ratio (P<0.001). CCL22⁺ TAMs were positive for VEGF-C and surrounded by CCR4⁺ cells. Additionally, VEGF-C expression was increased in IL-4/STAT6-stimulated macrophages. In addition, the STAT6 signaling pathway was activated in the SCC cells in the deeply invaded part of the tumor along with the aggregated macrophages. In conclusion, TAM CCL22 expression led to lymph node relapse via VEGF-C expression within the tumor microenvironment and the IL-4/STAT6 signaling pathway in early stage tongue SCC. Additionally, the worst pattern of invasion and depth of invasion were revealed to be useful parameters for lymph node relapse in patients with tongue SCC. The present study suggested that CCL22 contributed to the role of M2-like differentiated TAMs in prognosis and lymph node relapse via IL-4/STAT6 and VEGF. The IL-4/STAT6 signaling pathway may be a new molecular target for tongue SCC.

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